Quality of Life, Family Support, Spirometry, and 6-Minute Walking Distance Differences between COVID-19 and Non-COVID-19 Intensive Care Unit Patients in One Year Following Hospital Discharge.

BACKGROUND: Critically ill patients after Intensive Care Unit (ICU) discharge may present disability in their cognitive and physical functions. OBJECTIVES: To investigate the quality of life (QoL) of both COVID-19 and non-COVID-19 patients following ICU discharge, lung function, and physical performance of participants. METHODS: This study was prospective and conducted between 2020 and 2021 in the "X" hospital. If patients were Mechanically-Ventilated (MV) > 48 h, they were included. RESULTS: Fifty COVID-19 and seventy-two non-COVID-19 participants were included in this study. The mean (SD) of the total SF-36 scores at COVID-19 patients at hospital discharge and 3 and 12 months were 46.5 (14.5), 68.6 (17.8), and 82.3 (8.9) (p < 0.05), while non-COVID-19 participants were 48.5 (12.1), 72.2 (9.9), and 82.7 (5.4) (p < 0.05). The forced expiratory volume in one second (FEV1) and 6-minute walking distance (6MWD) were assessed at 3 and 12 months and significantly improved over 12 months. CONCLUSION: The QoL of COVID-19 patients improved significantly over time as FEV1 and 6MWD.

Meropenem plus Ertapenem and Ceftazidime-Avibactam plus Aztreonam for the Treatment of Ventilator Associated Pneumonia Caused by Pan-Drug Resistant Klebsiella pneumonia.

INTRODUCTION: Gram-negative bacteria (GNB) account for about 70% of infections in the intensive care unit (ICU) setting and are associated with significant morbidity and mortality. In recent years, pan-drug resistant (PDR) strains, strains that are not susceptible to any antibiotic, have been emerged and new treatment strategies are required. RESULTS: Fifty eligible patients were recruited in the three groups. A statistically significant reduction in the Sequential Organ Failure Assessment (SOFA) score was observed in the control group on day 4 in comparison to day 0 of VAP (p = 0.005). The Clinical Pulmonary Infection Score (CPIS) was also reduced on day 4 (p = 0.0016) and day 7 in comparison to day 0 (p = 0.001). Patients that received combination therapy, CAZ-AVI + ATM and DCT, presented with a lower SOFA score and CPIS on day 7 in comparison to day 0 (p = 0.0288 and p = 0.037, respectively). No differences in the ΔSOFA score and ΔCPIS were found between the groups. The control group presented with a significantly lower ICU stay and duration of mechanical ventilation (p = 0.03 and p = 0.02, respectively). There was no difference in mortality. MATERIALS AND METHODS: This is a retrospective analysis. This study was conducted in a mixed ICU in the University Hospital of Larissa, Thessaly, Greece during a three-year period (2020-2022). Patients suffering from ventilator associated pneumonia (VAP) due to carbapenem-resistant K. pneumonia (CR-KP) were divided in three different groups: the first one was treated using ceftazidime-avibactam plus aztreonam (CAZ-AVI + ATM group), the second was treated using double carbapenems (DCT group), and the last one (control group) received appropriate therapy since the strain was susceptible in vitro to at least to one antibiotic. CONCLUSIONS: Treatment with CAZ-AVI +ATM or DCT may offer a clinical benefit in patients suffering with infections due to PDR K. pneumoniae. Larger studies are required to confirm our findings.

Unveiling the Role of Endothelial Dysfunction: A Possible Key to Enhancing Catheter Ablation Success in Atrial Fibrillation.

Atrial fibrillation, a prevalent type of arrhythmia, is increasingly contributing to the economic burden on healthcare systems. The development of innovative treatments, notably catheter ablation, has demonstrated both impressive and promising outcomes. However, these treatments have not yet fully replaced pharmaceutical approaches, primarily due to the relatively high incidence of atrial fibrillation recurrence post-procedure. Recent insights into endothelial dysfunction have shed light on its role in both the onset and progression of atrial fibrillation. This emerging understanding suggests that endothelial function might significantly influence the effectiveness of catheter ablation. Consequently, a deeper exploration into endothelial dynamics could potentially elevate the status of catheter ablation, positioning it as a primary treatment option for atrial fibrillation.

