Timing to out-of-bed mobilization and mobility levels of COVID-19 patients admitted to the ICU: Experiences in Brazilian clinical practice.

INTRODUCTION: At the beginning of the coronavirus disease 2019 (COVID-19) pandemic, there was scarce data about clinical/functional conditions during hospitalization or after hospital discharge. Little was known about COVID-19 repercussions and how to do early mobilization in intensive care unit (ICU). OBJECTIVE: Identify the time to the initiation of out-of-bed mobilization and the levels of mobility (sitting over the edge of the bed, sitting in a chair, standing, and ambulating) reached by critically ill patients with COVID-19 during hospitalization and the factors that could impact early mobilization. METHODS: This was a retrospective observational study of patients with COVID-19 in the ICU. RESULTS: There were 157 surviving COVID-19 patients included in the study (median age: 61 years; median ICU length of stay: 12 days). The median time to initiate out-of-bed mobilization in the ICU was 6 days; between patients who received mechanical ventilation (MV) compared with those who did not, this time was 8 vs. 2.5 days (p < .001). Most patients who used MV were mobilized after extubation (79.6%). During ICU stays, 88.0% of all patients were mobilized out of bed, and 41.0% were able to ambulate either with assistance or independently. The time to initiate out-of-bed mobilization is associated with sedation time and MV time. CONCLUSION: Despite the pandemic scenario, patients were quickly mobilized out of bed, and most of the patients achieved higher mobility levels in the ICU and at hospital discharge. Sedation time and MV time were associated with delays in initiating mobilization.

Pre-frailty status increases the risk of rehospitalization in patients after elective cardiac surgery without complication.

BACKGROUND AND AIM: It has been demonstrated that patients with pre-frailty have more adverse outcomes after cardiac surgery; however, data on prognosis and long-term evolution in patients with pre-frailty after elective cardiac surgery without postoperative complications are still scarce. To evaluate the impact of pre-frailty status on functional survival in patients after elective cardiac surgery without surgical complications. METHODS: This was a retrospective study with 141 patients over 65 years old, with an established diagnosis of myocardial infarction or valve disease. Patients were evaluated by Clinical Frailty Scale (CFS) before surgery, according to the hospital protocol, and allocated into two groups: non-frail (CFS, 1-3) and pre-frail (CFS = 4). Patients with adverse cardiovascular events during surgery or at intensive care unit (ICU), mechanical ventilation more than 24 hours, ICU length of stay more than 48 hours, and in-hospital complications were excluded. For all analyses, the statistical significance was set at 5% (P < .05). RESULTS: There were no differences in demographic, anthropometric, surgical procedure, or baseline data on ICU. Pre-frail patients had more adverse events during the 3-year follow-up period with rehospitalization compared to non-frail (39.4% vs 14.3%, respectively). Rehospitalizations in pre-frail patients were in the first year after cardiac surgery (P < .05), and higher cumulative events in pre-frail have occurred with increased odds ratio (OR) (2.828, 95% confidence interval [CI]: 1.298-6.160; P = .001) and hazard ratio (HR) (3.560, 95% CI: 1.508-84.04; P = .004). The OR and HR for stroke or death were similar between groups when analyzed separately. CONCLUSION: Pre-frail patients have more adverse events after elective cardiac surgery without complications when compared to non-frail patients.

Pre-frailty status increases the risk of rehospitalization in patients after elective cardiac surgery without complication

ABSTRACT: background and aim: It has been demonstrated that patients with pre­frailty have more adverse outcomes after cardiac surgery; however, data on prognosis and long­ term evolution in patients with pre­frailty after elective cardiac surgery without postoperative complications are still scarce. To evaluate the impact of pre­frailty status on functional survival in patients after elective cardiac surgery without surgical complications. METHODS: This was a retrospective study with 141 patients over 65 years old, with an established diagnosis of myocardial infarction or valve disease. Patients were evaluated by Clinical Frailty Scale (CFS) before surgery, according to the hospital protocol, and allocated into two groups: non­frail (CFS, 1­3) and pre­frail (CFS = 4). Patients with adverse cardiovascular events during surgery or at intensive care unit (ICU), mechanical ventilation more than 24 hours, ICU length of stay more than 48 hours, and in­hospital complications were excluded. For all analyses, the statistical significance was set at 5% (P < .05). RESULTS: There were no differences in demographic, anthropometric, surgical procedure, or baseline data on ICU. Pre­frail patients had more adverse events during the 3­year follow­up period with rehospitalization compared to non­frail (39.4% vs 14.3%, respectively). Rehospitalizations in pre­frail patients were in the first year after cardiac surgery (P < .05), and higher cumulative events in pre­frail have occurred with increased odds ratio (OR) (2.828, 95% confidence interval [CI]: 1.298­6.160; P = .001) and hazard ratio (HR) (3.560, 95% CI: 1.508­84.04; P = .004). The OR and HR for stroke or death were similar between groups when analyzed separately. CONCLUSION: Pre­frail patients have more adverse events after elective cardiac surgery without complications when compared to non­frail patients.

