Effects of intubation timing in patients with COVID-19 throughout the four waves of the pandemic : a matched analysis

The primary aim of our study was to investigate the association between intubation timing and hospital mortality in critically ill patients with COVID-19-associated respiratory failure. We also analysed both the impact of such timing throughout the first four pandemic waves and the influence of prior non-invasive respiratory support on outcomes. This is a secondary analysis of a multicentre, observational and prospective cohort study that included all consecutive patients undergoing invasive mechanical ventilation due to COVID-19 from across 58 Spanish intensive care units (ICU) participating in the CIBERESUCICOVID project. The study period was between 29 February 2020 and 31 August 2021. Early intubation was defined as that occurring within the first 24 h of intensive care unit (ICU) admission. Propensity score (PS) matching was used to achieve balance across baseline variables between the early intubation cohort and those patients who were intubated after the first 24 h of ICU admission. Differences in outcomes between early and delayed intubation were also assessed. We performed sensitivity analyses to consider a different timepoint (48 h from ICU admission) for early and delayed intubation. Of the 2725 patients who received invasive mechanical ventilation, a total of 614 matched patients were included in the analysis (307 for each group). In the unmatched population, there were no differences in mortality between the early and delayed groups. After PS matching, patients with delayed intubation presented higher hospital mortality (27.3% versus 37.1%, p =0.01), ICU mortality (25.7% versus 36.1%, p=0.007) and 90-day mortality (30.9% versus 40.2%, p=0.02) when compared to the early intubation group. Very similar findings were observed when we used a 48-hour timepoint for early or delayed intubation. The use of early intubation decreased after the first wave of the pandemic (72%, 49%, 46% and 45% in the first, second, third and fourth wave, respectively; first versus second, third and fourth waves p<0.001). In both the main and sensitivity analyses, hospital mortality was lower in patients receiving high-flow nasal cannula (n=294) who were intubated earlier. The subgroup of patients undergoing NIV (n=214) before intubation showed higher mortality when delayed intubation was set as that occurring after 48 h from ICU admission, but not when after 24 h. In patients with COVID-19 requiring invasive mechanical ventilation, delayed intubation was associated with a higher risk of hospital mortality. The use of early intubation significantly decreased throughout the course of the pandemic. Benefits of such an approach occurred more notably in patients who had received high-flow nasal cannul

Clustering COVID-19 ARDS patients through the first days of ICU admission. An analysis of the CIBERESUCICOVID Cohort

Background Acute respiratory distress syndrome (ARDS) can be classified into sub-phenotypes according to different inflammatory/clinical status. Prognostic enrichment was achieved by grouping patients into hypoinflammatory or hyperinflammatory sub-phenotypes, even though the time of analysis may change the classification according to treatment response or disease evolution. We aimed to evaluate when patients can be clustered in more than 1 group, and how they may change the clustering of patients using data of baseline or day 3, and the prognosis of patients according to their evolution by changing or not the cluster.Methods Multicenter, observational prospective, and retrospective study of patients admitted due to ARDS related to COVID-19 infection in Spain. Patients were grouped according to a clustering mixed-type data algorithm (k-prototypes) using continuous and categorical readily available variables at baseline and day 3.Results Of 6205 patients, 3743 (60%) were included in the study. According to silhouette analysis, patients were grouped in two clusters. At baseline, 1402 (37%) patients were included in cluster 1 and 2341(63%) in cluster 2. On day 3, 1557(42%) patients were included in cluster 1 and 2086 (57%) in cluster 2. The patients included in cluster 2 were older and more frequently hypertensive and had a higher prevalence of shock, organ dysfunction, inflammatory biomarkers, and worst respiratory indexes at both time points. The 90-day mortality was higher in cluster 2 at both clustering processes (43.8% [n = 1025] versus 27.3% [n = 383] at baseline, and 49% [n = 1023] versus 20.6% [n = 321] on day 3). Four hundred and fifty-eight (33%) patients clustered in the first group were clustered in the second group on day 3. In contrast, 638 (27%) patients clustered in the second group were clustered in the first group on day 3.Conclusions During the first days, patients can be clustered into two groups and the process of clustering patients may change as they continue to evolve. This means that despite a vast majority of patients remaining in the same cluster, a minority reaching 33% of patients analyzed may be re-categorized into different clusters based on their progress. Such changes can significantly impact their prognosis

The evolution of the ventilatory ratio is a prognostic factor in mechanically ventilated COVID-19 ARDS patients