Comprehensive temporal analysis of right ventricular function and pulmonary haemodynamics in mechanically ventilated COVID-19 ARDS patients.

BACKGROUND: Cardiac injury is frequently reported in COVID-19 patients, the right ventricle (RV) is mostly affected. We systematically evaluated the cardiac function and longitudinal changes in severe COVID-19 acute respiratory distress syndrome (ARDS) admitted to the intensive care unit (ICU) and assessed the impact on survival. METHODS: We prospectively performed comprehensive echocardiographic analysis on mechanically ventilated COVID-19 ARDS patients, using 2D/3D echocardiography. We defined left ventricular (LV) systolic dysfunction as ejection fraction (EF) < 40%, or longitudinal strain (LS) > - 18% and right ventricular (RV) dysfunction if two indices among fractional area change (FAC) < 35%, tricuspid annulus systolic plane excursion (TAPSE) < 1.6 cm, RV EF < 44%, RV-LS > - 20% were present. RV afterload was assessed from pulmonary artery systolic pressure (PASP), PASP/Velocity Time Integral in the right ventricular outflow tract (VTIRVOT) and pulmonary acceleration time (PAcT). TAPSE/PASP assessed the right ventriculoarterial coupling (VACR). RESULTS: Among 176 patients included, RV dysfunction was common (69%) (RV-EF 41.1 ± 1.3%; RV-FAC 36.6 ± 0.9%, TAPSE 20.4 ± 0.4mm, RV-LS:- 14.4 ± 0.4%), usually accompanied by RV dilatation (RVEDA/LVEDA 0.82 ± 0.02). RV afterload was increased in most of the patients (PASP 33 ± 1.1 mmHg, PAcT 65.3 ± 1.5 ms, PASP/VTIRVOT, 2.29 ± 0.1 mmHg/cm). VACR was 0.8 ± 0.06 mm/mmHg. LV-EF < 40% was present in 21/176 (11.9%); mean LV-EF 57.8 ± 1.1%. LV-LS (- 13.3 ± 0.3%) revealed a silent LV impairment in 87.5%. A mild pericardial effusion was present in 70(38%) patients, more frequently in non-survivors (p < 0.05). Survivors presented significant improvements in respiratory physiology during the 10th ICU-day (PaO2/FiO2, 231.2 ± 11.9 vs 120.2 ± 6.7 mmHg; PaCO2, 43.1 ± 1.2 vs 53.9 ± 1.5 mmHg; respiratory system compliance-CRS, 42.6 ± 2.2 vs 27.8 ± 0.9 ml/cmH2O, all p < 0.0001). Moreover, survivors presented significant decreases in RV afterload (PASP: 36.1 ± 2.4 to 20.1 ± 3 mmHg, p < 0.0001, PASP/VTIRVOT: 2.5 ± 1.4 to 1.1 ± 0.7, p < 0.0001 PAcT: 61 ± 2.5 to 84.7 ± 2.4 ms, p < 0.0001), associated with RV systolic function improvement (RVEF: 36.5 ± 2.9% to 46.6 ± 2.1%, p = 0.001 and RV-LS: - 13.6 ± 0.7% to - 16.7 ± 0.8%, p = 0.001). In addition, RV dilation subsided in survivors (RVEDA/LVEDA: 0.8 ± 0.05 to 0.6 ± 0.03, p = 0.001). Day-10 CRS correlated with RV afterload (PASP/VTIRVOT, r: 0.535, p < 0.0001) and systolic function (RV-LS, 0.345, p = 0.001). LV-LS during the 10th ICU-day, while ΔRV-LS and ΔPASP/RVOTVTI were associated with survival. CONCLUSIONS: COVID-19 improvements in RV function, RV afterload and RV-PA coupling at day 10 were associated with respiratory function and survival.

Colistin Effects on Emphysematous Lung in an LPS-Sepsis Model.