Pre-Frailty Increases the Risk of Adverse Events in Older Patients Undergoing Cardiovascular Surgery / Pré-Fragilidade Aumenta o Risco de Eventos Adversos em Idosos Submetidos à Cirurgia Cardiovascular

Abstract Background: Frailty is identified as a major predictor of adverse outcomes in older surgical patients. However, the outcomes in pre-frail patients after cardiovascular surgery remain unknown. Objective: To investigate the main outcomes (length of stay, mechanical ventilation time, stroke and in-hospital death) in pre-frail patients in comparison with no-frail patients after cardiovascular surgery. Methods: 221 patients over 65 years old, with established diagnosis of myocardial infarction or valve disease were enrolled. Patients were evaluated by Clinical Frailty Score (CFS) before surgery and allocated into 2 groups: no-frailty (CFS 1~3) vs. pre-frailty (CFS 4) and followed up for main outcomes. For all analysis, the statistical significance was set at 5% (p < 0.05). Results: No differences were found in anthropometric and demographic data between groups (p > 0.05). Pre-frail patients showed a longer mechanical ventilation time (193 ± 37 vs. 29 ± 7 hours; p<0.05) than no-frail patients; similar results were observed for length of stay at the intensive care unit (5 ± 1 vs. 3 ± 1 days; p < 0.05) and total time of hospitalization (12 ± 5 vs. 9 ± 3 days; p < 0.05). In addition, the pre-frail group had a higher number of adverse events (stroke 8.3% vs. 3.9%; in-hospital death 21.5% vs. 7.8%; p < 0.05) with an increased risk for development stroke (OR: 2.139, 95% CI: 0.622-7.351, p = 0.001; HR: 2.763, 95%CI: 1.206-6.331, p = 0.0001) and in-hospital death (OR: 1.809, 95% CI: 1.286-2.546, p = 0.001; HR: 1.830, 95% CI: 1.476-2.269, p = 0.0001). Moreover, higher number of pre-frail patients required homecare services than no-frail patients (46.5% vs. 0%; p < 0.05). Conclusion: Patients with pre-frailty showed longer mechanical ventilation time and hospital stay with an increased risk for cardiovascular events compared with no-frail patients.

Resumo Fundamentos: A fragilidade é reconhecida como um importante preditor de eventos adversos em pacientes cirúrgicos idosos. Entretanto, os desfechos em pacientes com pré-fragilidade após a cirurgia cardiovascular ainda permanecem desconhecidos. Objetivos: Investigar os principais desfechos (tempo de internação, tempo de ventilação mecânica, incidência de acidente vascular cerebral e óbito intra-hospitalar) após cirurgia cardiovascular em pacientes com pré-fragilidade em comparação a pacientes sem fragilidade. Métodos: 221 pacientes acima de 65 anos de idade, com diagnóstico de infarto do miocárdio ou doença valvar foram recrutados no estudo. Os pacientes foram avaliados pela escala de fragilidade clínica (CFS, Clinical Frailty Score) antes da cirurgia e separados em 2 grupos: sem-fragilidade (CFS 1~3) vs. pré-fragilidade (CFS 4). Para todas as análises, foi considerada diferença significativa quando p < 0,05. Resultados: Não foram observadas diferenças nos dados antropométricos e demográficos entre os grupos. Os pacientes com pré-fragilidade apresentaram maior tempo de ventilação mecânica em comparação a pacientes sem fragilidade (193 ± 37 vs. 29 ± 7 horas; p < 0,05); resultados similares foram observados para tempo de permanência na unidade de terapia intensiva (5 ± 1 vs. 3 ± 1 days; p < 0,05) e tempo total de internação hospitalar (12 ± 5 vs. 9 ± 3 dias; p < 0,05). Além disso, os pacientes com pré-fragilidade apresentaram maior número de eventos adversos (acidente vascular cerebral-AVC 8,3% vs. 3,9%; óbito intra-hospitalar 21,5% vs. 7,8%; p<0,05) com risco aumentado para AVC (OR: 2,139, IC 95%: 0,622-7,351, p = 0,001; HR: 2,763, IC 95%: 1,206-6,331, p = 0,0001) e morte intra-hospitalar (OR: 1,809, IC 95%: 1,286-2,546, p = 0,001; HR: 1,830, IC 95%: 1,476-2,269, p = 0,0001). Além disso, um maior número de pacientes com pré-fragilidade necessitaram de fisioterapia domiciliar que pacientes sem fragilidade (46,5% vs. 0%; p< 0,05). Conclusão: Pacientes com pré-fragilidade apresentaram maior tempo de ventilação mecânica e maior tempo de internação hospitalar, com maior risco de desenvolverem eventos cardiovasculares adversos em comparação a pacientes sem fragilidade.

