The effect of the severity COVID-19 infection on electrocardiography

ObjectiveAcute myocardial damage is detected in a significant portion of patients with coronavirus 2019 disease (COVID-19) infection, with a reported prevalence of 7–28%. The aim of this study was to investigate the relationship between electrocardiographic findings and the indicators of the severity of COVID-19 detected on electrocardiography (ECG).MethodsA total of 219 patients that were hospitalized due to COVID-19 between April 15 and May 5, 2020 were enrolled in this study. Patients were divided into two groups according to the severity of COVID-19 infection: severe (n = 95) and non-severe (n = 124). ECG findings at the time of admission were recorded for each patient. Clinical characteristics and laboratory findings were retrieved from electronic medical records.ResultsMean age was 65.2 ± 13.8 years in the severe group and was 57.9 ± 16.0 years in the non-severe group. ST depression (28% vs. 14%), T-wave inversion (29% vs. 16%), ST-T changes (36% vs. 21%), and the presence of fragmented QRS (fQRS) (17% vs. 7%) were more frequent in the severe group compared to the non-severe group. Multivariate analysis revealed that hypertension (odds ratio [OR]: 2.42, 95% confidence interval [CI]:1.03–5.67; p = 0.041), the severity of COVID-19 infection (OR: 1.87, 95% CI: 1.09–2.65; p = 0.026), presence of cardiac injury (OR: 3.32, 95% CI: 1.45–7.60; p = 0.004), and d-dimer (OR: 3.60, 95% CI: 1.29–10.06; p = 0.014) were independent predictors of ST-T changes on ECG.ConclusionST depression, T-wave inversion, ST-T changes, and the presence of fQRS on admission ECG are closely associated with the severity of COVID-19 infection.     

Cardiac injury is associated with mortality and critically ill pneumonia in COVID-19: A meta-analysis

BackgroundIn this systematic review and meta-analysis, we aimed to explore the association between cardiac injury and mortality, the need for intensive care unit (ICU) care, acute respiratory distress syndrome (ARDS), and severe coronavirus disease 2019 (COVID-19) in patients with COVID-19 pneumonia.MethodsWe performed a comprehensive literature search from several databases. Definition of cardiac injury follows that of the included studies, which includes highly sensitive cardiac troponin I (hs-cTnl) >99th percentile.The primary outcome was mortality, and the secondary outcomes were ARDS, the need for ICU care, and severe COVID-19. ARDS and severe COVID-19 were defined per the World Health Organization (WHO) interim guidance of severe acute respiratory infection (SARI) of COVID-19.ResultsThere were a total of 2389 patients from 13 studies. This meta-analysis showed that cardiac injury was associated with higher mortality (RR 7.95 [5.12, 12.34], p < 0.001; I²: 65%). Cardiac injury was associated with higher need for ICU care (RR 7.94 [1.51, 41.78], p = 0.01; I²: 79%), and severe COVID-19 (RR 13.81 [5.52, 34.52], p < 0.001; I²: 0%). The cardiac injury was not significant for increased risk of ARDS (RR 2.57 [0.96, 6.85], p = 0.06; I²: 84%). The level of hs-cTnI was higher in patients with primary + secondary outcome (mean difference 10.38 pg/mL [4.44, 16.32], p = 0.002; I²: 0%).ConclusionCardiac injury is associated with mortality, need for ICU care, and severity of disease in patients with COVID-19.     

Impact of chronic liver disease in intensive care unit acquired pneumonia: a prospective study

Purpose

To assess the impact of chronic liver disease (CLD) on ICU-acquired pneumonia.

Methods

This was a prospective, observational study of the characteristics, microbiology, and outcomes of 343 consecutive patients with ICU-acquired pneumonia clustered according to the presence of CLD.