Emphysema is prevalent in various respiratory diseases like Chronic Obstructive Pulmonary Disease (COPD) and cystic fibrosis. Colistin and vasoconstrictive drugs are crucial for treating these patients when diagnosed with sepsis in the ICU. This study examines colistin impact in ether-induced emphysematous septic and non-septic animals, focusing on lung pathophysiology and inflammatory responses, including IL-1ß, TNF-α, AMPK, caspase-3, cyclin-D1, and colistin levels in lung tissue. All animals exhibited significant emphysematous changes, accentuated by LPS-induced septic conditions, validating the emphysema model and highlighting the exacerbating effect of sepsis on lung pathology. Colistin, alone or with vasoconstrictive drugs, stimulated immune responses through increased inflammatory cell infiltration and the presence of lymphocytes, indicating potential immunomodulatory effects. Vasoconstriction did not alter the effects of colistin or sepsis but correlated with increased colistin levels in the lungs of septic animals. These observations suggest a potential interplay between vasoconstrictive drugs and colistin distribution/metabolism, leading to enhanced local concentrations of colistin in the lung microenvironment. The findings suggest the need for further investigations to optimize colistin and vasoconstrictive drug delivery in critically ill patients with lung pathologies. Understanding these complexities may guide more effective management of inflammatory responses and lung pathologies in these critical conditions.

New-Onset Atrial Fibrillation in the Critically Ill COVID-19 Patients Hospitalized in the Intensive Care Unit.

New-onset atrial fibrillation (NOAF) is the most frequently encountered cardiac arrhythmia observed in patients with COVID-19 infection, particularly in Intensive Care Unit (ICU) patients. The purpose of the present review is to delve into the occurrence of NOAF in COVID-19 and thoroughly review recent, pertinent data. However, the causality behind this connection has yet to be thoroughly explored. The proposed mechanisms that could contribute to the development of AF in these patients include myocardial damage resulting from direct virus-induced cardiac injury, potentially leading to perimyocarditis; a cytokine crisis and heightened inflammatory response; hypoxemia due to acute respiratory distress; disturbances in acid-base and electrolyte levels; as well as the frequent use of adrenergic drugs in critically ill patients. Additionally, secondary bacterial sepsis and septic shock have been suggested as primary causes of NOAF in ICU patients. This notion gains strength from the observation of a similar prevalence of NOAF in septic non-COVID ICU patients with ARDS. It is plausible that both myocardial involvement from SARS-CoV-2 and secondary sepsis play pivotal roles in the onset of arrhythmia in ICU patients. Nonetheless, there exists a significant variation in the prevalence of NOAF among studies focused on severe COVID-19 cases with ARDS. This discrepancy could be attributed to the inclusion of mixed populations with varying degrees of illness severity, encompassing not only patients in general wards but also those admitted to the ICU, whether intubated or not. Furthermore, the occurrence of NOAF is linked to increased morbidity and mortality. However, it remains to be determined whether NOAF independently influences outcomes in critically ill COVID-19 ICU patients or if it merely reflects the disease's severity. Lastly, the management of NOAF in these patients has not been extensively studied. Nevertheless, the current guidelines for NOAF in non-COVID ICU patients appear to be effective, while accounting for the specific drugs used in COVID-19 treatment that may prolong the QT interval (although drugs like lopinavir/ritonavir, hydrochlorothiazide, and azithromycin have been discontinued) or induce bradycardia (e.g., remdesivir).

Pleural Fluid-to-Blood BNP Ratio May Contribute to Prognosis in Malignant Pleural Mesothelioma.

BACKGROUND: Brain natriuretic peptide (BNP) seems to be produced from malignant mesothelial cells other than cardiomyocytes. We aimed to evaluate whether an increased pleural fluid-to-blood BNP ratio in patients with malignant pleural mesothelioma (MPM) could facilitate prognosis beyond diagnosis. MATERIALS AND METHODS: Patients with MPM were included (observational study). One- and two-year survival and factors affecting it were tested. To evaluate the prognostic significance of the natriuretic peptide precursor B (NPPB) gene expression in MPM, we constructed a survival curve from data derived from The Cancer Genome Atlas. RESULTS: Nineteen consecutive patients with MPM were included (age: 67 (61, 80), male 78.9%). One- and two-year survival were 52.6% and 31.6%, respectively. Age, performance status, and the other variables tested did not differ between survivors and non-survivors. Non-survivors presented higher pleural fluid BNP in two years (699 (210, 5000) vs. 379.5 (5, 567), p = 0.036) and BNP ratios than survivors (1-year: 28.75 (4.05, 150.24) vs. 3.49 (0.3, 26) p = 0.001, 2-years: 22.8 (2.42, 150.24) vs. 3.49 (0.3, 7.76), p = 0.001). One- and two-year survival rates in patients with BNP ratios above/equal to the median value (8.82) were 20% and 0%, and 88.9% and 66.7%, respectively, in patients with BNP ratios below 8.82 (p = 0.006 and p = 0.002, respectively). MPM patients with low NPPB expression presented significantly higher survival rates compared to patients with higher expressions (p = 0.032). CONCLUSION: A high pleural fluid/blood BNP ratio, an easily performed in everyday practice, costless biomarker seems to predict poorer survival better than the commonly reported prognostic factors in MPM.

