Barotrauma in patients with severe coronavirus disease 2019-retrospective observational study.

Background: Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. Although it is known that the COVID-19 acute respiratory distress syndrome (ARDS) is associated with higher incidence of pulmonary barotrauma, unique mechanisms causing the aforementioned complication are still to be investigated. The goal of this research was to investigate the incidence of barotrauma among COVID-19 patients treated in the intensive care unit (ICU) and to examine different clinical outcomes among those subjects. Methods: This retrospective observational cohort study included adult COVID-19 patients admitted to ICU from September 1, 2020, to February 28, 2022. All admitted subjects received invasive respiratory support. Subjects were divided into two groups based on occurrence of pulmonary barotrauma. Data were collected from available electronical medical records. Results: In the study period, a total of 900 subjects met inclusion criteria. Pulmonary barotrauma occurred in 88 (9.8%) of them. Subcutaneous emphysema developed in 73 (83%), pneumomediastinum in 68 (77.3%) and pneumothorax in 54 (61.4%) subjects. A small group of subjects developed less common complications like pneumoperitoneum (8 subjects, 9.1%) and pneumopericardium (2 subjects, 2.3%). Survival rate was higher in control than in barotrauma group [396 (48.8%) vs. 22 (25.0%), P<0.05]. There was also a significant difference between two groups in PaO2/FiO2 ratio on admission, duration of non-invasive respiratory support before mechanical ventilation, duration of mechanical ventilation and duration of ICU and hospital stay, all in favour of control group. Conclusions: Development of barotrauma in patients with severe forms of COVID-19 disease and in need of respiratory support is associated with longer ICU and hospital stay as well as lower survival rates at hospital discharge. Further efforts are needed in understanding mechanism in developing barotrauma and finding new prevention and treatment options.

Vitamin D Supplementation and Clinical Outcomes in Severe COVID-19 Patients-Randomized Controlled Trial.

COVID-19 symptoms vary from asymptomatic cases to moderate and severe illness with patients needing hospitalization and intensive care treatment. Vitamin D is associated with severity of viral infections and has an immune-modulatory effect in immune response. Observational studies showed a negative association of low vitamin D levels and COVID-19 severity and mortality outcomes. In this study, we aimed to determine whether daily supplementation of vitamin D during intensive care unit (ICU) stay in COVID-19 patients with severe illness affects clinically relevant outcomes. Patients with COVID-19 disease in need of respiratory support admitted to the ICU were eligible for inclusion. Patients with low vitamin D levels were randomized into one of two groups: the intervention group received daily supplementation of vitamin D and the control group did not receive vitamin D supplementation. In total, 155 patients were randomized: 78 into the intervention group and 77 into the control group. There was no statistically significant difference in number of days spent on respiratory support, although the trial was underpowered for the main outcome. There was no difference in any of the secondary outcomes analyzed between two groups. Our study suggests no benefit in vitamin D supplementation to patients with severe COVID-19 disease admitted to the ICU and in need of respiratory support in any of the analyzed outcomes.

Health-Related Quality of Life of COVID-19 Survivors Treated in Intensive Care Unit-Prospective Observational Study.

Purpose: To investigate the quality of life (QoL) of survivors from severe forms of COVID-19 treated in the ICU. Methods: In this study, we investigated the QoL of patients with severe COVID-19 treated in the ICU from November 2021 to February 2022. In the study period, 288 patients were treated in ICU and 162 were alive at the time of analysis. Of those, 113 patients were included in this study. QoL was analyzed 4 months after ICU admission using the EQ-5D-5L questionnaire administered by telephone. Results: Of the 162 surviving patients, 46% reported moderate to severe problems in the anxiety/depression domain, 37% had moderate to severe problems in usual activities, and 29% in the mobility domain. Older patients had lower QoL in mobility, self-care and usual activities domains. Female patients had lower QoL in usual activities, while male patients had lower QoL in the self-care domain. Patients who spent longer time on invasive respiratory support and those with longer hospital lengths of stay had lower QoL in all domains. Conclusion: Severe COVID-19 reduces HRQoL in a significant number of survivors 4 months after ICU admission. Early recognition of patients at increased risk for reduced QoL could lead to early focused rehabilitation and improved QoL of these patients.

Effects of Different Inhalation Therapy on Ventilator-Associated Pneumonia in Ventilated COVID-19 Patients: A Randomized Controlled Trial.

The effect of routine inhalation therapy on ventilator-associated pneumonia (VAP) in mechanically ventilated patients with the coronavirus disease (COVID-19) has not been well-defined. This randomized controlled trial included 175 eligible adult patients with COVID-19 who were treated with mechanical ventilation at the University Hospital of Split between October 2020 and June 2021. Patients were randomized and allocated to a control group (no routine inhalation) or one of the treatment arms (inhalation of N-acetylcysteine; 5% saline solution; or 8.4% sodium bicarbonate). The primary outcome was the incidence of VAP, while secondary outcomes included all-cause mortality. Routine inhalation therapy had no effect on the incidence of bacterial or fungal VAP nor on all-cause mortality (p > 0.05). Secondary analyses revealed a significant reduction of Gram-positive and methicillin-resistant Staphylococcus aureus (MRSA) VAP in the treatment groups. Specifically, the bicarbonate group had a statistically significantly lower incidence of Gram-positive bacterial VAP (4.8%), followed by the N-acetylcysteine group (10.3%), 5% saline group (19.0%), and control group (34.6%; p = 0.001). This difference was driven by a lower incidence of MRSA VAP in the bicarbonate group (2.4%), followed by the N-acetylcysteine group (7.7%), 5% saline group (14.3%), and control group (34.6%; p < 0.001). Longer duration of ventilator therapy was the only significant, independent predictor of any bacterial or fungal VAP in the multivariate analysis (aOR 1.14, 95% CI 1.01−1.29, p = 0.038 and aOR 1.05, 95% CI 1.01−1.10, p = 0.028, respectively). In conclusion, inhalation therapy had no effect on the overall VAP incidence or all-cause mortality. Further studies should explore the secondary findings of this study such as the reduction of Gram-positive or MRSA-caused VAP in treated patients.