Results

Sixty-seven (20 %) patients had CLD (67 % had liver cirrhosis, LC), MELD score 26 ± 9, 20 % Child–Pugh class C). They presented higher severity scores than patients without CLD both on admission to the ICU (APACHE II, LC 19 ± 6 vs. other CLD 18 ± 6 vs. no CLD 16 ± 6; p < 0.001; SOFA, 10 ± 3 vs. 8 ± 4 vs. 7 ± 3; p < 0.001) and at onset of pneumonia (APACHE II, 19 ± 6 vs. 17 ± 6 vs. 16 ± 5; p = 0.001; SOFA, 11 ± 4 vs. 9 ± 4 vs. 7 ± 3; p < 0.001). Levels of CRP were lower in patients with LC than in the other two groups (day 1, 6.5 [2.5–11.5] vs. 13 [6–23] vs. 15.5 [8–24], p < 0.001, day 3, 6 [3–12] vs. 16 [9–21] vs. 11 [5–20], p = 0.001); all the other biomarkers were higher in LC and other CLD patients. LC patients had higher 28- and 90-day mortality (63 vs. 28 %, p < 0.001; 72 vs. 38 %, p < 0.001, respectively) than non-CLD patients. Presence of LC was independently associated with decreased 28- and 90-day survival (95 % confidence interval [CI], 1.982–17.250; p = 0.001; 95 % confidence interval [CI], 2.915–20.699, p = 0.001, respectively).

Conclusions

In critically ill patients with ICU-acquired pneumonia, CLD is associated with a more severe clinical presentation and poor clinical outcomes. Moreover, LC is independently associated with 28- and 90-day mortality. The results of this study are important for future trials focused on mortality.     

QRS duration predicts outcomes in cardiac arrest survivors undergoing therapeutic hypothermia

BackgroundWhether the electrocardiography (ECG) serial changes predict outcomes in cardiac arrest survivors undergoing therapeutic hypothermia remains unclear.Methods and resultsThis retrospective observational study enrolled 366 adult nontraumatic cardiac arrest survivors who underwent therapeutic hypothermia in a tertiary transfer center during 2006–2018. The ECG at return of spontaneous circulation (ROSC), during hypothermia and after rewarming were analyzed. 295 cardiac arrest survivors were included. Compared with the survivors, the non-survivors had longer QRS durations at the ROSC (118.33 ± 32.47 ms vs 106.88 ± 29.78 ms, p < 0.001) and after rewarming (99.26 ± 25.07 ms vs 93.03 ± 19.09 ms, p = 0.008). The enrolled patients were classified into 4 groups based on QRS duration at the ROSC and after rewarming, namely (1) narrow–narrow (narrow QRS at ROSC and narrow QRS after rewarming, n = 156), (2) narrow–wide (n = 29), (3) wide–narrow (n = 87), and (4) wide–wide (n = 23) group. The wide–wide group had the worst survival rates [odds ratio (OR) = 0.141, p = 0.001], followed by the narrow–wide group (OR 0.223, p = 0.003) and the wide–narrow group (OR 0.389, p = 0.003).ConclusionsIn cardiac arrest survivors given therapeutic hypothermia, QRS durations at the ROSC, after rewarming and their changes may predict survival to hospital discharge.     

Effect of heart failure on the outcome of COVID-19 — A meta analysis and systematic review