Pre-Frailty Increases the Risk of Adverse Events in Older Patients Undergoing Cardiovascular Surgery.

BACKGROUND: Frailty is identified as a major predictor of adverse outcomes in older surgical patients. However, the outcomes in pre-frail patients after cardiovascular surgery remain unknown. OBJECTIVE: To investigate the main outcomes (length of stay, mechanical ventilation time, stroke and in-hospital death) in pre-frail patients in comparison with no-frail patients after cardiovascular surgery. METHODS: 221 patients over 65 years old, with established diagnosis of myocardial infarction or valve disease were enrolled. Patients were evaluated by Clinical Frailty Score (CFS) before surgery and allocated into 2 groups: no-frailty (CFS 1~3) vs. pre-frailty (CFS 4) and followed up for main outcomes. For all analysis, the statistical significance was set at 5% (p < 0.05). RESULTS: No differences were found in anthropometric and demographic data between groups (p > 0.05). Pre-frail patients showed a longer mechanical ventilation time (193 ± 37 vs. 29 ± 7 hours; p<0.05) than no-frail patients; similar results were observed for length of stay at the intensive care unit (5 ± 1 vs. 3 ± 1 days; p < 0.05) and total time of hospitalization (12 ± 5 vs. 9 ± 3 days; p < 0.05). In addition, the pre-frail group had a higher number of adverse events (stroke 8.3% vs. 3.9%; in-hospital death 21.5% vs. 7.8%; p < 0.05) with an increased risk for development stroke (OR: 2.139, 95% CI: 0.622-7.351, p = 0.001; HR: 2.763, 95%CI: 1.206-6.331, p = 0.0001) and in-hospital death (OR: 1.809, 95% CI: 1.286-2.546, p = 0.001; HR: 1.830, 95% CI: 1.476-2.269, p = 0.0001). Moreover, higher number of pre-frail patients required homecare services than no-frail patients (46.5% vs. 0%; p < 0.05). CONCLUSION: Patients with pre-frailty showed longer mechanical ventilation time and hospital stay with an increased risk for cardiovascular events compared with no-frail patients.

Additive effects of non-invasive ventilation to hyperoxia on cerebral oxygenation in COPD patients with exercise-related O2 desaturation.

BACKGROUND: It is currently unknown whether potential haemodynamic improvements induced by non-invasive ventilation (NIV) would positively impact upon cerebral oxygenation (COx) in patients with moderate-to-severe chronic obstructive pulmonary disease (COPD). OBJECTIVE: To investigate the effects of NIV on exercise COx in COPD patients presenting with exercise-related O(2) desaturation. METHODS: On a double-blind trial, 13 males (FEV1 = 48·8 ± 15·1% predicted) were randomly assigned to NIV (16 cmH(2)O IPS and 5 cmH(2)O PEEP) plus HOx (FiO(2) = 0·4) or sham NIV (7 cmH(2)O IPS and 5 cmH(2)O PEEP to overcome breathing circuit resistance) plus HOx during ramp-incremental exercise performed on different days. Near-infrared spectroscopy and impedance cardiography assessed changes (Δ) in COx and cardiac output (Q(T)), respectively. RESULTS: There were no significant between-intervention differences in peak work rate, ventilation and reported symptoms (P>0·05). Peripheral oxyhaemoglobin saturation remained above 98% throughout the tests. NIV + HOx was associated with larger increases in Δ COx, Δ Q(T) and Δ stroke volume at maximal and submaximal exercise (P<0·05). Increases in the area under the curve (to an iso-work rate) of Δ COx under NIV + HOx were significantly (P<0·01) correlated with improvements in Δ Q(T) (r = 0·82) and Δ stroke volume (r = 0·87). There was, however, no significant correlation between enhancement in these physiological responses with changes in peak work rate with NIV + HOx (P>0·05). CONCLUSIONS: NIV added benefit to HOx in improving central haemodynamics and COx in O(2) 'desaturators' with COPD. The clinical relevance of such beneficial effects on exercise tolerance, however, remains to be demonstrated.