Biomedical conferences' author instructions rarely mention guidelines for reporting abstracts of trials and systematic reviews.

Aim: To analyze whether instructions for authors of biomedical conference abstracts mention guidelines for writing randomized controlled trial and systematic review abstracts and to evaluate reasons for their absence from instructions. Materials & methods: We analyzed instructions for authors of biomedical conferences advertized in 2019 and assessed whether they mentioned Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Abstracts and Consolidated Standards of Reporting Trials for Abstracts guidelines. We surveyed contact persons from abstract/publication committees of selected conferences to analyze why relevant guidelines were missing. Results: Instructions for abstracts were available for 819 conferences. Only two (0.2%) had reporting instructions for randomized controlled trial/systematic review authors. Almost half of the contacted conference organizers whose response we received were not aware of Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Abstracts and Consolidated Standards of Reporting Trials for Abstracts guidelines. Conclusion: Conference organizers do not require and are not familiar enough with reporting guidelines.

Conference abstracts describing systematic reviews on pain were selectively published, not reliable, and poorly reported.

OBJECTIVE: The objective of the study was to determine the reporting quality of systematic review (SR) abstracts presented at World Congresses on Pain (WCPs) and to quantify agreement in results presented in those abstracts with their corresponding full-length publications. STUDY DESIGN AND SETTING: We screened abstracts of five WCPs held from 2008 to 2016 to find abstracts describing SRs. Two authors searched for corresponding full publications using PubMed and Google Scholar in April 2018. Methods and outcomes extracted from abstracts were compared with their corresponding full publications. The reporting quality of abstracts was evaluated against the PRISMA for Abstracts (PRISMA-A) checklist. RESULTS: We identified 143 conference abstracts describing SRs. Of these, 90 (63%) were published as full-length articles in peer-reviewed journals by April 2018, with a median time from conference presentation to publication of 5 months (interquartile range: -0.25 to 14 months). Among 79 abstract-publication pairs evaluable for discordance, there was some form of discordance in 40% of pairs. Qualitative discordance (different direction of the effect) was found in 13 analyzed pairs (16%). The median adherence by abstracts to each PRISMA-A checklist item was 33% (interquartile range: 29% to 42%). CONCLUSION: Conference abstracts of pain SRs are selectively published, not reliable, and poorly reported.

Futile Treatment-A Review.

The main goal of intensive care medicine is helping patients survive acute threats to their lives, while preserving and restoring life quality. Because of medical advancements, it is now possible to sustain life to an extent that would previously have been difficult to imagine. However, the goals of medicine are not to preserve organ function or physiological activity but to treat and improve the health of a person as a whole. When dealing with medical futilities, physicians and other members of the care team should be aware of some ethical principles. Knowing these principles could make decision-making easier, especially in cases where legal guidelines are insufficient or lacking. Understanding of these principles can relieve the pressure that healthcare professionals feel when they have to deal with medical futility. Efforts should be made to promote an ethics of care, which means caring for patients even after further invasive treatment has been deemed to be futile. Treatments that improve patients' comfort and minimize suffering of both patients and their families are equally as important as those aimed at saving patients' lives.

Medical futility treatment in intensive care units.

OBJECTIVE: To investigate cases of potential medical futility treatment in intensive care unit (ICU). MATERIALS AND METHODS: Retrospective review of 1567 charts of patients treated during the three-year period (2012 - 2014) in the ICU of the University Hospital Centre Split, Croatia, was conducted. More detailed analysis of the deceased patients' (n=429) charts was performed to identify cases of potential medical futility treatment. There were 99 patients for which ICU treatment was questionable due to their low Glasgow coma scale (GCS) score. For those patients types and duration of treatment were analyzed. RESULTS: Among patients who were treated during that period, 27% had died. Treatment of 99 patients (6.3% of the deceased) was considered a potential medical futility. Mean age of those 99 patients was 68±14 years and the mean stay in the ICU was 14±11 days. They spent 1302 patient days in the ICU, of which 52% days they had GCS 3 score. They were treated with catecholamines during 40% of the patient days. Minimal therapy was provided during 44% of the patient days. CONCLUSIONS: Analysis of the deceased patients' charts in the ICU indicated that a certain percentage of patients did not need prolonged ICU treatment. Instead, they were supposed to be treated in a palliative care unit. To avoid medical futility treatment in ICUs, palliative care unit needs to be established, as well as protocols for determining medical futility cases and ethical committee that will decide which patients will be transferred to palliative care.