BackgroundSeveral comorbidities have been associated with an increased risk of severity and mortality in coronavirus disease 2019 (COVID-19), including hypertension, diabetes, cerebrovascular disease, chronic kidney disease, and chronic obstructive pulmonary disease.PurposeIn this systematic review and meta-analysis, we attempted to investigate the association between heart failure (HF) and poor outcome in patients with COVID-19.MethodsWe performed a systematic literature search from PubMed, EuropePMC, SCOPUS, Cochrane Central Database, and medRxiv with the search terms, “Heart failure” and “COVID-19”. The outcome of interest was mortality and poor prognosis (defined by incidence of severe COVID-19 infection, admission to ICU, and use of ventilator) in patients with preexisting heart failure with coronavirus disease.ResultsWe identified 204 potential articles from our search, and 22 duplicates were removed. After screening of the titles and abstracts of the remaining 182 articles we identified 92 potentially relevant articles. We excluded 74 studies due to the following reasons: four studies were systematic reviews, two studies were meta-analyses, three articles were literature reviews, and 65 articles did not report on the outcome of interest. Finally, we included the remaining 18 studies in our qualitative synthesis and meta-analysis. There were 21,640 patients from 18 studies. HF was associated with hospitalization in COVID19 HR was 2.37 [1.48, 3.79; p < 0.001], high heterogeneity [I², 82%; p < 0.001]. HF was associated with a poor outcome demonstrated by an OR of 2.86 [2.07; 3.95; p < 0.001] high heterogeneity [I², 80%; p < 0.001]. Patient with preexisting HF was associated with higher mortality OR of 3.46 [2.52, 4.75; p < 0.001] moderately high heterogeneity [I², 77%; p < 0.001].ConclusionPatients with heart failure are at increased risk for hospitalization, poor outcome, and death from COVID-19. A significant difference in mortality between patients with and without heart failure was observed, patients with heart failure having a higher mortality.     

Clinical and Cancer-Related Predictors for Venous Thromboembolism in Cancer Patients Presenting to the Emergency Department

BackgroundThe accurate detection of cancer-associated venous thromboembolism (VTE) can avoid unnecessary diagnostic imaging or laboratory tests.ObjectiveWe sought to determine clinical and cancer-related risk factors of VTE that can be used as predictors for oncology patients presenting to the emergency department (ED) with suspected VTE.MethodsWe retrospectively analyzed all consecutive patients who presented with suspicion of VTE to The University of Texas MD Anderson Cancer Center ED between January 1, 2009, and January 1, 2013. Logistic regression models were used to identify risk factors that were associated with VTE. The ability of these factors to predict VTE was externally validated using a second cohort of patients who presented to King Hussein Cancer Center ED between January 1, 2009, and January 1, 2016.ResultsCancer-related covariates associated with the occurrence of VTE were high-risk cancer type (odds ratio [OR] 3.64 [95% confidence interval {CI} 2.37–5.60], p < 0.001), presentation within 6 months of the cancer diagnosis (OR 1.92 [95% CI 1.62–2.28], p < 0.001), active cancer (OR 1.35 [95% CI 1.10–1.65], p = 0.003), advanced stage (OR 1.40 [95% CI 1.01–1.94], p = 0.044), and the presence of brain metastasis (OR 1.73 [95% CI 1.32–2.27], p < 0.001). When combined, these factors along with other clinical factors showed high prediction performance for VTE in the external validation cohort.ConclusionsCancer risk group, presentation within 6 months of cancer diagnosis, active and advanced cancer, and the presence of brain metastases along with other related clinical factors can be used to predict VTE in patients with cancer presenting to the ED.     

Examining emergency medical services' prehospital transport times for trauma patients during COVID-19

IntroductionLonger prehospital times were associated with increased odds for survival in trauma patients. The purpose of this study was to determine how the COVID-19 pandemic affected emergency medical services (EMS) prehospital times for trauma patients.MethodsThis retrospective cohort study compared trauma patients transported via EMS to six US level I trauma centers admitted 1/1/19–12/31/19 (2019) and 3/16/20–6/30/20 (COVID-19). Outcomes included: total EMS pre-hospital time (dispatch to hospital arrival), injury to dispatch time, response time (dispatch to scene arrival), on-scene time (scene arrival to scene departure), and transportation time (scene departure to hospital arrival). Fisher's exact, chi-squared, or Kruskal-Wallis tests were used, alpha = 0.05. All times are presented as median (IQR) minutes.ResultsThere were 9400 trauma patients transported by EMS: 79% in 2019 and 21% during the COVID-19 pandemic. Patients were similar in demographics and transportation mode. Emergency room deaths were also similar between 2019 and COVID-19 [0.6% vs. 0.9%, p = 0.13].There were no differences between 2019 and during COVID-19 for total EMS prehospital time [44 (33, 63) vs. 43 (33, 62), p = 0.12], time from injury to dispatch [16 (6, 55) vs. 16 (7, 77), p = 0.41], response time [7 (5, 12) for both groups, p = 0.27], or on-scene time [16 (12−22) vs. 17 (12,22), p = 0.31]. Compared to 2019, transportation time was significantly shorter during COVID-19 [18 (13, 28) vs. 17 (12, 26), p = 0.01].ConclusionThe median transportation time for trauma patients was marginally significantly shorter during COVID-19; otherwise, EMS prehospital times were not significantly affected by the COVID-19 pandemic.     