Background: Mortality due to COVID-19 is high, especially in patients requiring mechanical ventilation. The purpose of the study is to investigate associations between mortality and variables measured during the first three days of mechanical ventilation in patients with COVID-19 intubated at ICU admission. Methods: Multicenter, observational, cohort study includes consecutive patients with COVID-19 admitted to 44 Spanish ICUs between February 25 and July 31, 2020, who required intubation at ICU admission and mechanical ventilation for more than three days. We collected demographic and clinical data prior to admission; information about clinical evolution at days 1 and 3 of mechanical ventilation; and outcomes. Results: Of the 2,095 patients with COVID-19 admitted to the ICU, 1,118 (53.3%) were intubated at day 1 and remained under mechanical ventilation at day three. From days 1 to 3, PaO2/FiO2 increased from 115.6 [80.0-171.2] to 180.0 [135.4-227.9] mmHg and the ventilatory ratio from 1.73 [1.33-2.25] to 1.96 [1.61-2.40]. In-hospital mortality was 38.7%. A higher increase between ICU admission and day 3 in the ventilatory ratio (OR 1.04 [CI 1.01-1.07], p = 0.030) and creatinine levels (OR 1.05 [CI 1.01-1.09], p = 0.005) and a lower increase in platelet counts (OR 0.96 [CI 0.93-1.00], p = 0.037) were independently associated with a higher risk of death. No association between mortality and the PaO2/FiO2 variation was observed (OR 0.99 [CI 0.95 to 1.02], p = 0.47). Conclusions: Higher ventilatory ratio and its increase at day 3 is associated with mortality in patients with COVID-19 receiving mechanical ventilation at ICU admission. No association was found in the PaO2/FiO2 variation

El làser i les obres d’art

El patrimoni cultural ha de ser analitzat, conservat, datat i catalogat. Però tot això només és possible portar-ho a terme, de forma seriosa i objectiva, si s’uneixen coneixements qualificats de diferents àmbits professionals

Protocol for regional implementation of community-based collaborative management of complex chronic patients

Supported by CONNECARE (H2020-PHC-2015, Grant no. 689802), PITES (FIS-PI15/00576), SELFIE (H2020, Grant no. 634288), and NEXTCARE (RIS3CAT), Generalitat de Catalunya (2014SGR661), and CERCA Programme / Generalitat de Cataluny

Protocol for regional implementation of community-based collaborative management of complex chronic patients

Over the last few years, the epidemics of noncommunicable diseases and the need for cost-containment1 are triggering factors for a profound transformation of the way we approach delivery of care for chronic patients. In this new scenario, conventional disease-oriented approaches, centered on the management of clinical episodes, are being replaced by patient-centered integrated care services,2 as promoted by the World Health Organization. Lessons learnt from deployment experiences4, 5 following patient-centered approaches are being disseminated as good practices.6 However, there are several factors that need further attention, such as the need for further assessment of implementation strategies in real-world scenarios and the lack of transferability from progress achieved in disease-oriented integrated care to management of complex chronic patients (CCP).5, 7 Likewise, efficacy achieved in integrated care interventions, assessed through randomized controlled trials, may not translate into effectiveness at health system level. In addition, poor comparability among experiences on management of multimorbidity emerges as an important hurdle for the adoption of integrated care. In this regard, the lack of an operational definition for CCP is not a negligible factor, as it clearly limits an appropriate service workflow design, which, in turn, precludes both evaluation and comparability of reported experiences

Protocol for regional implementation of community-based collaborative management of complex chronic patients

Over the last few years, the epidemics of noncommunicable diseases and the need for cost-containment1 are triggering factors for a profound transformation of the way we approach delivery of care for chronic patients. In this new scenario, conventional disease-oriented approaches, centered on the management of clinical episodes, are being replaced by patient-centered integrated care services,2 as promoted by the World Health Organization. Lessons learnt from deployment experiences4, 5 following patient-centered approaches are being disseminated as good practices.6 However, there are several factors that need further attention, such as the need for further assessment of implementation strategies in real-world scenarios and the lack of transferability from progress achieved in disease-oriented integrated care to management of complex chronic patients (CCP).5, 7 Likewise, efficacy achieved in integrated care interventions, assessed through randomized controlled trials, may not translate into effectiveness at health system level. In addition, poor comparability among experiences on management of multimorbidity emerges as an important hurdle for the adoption of integrated care. In this regard, the lack of an operational definition for CCP is not a negligible factor, as it clearly limits an appropriate service workflow design, which, in turn, precludes both evaluation and comparability of reported experiences