Sildenafil improves microvascular O2 delivery-to-utilization matching and accelerates exercise O2 uptake kinetics in chronic heart failure.

Nitric oxide (NO) can temporally and spatially match microvascular oxygen (O(2)) delivery (Qo(2mv)) to O(2) uptake (Vo(2)) in the skeletal muscle, a crucial adjustment-to-exercise tolerance that is impaired in chronic heart failure (CHF). To investigate the effects of NO bioavailability induced by sildenafil intake on muscle Qo(2mv)-to-O(2) utilization matching and Vo(2) kinetics, 10 males with CHF (ejection fraction = 27 ± 6%) undertook constant work-rate exercise (70-80% peak). Breath-by-breath Vo(2), fractional O(2)extraction in the vastus lateralis {∼deoxygenated hemoglobin + myoglobin ([deoxy-Hb + Mb]) by near-infrared spectroscopy}, and cardiac output (CO) were evaluated after sildenafil (50 mg) or placebo. Sildenafil increased exercise tolerance compared with placebo by ∼20%, an effect that was related to faster on- and off-exercise Vo(2) kinetics (P < 0.05). Active treatment, however, failed to accelerate CO dynamics (P > 0.05). On-exercise [deoxy-Hb + Mb] kinetics were slowed by sildenafil (∼25%), and a subsequent response "overshoot" (n = 8) was significantly lessened or even abolished. In contrast, [deoxy-Hb + Mb] recovery was faster with sildenafil (∼15%). Improvements in muscle oxygenation with sildenafil were related to faster on-exercise Vo(2) kinetics, blunted oscillations in ventilation (n = 9), and greater exercise capacity (P < 0.05). Sildenafil intake enhanced intramuscular Qo(2mv)-to-Vo(2) matching with beneficial effects on Vo(2) kinetics and exercise tolerance in CHF. The lack of effect on CO suggests that improvement in blood flow to and within skeletal muscles underlies these effects.

Effects of oxygen supplementation on cerebral oxygenation during exercise in chronic obstructive pulmonary disease patients not entitled to long-term oxygen therapy.

BACKGROUND: The rate of change (Δ) in cerebral oxygenation (COx) during exercise is influenced by blood flow and arterial O(2) content (CaO(2)). It is currently unclear whether ΔCOx would (i) be impaired during exercise in patients with chronic obstructive pulmonary disease (COPD) who do not fulfil the current criteria for long-term O(2) therapy but present with exercise-induced hypoxaemia and (ii) improve with hyperoxia (FIO(2) = 0·4) in this specific sub-population. METHODS: A total of 20 non-hypercapnic men (FEV(1) = 47·2 ± 11·5% pred) underwent incremental cycle ergometer exercise tests under normoxia and hyperoxia with ΔCOx (fold-changes from unloaded exercise in O(2)Hb) being determined by near-infrared spectroscopy. Pulse oximetry assessed oxyhaemoglobin saturation (SpO(2)), and impedance cardiography estimated changes in cardiac output (ΔQT). RESULTS: Peak work rate and ΔCOx in normoxia were lower in eight O(2) 'desaturators' compared with 12 'non-desaturators' (P < 0·05). Area under ΔCOx during sub-maximal exercise was closely related to SpO(2) decrements in 'desaturators' (r = 0·92, P < 0·01). These patients showed the largest improvement in peak exercise capacity with hyperoxia (P < 0·05). Despite a trend to lower sub-maximal ΔQT and mean arterial pressure with active intervention, ΔCOx was significantly improved only in this group (0·57 ± 0·20 versus 2·09 ± 0·42 for 'non-desaturators' and 'desaturators', respectively; P < 0·05). CONCLUSIONS: ΔCOx was impaired in non-hypoxaemic patients with COPD who desaturated during exercise. Hyperoxic breathing was able to correct for these abnormalities, an effect related to enhanced CaO(2) rather than improved central haemodynamics. This indicates that O(2) supplementation ameliorates exercise COx in patients with COPD who are not currently entitled to ambulatory O(2) therapy.