Symptomatic but not Asymptomatic COVID-19 Impairs Conditioned Pain Modulation in Young Adults

Pain is a common symptom reported in COVID-19 patients. Impaired endogenous pain-modulatory mechanisms such as conditioned pain modulation (CPM), and exercise-induced hypoalgesia (EIH) have been found in chronic pain conditions but is often overlooked in acute conditions that evoke painful symptoms, such as COVID-19. The purpose was to compare pressure-pain sensitivity, CPM, and EIH function among individuals who previously had COVID-19, both symptomatically and asymptomatically, and a healthy control group. Pressure pain thresholds of 59 participants were assessed in the forearm and leg using a pressure algometer before and after 1) submersion of their dominant foot in cold water (2°C) for 1min; and 2) isometric knee extension performed to task-failure at 25% of their maximal contraction. The CPM response was attenuated in individuals who were infected with symptomatic COVID-19 (N = 26) compared to asymptomatic COVID-19 (N = 13) in arm (-1.0% ± 20.3 vs 33.3% ± 26.2; P < .001) and leg (12.8% ± 22.0 vs 33.8% ± 28.2; P = .014) and compared to controls (N = 20) in arm only (-1.0% ± 26.2 vs 23.4% ± 28.2; P = .004). The EIH response was not different between groups. CPM was impaired in individuals who had symptomatic COVID-19, which may have long-term implications on pain modulation.PerspectiveThis study reveals that CPM was impaired in individuals who had symptomatic COVID-19 during the first wave of COVID-19, pre vaccine. These findings present a preliminary motive to study the long-term implications of COVID-19 and its effects on pain modulation.     

Wearing a N95 mask increases rescuer's fatigue and decreases chest compression quality in simulated cardiopulmonary resuscitation

ObjectivesN95 mask is essential for healthcare workers dealing with the coronavirus disease 2019 (COVID-19). However, N95 mask causes discomfort breathing with marked reduction in air exchange. This study was designed to investigate whether the use of N95 mask affects rescuer's fatigue and chest compression quality during cardiopulmonary resuscitation (CPR).MethodsAfter a brief review of CPR, each participant performed a 2-minute continuous chest compression on a manikin wearing N95 (N95 group, n = 40) or surgical mask (SM group, n = 40). Compression rate and depth, the proportions of correct compression rate, depth, complete chest recoil and hand position were documented. Participants' fatigue was assessed using Borg score.ResultsSignificantly lower mean chest compression rate and depth were both achieved in the N95 group than in the SM group (p < 0.05, respectively). In addition, the proportion of correct compression rate (61 ± 19 vs. 75 ± 195, p = 0.0067), depth (67 ± 16 vs. 90 ± 14, p < 0.0001) and complete recoil (91 ± 16 vs. 98 ± 5%, p = 0.0248) were significantly decreased in the N95 group as compared to the SM group. At the end of compression, the Borg score in the N95 group was significantly higher than that in the SM group (p = 0.027).ConclusionWearing a N95 mask increases rescuer's fatigue and decreases chest compression quality during CPR. Therefore, the exchange of rescuers during CPR should be more frequent than that recommended in current guidelines when N95 masks are applied.     