Metabolic Syndrome and Atrial Fibrillation: Different Entities or Combined Disorders.

Obesity, hypertension, insulin resistance, and dyslipidemia are all clusters of an entity called "Metabolic Syndrome". The global trends of this syndrome's incidence/prevalence continue to increase reciprocally, converting it into a massive epidemic problem in the medical community. Observing the risk factors of atrial fibrillation, a medical condition that is also converted to a scourge, almost all parts of the metabolic syndrome are encountered. In addition, several studies demonstrated a robust correlation between metabolic syndrome and the occurrence of atrial fibrillation. For atrial fibrillation to develop, a combination of the appropriate substrate and a trigger point is necessary. The metabolic syndrome affects the left atrium in a multifactorial way, leading to atrial remodeling, thus providing both the substrate and provoking the trigger needed, which possibly plays a substantial role in the progression of atrial fibrillation. Due to the remodeling, treatment of atrial fibrillation may culminate in pernicious sequelae, such as repeated catheter ablation procedures. A holistic approach of the patient, with simultaneous treatment of both entities, is suggested in order to ensure better outcomes for the patients.

Risk Factors for Weaning Failure in COVID-19 Patients.

Background: Data on risk factors associated with mechanical ventilation (MV) weaning failure among SARS-CoV2 ARDS patients is limited. We aimed to determine clinical characteristics associated with weaning outcome in SARS-CoV2 ARDS patients under MV. Objectives: To determine potential risk factors for weaning outcome in patients with SARS-CoV2 ARDS. Methods: A retrospective observational study was conducted in the ICUs of four Greek hospitals via review of the electronic medical record for the period 2020-2021. All consecutive adult patients were screened and were included if they fulfilled the following criteria: a) age equal or above 18 years, b) need for MV for more than 48 hours and c) diagnosis of ARDS due to SARS-CoV2 pneumonia or primary or secondary ARDS of other aetiologies. Patient demographic and clinical characteristics were recorded for the first 28 days following ICU admission. The primary outcome was weaning success defined as spontaneous ventilation for more than 48 hours. Results: A hundred and fifty eight patients were included; 96 SARS-CoV2 ARDS patients. SOFA score, Chronic Obstructive Pulmonary Disease (COPD) and shock were independently associated with the weaning outcome OR(95% CI), 0.86 (0.73-0.99), 0.27 (0.08-0.89) and 0.30 (0.14-0.61), respectively]. When we analysed data from SARS-CoV2 ARDS patients separately, COPD [0.18 (0.03-0.96)] and shock [0.33(0.12 - 0.86)] were independently associated with the weaning outcome. Conclusions: The presence of COPD and shock are potential risk factors for adverse weaning outcome in SARS-CoV2 ARDS patients.

Levosimendan in the Treatment of Patients with Severe Septic Cardiomyopathy.

(1) Background: The optimal treatment of septic cardiomyopathy (SCM) remains questionable. The aim of the study was to compare the treatment of SCM based on levosimendan versus the best available therapy. (2) Methods: We conducted an observational study including patients with severe septic cardiomyopathy and circulatory failure. (3) Results: Fourteen patients (61%) received levosimendan, and nine received other treatments. The patients in the levosimendan group were more severely ill [APACHE II: 23.5 (14, 37) vs. 14 (13, 28), respectively, p = 0.012], and there was a trend for more decompensated LV function depicted by the LVEF [15% (10, 20) vs. 25% (5, 30), respectively, p = 0.061]. However, they presented a significantly higher increase in LVEF after seven days [15% (10, 20) to 50% (30, 68) (p < 0.0001) vs. 25% (5, 30) to 25% (15, 50) (p = 0.309), and a significantly higher decrease in lactate levels during the first 24 h [4.5 (2.5, 14.4) to 2.85 (1.2, 15), p = 0.036 vs. 2.9 (2, 18.9) to 2.8 (1, 15), p = 0.536]. Seven-day survival (64.3% vs. 33.3%, p = 0.424) and ICU survival (50% vs. 22.2%, p = 0.172) were higher in the first group, although differences did not reach statistical significance. The degree of left ventricular impairment and the magnitude of EF improvement by the seventh-day post-SCM onset were associated with mortality in regression analysis. (4) Conclusions: Our study presents main hemodynamic data supporting the possible efficacy of levosimendan treatment in patients with severe SCM.