Gender distribution of editorial board members in critical care journals: Assessment of gender parity

PurposeTo reveal factors related to gender parity on editorial boards of critical care journals indexing in SCI-E.MethodsThe genders were defined according to data obtained from journals' websites between 01—30 September 2022. Publisher properties and journal metrics were analyzed by using Chi-square, Fisher exact, Mann–Whitney U tests, and Spearman's correlation coefficient. Logistic regression analysis was used to reveal independent factors.ResultsWomen's representation on editorial boards was 23.6%. The USA (OR, 0.04, 95% CI, 0.01–0.15, p < 0.001) and Netherlands (OR, 0.04, 95% CI, 0.01–0.16, p < 0.001) as publisher's countries, an IF >5 (OR, 0.25, 95% CI, 0.17–0.38, p < 0.001), publication duration <30 years (OR, 0.09, 95% CI, 0.06–0.12, p < 0.001), multidisciplinary perspective of editorial policy (OR, 0.46, 95% CI, 0.32–0.65, p < 0.001), journals categorized also in nursing (OR, 0.38, 95% CI, 0.22–0.66, p < 0.001), and being a section editor (OR, 0.49, 95% CI, 0.32–0.74, p = 0.001) were associated with gender parity. Europe as a journal continent (OR, 36.71, 95% CI, 8.39–160.53, p < 0.001) was related to gender disparity.ConclusionsFurther efforts are needed to expand diversity policies in critical care medicine.     

Comparative characteristics of the background and blood test findings in adults with pneumococcal pneumonia and invasive pneumococcal disease: A retrospective study

IntroductionInvasive pneumococcal disease (IPD) is often fatal, requiring prompt diagnosis and treatment. To evaluate the factors associated with IPD in adults, we retrospectively investigated its characteristics compared to pneumococcal pneumonia without confirmation of invasion (PP).MethodsPatients >18 years with PP (n = 79) and IPD (n = 53) from whom Streptococcus pneumoniae was isolated were enrolled from two hospitals between 2011 and 2017. Clinical backgrounds, blood test results at admission, initial antimicrobials administered, isolate serotypes, and outcomes were compared between the PP and IPD groups.ResultsPatients with IPD exhibited higher mortality (28.3%) than those with PP (2.5%) (p<0.001), regardless of the type of antimicrobials first administered. The majority (80.0%) of fatal cases of IPD were due to vaccine serotypes. Almost all patients with PP (97.4%) and IPD (88.7%) had underlying disease. C-reactive protein (CRP) ≥17.0 mg/dL (odds ratio [OR], 7.1; 95% CI, 2.7–19.0; p<0.001), white blood cell counts <11.0 × 10³/μL (OR, 3.2; 95% CI, 1.3–8.4; p = 0.016), and platelet (PLT) counts <16.2 × 10⁴/μL (OR, 2.8; 95% CI, 1.1–7.4; p = 0.036) were significantly more common in IPD. Moreover, 89.5% of cases with both CRP ≥23.8 mg/dL and PLT <18.5 × 10⁴/μL were diagnosed with IPD.ConclusionLaboratory blood test findings at admission, particularly high CRP and low PLT values, are useful early indicators of IPD in adults. These results could be used to initiate rapid and intensive treatment and improve prognosis.     

Effect of an emergency department intensive care unit on medical intensive unit admissions and care: A retrospective cohort study

ObjectiveEvaluate the impact of an emergency critical care center (EC3) on the admissions of critically ill patients to a critical care medicine unit (CCMU) and their outcomes.MethodsThis was a retrospective before/after cohort study in a tertiary university teaching hospital. To improve the care of critically ill patients in the emergency department (ED), a 9-bed EC3 was opened in the ED in February 2015. All critically ill patients in the emergency department must receive intensive support in EC3 before being considered for admission to the CCMU for further treatment. Patients from the emergency department account for a significant proportion of the patients admitted to the CCMU. The proportions of patients admitted to the CCMU from the ED were analyzed 1 year before and 1 year after the opening of the EC3. We also compared the admission data, demographic data, APACHE III scores and patient outcomes among patients admitted from ED to the CCMU in the year before and the year after the opening of the EC3.ResultThe establishment of the EC3 was associated with a decreased proportion of patients admitted to the CCMU from the ED (OR 0.73 95% CI 0.63–0.84, p < 0.01), a decrease in the proportion of patients with sepsis admitted from the ED (OR 0.68, 95% CI, 0.54–0.87, p < 0.01) and a decrease in the proportion of patients with gastrointestinal bleeding admitted from the ED (OR 0.49, 95% CI 0.28–0.84, p < 0.05). Following the establishment of the EC3, patients admitted to the CCMU had a higher APACHE III score in 2015 (74.85 ± 30.42 vs 72.39 ± 29.64, p = 0.015). Fewer low-risk patients were admitted to the CCMU for monitoring following the opening of the EC3 (112 [6.8%] vs. 181 [9.3%], p < 0.01). Propensity score matching analysis showed that the opening of the EC3 was associated with improved 60-day survival (HR 0.84, 95% CI 0.70–0.99, p = 0.046).ConclusionFollowing the opening of the EC3, the proportion of CCMU admissions from the ED decreased. The EC3 may be most effective at reducing the admission of lower-acuity patients with GI bleeding and possibly sepsis. The EC3 may be associated with improved survival in ED patients.     

Inflammatory and hematologic markers as predictors of severe outcomes in COVID-19 infection: A systematic review and meta-analysis

BackgroundLaboratory testing is commonly performed in patients with COVID-19. Each of the laboratory parameters has potential value for risk stratification and prediction of COVID-19 outcomes. This systematic review and meta-analysis aimed to evaluate the difference between these parameters in severe and nonsevere disease and to provide the optimal cutoff value for predicting severe disease.MethodWe performed a systematic literature search through electronic databases. The variables of interest were serum procalcitonin, albumin, C-reactive protein (CRP), D-dimer, and lactate dehydrogenase (LDH) levels in each group of severity outcomes from COVID-19.ResultsThere were a total of 4848 patients from 23 studies. Our meta-analysis suggest that patients with severe COVID-19 infections have higher procalcitonin, (mean difference 0.07; 95% CI 0.05–0.10; p < 0.00001), CRP (mean difference 36.88; 95% CI 29.10–44.65; p < 0.00001), D-Dimer (mean difference 0.43; 95% CI 0.31–0.56; p < 0.00001), and LDH (mean difference 102.79; 95% CI 79.10–126.49; p < 0.00001) but lower levels of albumin (mean difference −4.58; 95% CI −5.76 to −3.39; p < 0.00001) than those with nonsevere COVID-19 infections. The cutoff values for the parameters were 0.065 ng/mL for procalcitonin, 38.85 g/L for albumin, 33.55 mg/L for CRP, 0.635 μ/L for D-dimer, and 263.5 U/L for LDH, each with high sensitivity and specificity.ConclusionThis meta-analysis suggests elevated procalcitonin, CRP, D-dimer, and LDH and decreased albumin can be used for predicting severe outcomes in COVID-19.     

Impact in total ischemic time and ST-segment elevation myocardial infarction admissions during COVID-19

BackgroundDespite the COVID-19 pandemic, cardiovascular disease is still the main cause of death in developed countries. Of these deaths, acute coronary syndromes (ACS) account for a substantial percentage of deaths. Improvement in ACS outcomes, are achieved by reducing the time from symptom onset until reperfusion or total ischemic time (TIT). Nevertheless, due to the overwhelming reality at the beginning of the pandemic, acute coronary syndrome (ACS) care may have been compromised.ObjectivesWe evaluated delays in TIT based on the date and timing of admissions in patients with STEMI, by a timeline follow-up form, before and during the current COVID-19 pandemic.MethodsBetween July 2018 and June 2020, two hundred and twelve patients diagnosed with ST-segment elevation myocardial infarction (STEMI) were admitted to our medical center. Upon presentation, cases were assigned a timeline report sheet and each time interval, from onset of symptoms to the catheterization lab, was documented. The information was later evaluated to study potential excessive delays throughout ACS management.ResultsOur data evidenced that during the COVID-19 pandemic ACS admissions were reduced by 34.54%, in addition to several in-hospital delays in patient's ACS management including delays in door-to-ECG time (9.43 ± 18.21 vs. 18.41 ± 28.34, p = 0.029), ECG-to-balloon (58.25 ± 22.59 vs. 74.39 ± 50.30, p = 0.004) and door-to-balloon time (57.41 ± 27.52 vs. 69.31 ± 54.14, p = 0.04).ConclusionsDuring the pandemic a reduction in ACS admissions occurred in our hospital that accompanied with longer in-hospital TIT due to additional tests, triage, protocols to protect and prevent infection within hospital staff, and maintenance of adequate standards of care. However, door-to-balloon time was maintained under 90 min.     