Quality of Life and Family Support in Critically Ill Patients following ICU Discharge.

BACKGROUND: Following discharge from the intensive care unit (ICU), critically ill patients may present cognitive dysfunction and physical disability. OBJECTIVES: To investigate the quality of life (QoL) of patients following discharge from ICU, physical performance and lung function and to assess the role of support by family members and friends. METHODS: This prospective study was conducted in the University Hospital of Larissa Greece between 2020 and 2021. Patients hospitalized at the ICU for at least 48 h were included and assessed at hospital discharge, at 3 and at 12 months later. The research implements of the study were a dedicated questionnaire and the SF-36 health questionnaire for the appraisal of the QoL. Lung function changes were assessed by spirometry and physical performance by the 6-min walking test (6MWT). RESULTS: One hundred and forty-three participants were included in the study. The mean (SD) of the physical and mental health SF-36 scores at hospital discharge, 3 and 12 months were 27.32 (19.59), 40.97 (26.34) and 50.78 (28.26) (p < 0.0001) and 42.93 (17.00), 55.19 (23.04) and 62.24 (23.66), (p < 0.0001), respectively. The forced expiratory volume in one second and 6MWT significantly improved over 12 months. Patients who were supported by two or more family members or patients who were visited by their friends >3 times/week presented better scores in the physical and mental SF36 domains at 12 months. CONCLUSION: This study shows that the quality of life of Greek patients who were discharged from the ICU can be positively affected both by the support they receive from their family environment and friends.

The Impact of the COVID-19 Pandemic on Mental Health and Quality of Life in COVID-19 Department Healthcare Workers in Central Greece.

BACKGROUND: The pandemic crisis created conditions of insecurity and threat and brought about changes in social contacts and everyday life. Frontline healthcare workers (HCW) were mostly affected. We aimed to evaluate the quality of life and negative emotions in COVID-19 HCW and searched for factors influencing the above. METHODS: The present study was conducted among three different academic hospitals in central Greece (04/2020-03/2021). Demographics, attitude towards COVID-19, quality of life, depression, anxiety, stress (using the WHOQOL-BREF and DASS21 questionnaire) and the fear of COVID-19 were assessed. Factors affecting the reported quality of life were also assessed. RESULTS: The study involved 170 HCW in COVID-19 dedicated departments. Moderate levels of quality of life (62.4%), satisfaction with social relations (42.4%), working environment (55.9%) and mental health (59.4%) were reported. Stress was present in 30.6% of HCW; 20.6% reported fear for COVID-19, depression (10.6%) and anxiety (8.2%). HCW in the tertiary hospital were more satisfied with social relations and working environment and had less anxiety. Personal Protective Equipment (PPE) availability affected the quality of life, satisfaction in the work environment and the presence of anxiety and stress. Feeling safe during work influenced social relations and fear of COVID-19 Conclusion: The HCW quality of life is affected in the pandemic. Feelings of safety during work related to the reported quality of life.

Relationship Between Intra-Abdominal pressure and microaspiration of gastric contents in critically ill mechanically ventilated patients.

The relationship between increased intra-abdominal pressure (IAP) and microaspiration of oro-gastric content in mechanically-ventilated patients has not yet been established. Microaspiration is proposed as one of the causes of ventilator-associated pneumonia (VAP). We aimed to investigate whether mechanically-ventilated patients with increased IAP present evidence of lung microaspiration by assessing pepsin levels in bronchial secretions and evaluated the relationship between pepsin and VAP. 68 mechanically-ventilated patients and 10 control subjects were recruited from an academic ICU in Greece. IAP, pH, pepsin and total protein levels, in bronchial secretions, were assessed within 14 days. Patients underwent assessment for timely VAP diagnosis based on clinical, radiological and laboratory criteria. Pepsin and total protein levels were significantly elevated in patients compared to controls. Pepsin values correlated significantly with IAP (r = 0.61, ***p < 0.001). Multivariate regression analysis showed that IAP was an independent risk factor for increased pepsin values in bronchial secretions [OR95%CI 1.463(1.061-1.620), *p = 0.014]. Pepsin values were higher in patients with VAP, while IAP was independently associated with VAP. There was an indication towards increased VAP in patients with increased pepsin. In conclusion, our results show that pepsin in bronchial secretions may be elevated when IAP is increased, indicating microaspiration and potentially VAP.