Psychiatric patients' intensive care admission characteristics,weaning from mechanical ventilation and sedative drug use: A single center retrospective case-control study

PurposeTo describe the characteristics, treatment and outcome, in particular weaning from mechanical ventilation (MV), of critically ill Patients with prior psychiatric conditions (PPC).MethodsSingle center, 6-year, retrospective study comparing critically ill PPC to randomly sex and age matched cohort without PPC (1:1 ratio). Main outcome measure- adjusted mortality rates. Secondary outcome measures- unadjusted mortality, rates of MV, extubation failure and amount/dose of pre-extubation sedatives/analgesics.ResultsIncluded were 214 patients per group. PPC adjusted mortality rates were higher in the ICU (14.0% vs 4.7%; OR 3.058 [95%CI 1.380, 6.774]; p = 0.006) and in-hospital (26.6% vs 13.1%; OR 2.639 [95% CI 1.496, 4.655]; p = 0.001). PPC had higher MV rates (63.6% vs 51.4%; p = 0.011). These patients were more likely to have more than two weaning attempts (29.4% vs 10.9%; p < 0.001), more commonly treated with >2 sedative drugs in the 48-h pre-extubation (39.2% vs 23.3%; p = 0.026) and received more propofol in the 24-h pre-extubation. PPC were more likely to self-extubate (9.6% vs 0.9%; p = 0.004) and had lower likelihood of success in planned extubations (50.0% vs 76.4%; p < 0.001).ConclusionCritically ill PPC had higher mortality rates than their matched counterparts. They also had higher MV rates and were more difficult to wean.     

An analysis of the incidence of hypothermia in casualties presenting to emergency departments in Iraq and Afghanistan

IntroductionHypothermia on the battlefield has been shown to be associated with severe injury and higher mortality. The incidence of battlefield casualties presenting with hypothermia are described.MethodsThe Department of Defense Trauma Registry (DoDTR) was queried from January 2007 to August 2016. We identified casualties with a documented temperature of <32°Celsius (C) (severe), 32–33.9 °C (moderate), 34–36 °C (mild). We defined serious injuries as those resulting in an AIS of ≥3 by body region.ResultsThere were 25,484 records with at least one documented temperature and 2501 (9.8%) casualties with hypothermia within our range. Nineteen (0.75%) casualties presented with severe hypothermia, 225 (9%) with moderate, and 2257 (90%) with mild. The mean injury severity score (ISS) for non-hypothermic, mild, moderate, and severe hypothermic casualties was 8 [4–14], 14 [6–24], 21 [13–29], and 21 [9–25], (p <0.001), respectively. Survival for casualties with severe hypothermia was 57.8%, moderate 80.9%, mild hypothermia 90.9%, and non-hypothermic group 97.6%, p<0.001. When adjusting for composite injury score, patient category, mechanism of injury, and location, this finding remained significant (OR 0.27, 0.21–0.34, p<0.001). Massive transfusion was more common in hypothermia casualties n = 566 (19%) versus non-hypothermic recipients n = 1734 (6.9%), p <0.001.ConclusionsThough the number of casualties that presented hypothermic was small, their injuries were more severe, and were more likely to receive massive blood transfusions. This cohort also had a higher mortality rate, a finding which held when adjusting for confounders. There appears to be an opportunity to improve hypothermia prevention for combat.     

Association Between Clinical Manifestations and Prognosis in Patients with COVID-19

PurposeThe purpose of this study was to determine the risk factors associated with pneumonia, acute respiratory distress syndrome (ARDS), and clinical outcome among patients with novel coronavirus disease 2019 (COVID-19).MethodsThis was a cross-sectional multicenter clinical study. A total of 95 patients infected with COVID-19 were enrolled. The COVID-19 diagnostic standard was polymerase chain reaction detection of target genes of 2019 novel coronavirus (2019-nCoV). Clinical, laboratory, and radiologic results, as well as treatment outcome data, were obtained. ARDS was defined as an oxygenation index (arterial partial pressure of oxygen/fraction of inspired oxygen) ≤300 mm Hg.FindingsMultivariate analysis showed that older age (odds ratio [OR], 1.078; p = 0.008) and high body mass index (OR, 1.327; p = 0.024) were independent risk factors associated with patients with pneumonia. For patients with ARDS, multivariate analysis showed that only high systolic blood pressure (OR, 1.046; p = 0.025) and high lactate dehydrogenase level (OR, 1.010; p = 0.021) were independent risk factors associated with ARDS. A total of 70 patients underwent CT imaging repeatedly after treatment. Patients were divided in a disease exacerbation group (n = 19) and a disease relief group (n = 51). High body mass index (OR, 1.285; p = 0.017) and tobacco smoking (OR, 16.13; p = 0.032) were independent risk factors associated with disease exacerbation after treatment.ImplicationsThese study results help in the risk stratification of patients with 2019-nCoV infection. Patients with risk factors should be given timely intervention to avoid disease progression.     

Long-term physical impairments in survivors of COVID-19-associated ARDS compared with classic ARDS: A two-center study

PurposeThis work aimed to compare physical impairment in survivors of classic ARDS compared with COVID-19–associated ARDS (CARDS) survivors.Material and methodsThis is a prospective observational cohort study on 248 patients with CARDS and compared them with a historical cohort of 48 patients with classic ARDS. Physical performance was evaluated at 6 and 12 months after ICU discharge, using the Medical Research Council Scale (MRCss), 6-min walk test (6MWT), handgrip dynamometry (HGD), and fatigue severity score (FSS). We also assessed activities of daily living (ADLs) using the Barthel index.ResultsAt 6 months, patients with classic ARDS had lower HGD (estimated difference [ED]: 11.71 kg, p < 0.001; ED 31.9% of predicted value, p < 0.001), 6MWT distance (ED: 89.11 m, p < 0.001; ED 12.96% of predicted value, p = 0.032), and more frequent significant fatigue (OR 0.35, p = 0.046). At 12 months, patients with classic ARDS had lower HGD (ED: 9.08 kg, p = 0.0014; ED 25.9% of predicted value, p < 0.001) and no difference in terms of 6MWT and fatigue. At 12 months, patients with classic ARDS improved their MRCss (ED 2.50, p = 0.006) and HGD (ED: 4.13 kg, p = 0.002; ED 9.45% of predicted value, p = 0.005), while those with CARDS did not. Most patients in both groups regained independence in ADLs at 6 months.COVID-19 diagnosis was a significant independent predictor of better HGD (p < 0.0001) and 6MWT performance (p = 0.001), and lower prevalence of fatigue (p = 0.018).ConclusionsBoth classic ARDS and CARDS survivors experienced long-term impairments in physical functioning, confirming that post-intensive care syndrome remains a major legacy of critical illness. Surprisingly, however, persisting disability was more common in survivors of classic ARDS than in CARDS survivors. In fact, muscle strength measured with HGD was reduced in survivors of classic ARDS compared to CARDS patients at both 6 and 12 months. The 6MWT was reduced and fatigue was more common in classic ARDS compared to CARDS at 6 months but differences were no longer significant at 12 months. Most patients in both groups regained independent function in ADLs at 6 months.