The Role of Left Ventricular Ejection Fraction and Left Ventricular Outflow Tract Velocity-Time Integral in Assessing Cardiovascular Impairment in Septic Shock.

Background: the role of echocardiography in septic shock remains controversial, since depressed cardiac afterload may overestimate left ventricular (LV) systolic performance and mask septic cardiomyopathy (SC). We hypothesized that afterload-adjusted LV ejection fraction (LVEF) and LV outflow tract velocity-time integral (VTI) values for given systemic vascular resistances (SVR) could provide novel insights into recognizing and stratifying the severity of SC. Methods: in this observational, monocentric study, we prospectively included 14 mechanically-ventilated patients under septic-shock who all had a Pulse index Continuous Cardiac Output (PiCCO) system in place for hemodynamic monitoring. Echocardiographic and PiCCO longitudinal examinations (71 measurements overall) were performed simultaneously at the onset of septic shock and every 12 h for 60 h overall. Results: VTI-derived stroke volume (SV) and cardiac output (CO) were significantly correlated with PiCCO measurements (r ≥ 0.993, both p < 0.001). LVEF and VTI showed linear and exponential inverse correlation to SVR (R2 = 0.183 vs. 0.507 and p < 0.001 vs. p < 0.001, respectively). The equations LVEF = 86.168 − 0.011 × SVR and VTI = 41.23 × e(−0.0005×SVR) were found to provide "predicted" values for given SVR. Measured to predicted LVEF ratios (for given SVR), the afterload-adjusted LVEF defined the severity of SC (mild ≥ 90%, 80% ≤ moderate < 90% and severe < 80%). Mild SC demonstrated normal/supra-normal LVEF, normal VTI and SVR. Moderate SC showed lower LVEF and SVR, yet increased LV end-diastolic volume (LVEDV), VTI, SV and CO compared with mild SC (all p < 0.05). Severe SC was distinguished from moderate SC by markedly reduced LVEF, LVEDV, VTI, SV, CO and significantly increased SVR (all p < 0.05). LVEF and VTI decreased over time in mild SC, LVEF decreased in moderate SC, and LVEF and VTI increased over time in severe SC (p ≤ 0.038). LVEF and VTI demonstrated significant performance in identifying severe SC [cut-off < 61.5%, area under the curve (AUC) = 1 ± 0.0, sensitivity/specificity = 100/100, p < 0.001 vs. cut-off < 17.9 cm, AUC = 0.882 ± 0.042, sensitivity/specificity = 80/77, p < 0.001, respectively]. VTI but not LVEF demonstrated significant diagnostic performance in identifying both SVR < 800 dynes·s·cm−5 and SVR > 1500 dynes·s·cm−5 (cut-off > 24.46 cm, AUC = 0.889 ± 0.049, sensitivity/specificity = 75/100, p < 0.001; cut-off < 16.8, AUC = 0.0.857 ± 0.082, sensitivity/specificity = 83/86, p = 0.002, respectively).Conclusions: our study suggests that ICU bedside echocardiographic assessment of LVEF, VTI and their adjusted to corresponding SVR values provides valuable insights for the comprehension of SC phenotypes, underlying vasoplegia and cardiac output fluctuations in septic shock.

Neuromuscular Blockade in the Pre- and COVID-19 ARDS Patients.

Acute respiratory distress syndrome (ARDS) accounts for a quarter of mechanically ventilated patients, while during the pandemic, it overwhelmed the capacity of intensive care units (ICUs). Lung protective ventilation (low tidal volume, positive-end expiratory pressure titrated to lung mechanics and oxygenation, permissive hypercapnia) is a non-pharmacological approach that is the gold standard of management. Among the pharmacological treatments, the use of neuromuscular blocking agents (NMBAs), although extensively studied, has not yet been well clarified. The rationale is to minimize the risk for lung damage progression, in the already-injured pulmonary parenchyma. By abolishing rigorous spontaneous efforts, NMBAs may decrease the generation of high transpulmonary pressures that could aggravate patients' self-inflicted lung injury. Moreover, NMBAs can harmonize the patient-ventilator interaction. Recent randomized controlled trials reported contradictory results and changed the clinical practice in a bidirectional way. NMBAs have not been documented to improve long-term survival; thus, the current guidance suggests their use only in patients in whom a lung protective ventilation protocol cannot be applied, due to asynchrony or increased respiratory efforts. In the present review, we discuss the published data and additionally the clinical practice in the "war" conditions of the COVID-19 pandemic, concerning NMBA use in the management of patients with ARDS.

Incidence and Risk Factors for Blood Stream Infection in Mechanically Ventilated COVID-19 Patients.

It is widely known that blood stream infections (BSIs) in critically ill patients may affect mortality, length of stay, or the duration of mechanical ventilation. There is scarce data regarding blood stream infections in mechanically ventilated COVID-19 patients. Preliminary studies report that the number of secondary infections in COVID-9 patients may be higher. This retrospective analysis was conducted to determine the incidence of BSI. Furthermore, risk factors, mortality, and other outcomes were analyzed. The setting was an Intensive Care Unit (ICU) at a University Hospital. Patients suffering from SARS-CoV-2 infection and requiring mechanical ventilation (MV) for >48 h were eligible. The characteristics of patients who presented BSI were compared with those of patients who did not present BSI. Eighty-four patients were included. The incidence of BSI was 57%. In most cases, multidrug-resistant pathogens were isolated. Dyslipidemia was more frequent in the BSI group (p < 0.05). Moreover, BSI-group patients had a longer ICU stay and a longer duration of both mechanical ventilation and sedation (p < 0.05). Deaths were not statistically different between the two groups (73% for BSI and 56% for the non-BSI group, p > 0.05). Compared with non-survivors, survivors had lower baseline APACHE II and SOFA scores, lower D-dimers levels, a higher baseline compliance of the respiratory system, and less frequent heart failure. They received anakinra less frequently and appropriate therapy more often (p < 0.05). The independent risk factor for mortality was the APACHE II score [1.232 (1.017 to 1.493), p = 0.033].

Rapidly improving acute respiratory distress syndrome in COVID-19: a multi-centre observational study.

BACKGROUND: Before the pandemic of coronavirus disease (COVID-19), rapidly improving acute respiratory distress syndrome (ARDS), mostly defined by early extubation, had been recognized as an increasingly prevalent subphenotype (making up 15-24% of all ARDS cases), associated with good prognosis (10% mortality in ARDSNet trials). We attempted to determine the prevalence and prognosis of rapidly improving ARDS and of persistent severe ARDS related to COVID-19. METHODS: We included consecutive patients with COVID-19 receiving invasive mechanical ventilation in three intensive care units (ICU) during the second pandemic wave in Greece. We defined rapidly improving ARDS as extubation or a partial pressure of arterial oxygen to fraction of inspired oxygen ratio (PaO2:FiO2) greater than 300 on the first day following intubation. We defined persistent severe ARDS as PaO2:FiO2 of equal to or less than 100 on the second day following intubation. RESULTS: A total of 280 intubated patients met criteria of ARDS with a median PaO2:FiO2 of 125.0 (interquartile range 93.0-161.0) on day of intubation, and overall ICU-mortality of 52.5% (ranging from 24.3 to 66.9% across the three participating sites). Prevalence of rapidly improving ARDS was 3.9% (11 of 280 patients); no extubation occurred on the first day following intubation. ICU-mortality of patients with rapidly improving ARDS was 54.5%. This low prevalence and high mortality rate of rapidly improving ARDS were consistent across participating sites. Prevalence of persistent severe ARDS was 12.1% and corresponding mortality was 82.4%. CONCLUSIONS: Rapidly improving ARDS was not prevalent and was not associated with good prognosis among patients with COVID-19. This is starkly different from what has been previously reported for patients with ARDS not related to COVID-19. Our results on both rapidly improving ARDS and persistent severe ARDS may contribute to our understanding of trajectory of ARDS and its association with prognosis in patients with COVID-19.