Sustained oxygenation improvement after first prone positioning is associated with liberation from mechanical ventilation and mortality in critically ill COVID-19 patients: a cohort study

none95noBackground: Prone positioning (PP) has been used to improve oxygenation in patients affected by the SARS-CoV-2 disease (COVID-19). Several mechanisms, including lung recruitment and better lung ventilation/perfusion matching, make a relevant rational for using PP. However, not all patients maintain the oxygenation improvement after returning to supine position. Nevertheless, no evidence exists that a sustained oxygenation response after PP is associated to outcome in mechanically ventilated COVID-19 patients. We analyzed data from 191 patients affected by COVID-19-related acute respiratory distress syndrome undergoing PP for clinical reasons. Clinical history, severity scores and respiratory mechanics were analyzed. Patients were classified as responders (≥ median PaO2/FiO2 variation) or non-responders (< median PaO2/FiO2 variation) based on the PaO2/FiO2 percentage change between pre-proning and 1 to 3 h after re-supination in the first prone positioning session. Differences among the groups in physiological variables, complication rates and outcome were evaluated. A competing risk regression analysis was conducted to evaluate if PaO2/FiO2 response after the first pronation cycle was associated to liberation from mechanical ventilation. Results: The median PaO2/FiO2 variation after the first PP cycle was 49 [19–100%] and no differences were found in demographics, comorbidities, ventilatory treatment and PaO2/FiO2 before PP between responders (96/191) and non-responders (95/191). Despite no differences in ICU length of stay, non-responders had a higher rate of tracheostomy (70.5% vs 47.9, P = 0.008) and mortality (53.7% vs 33.3%, P = 0.006), as compared to responders. Moreover, oxygenation response after the first PP was independently associated to liberation from mechanical ventilation at 28 days and was increasingly higher being higher the oxygenation response to PP. Conclusions: Sustained oxygenation improvement after first PP session is independently associated to improved survival and reduced duration of mechanical ventilation in critically ill COVID-19 patients.noneScaramuzzo G.; Gamberini L.; Tonetti T.; Zani G.; Ottaviani I.; Mazzoli C.A.; Capozzi C.; Giampalma E.; Bacchi Reggiani M.L.; Bertellini E.; Castelli A.; Cavalli I.; Colombo D.; Crimaldi F.; Damiani F.; Fusari M.; Gamberini E.; Gordini G.; Laici C.; Lanza M.C.; Leo M.; Marudi A.; Nardi G.; Papa R.; Potalivo A.; Russo E.; Taddei S.; Consales G.; Cappellini I.; Ranieri V.M.; Volta C.A.; Guerin C.; Spadaro S.; Tartaglione M.; Chiarini V.; Buldini V.; Coniglio C.; Moro F.; Barbalace C.; Citino M.; Cilloni N.; Giuntoli L.; Bellocchio A.; Matteo E.; Pizzilli G.; Siniscalchi A.; Tartivita C.; Matteo F.; Marchio A.; Bacchilega I.; Bernabe L.; Guarino S.; Mosconi E.; Bissoni L.; Viola L.; Meconi T.; Pavoni V.; Pagni A.; Pompa Cleta P.; Cavagnino M.; Malfatto A.; Adduci A.; Pareschi S.; Melegari G.; Maccieri J.; Marinangeli E.; Racca F.; Verri M.; Falo G.; Marangoni E.; Boni F.; Felloni G.; Baccarini F.D.; Terzitta M.; Maitan S.; Becherucci F.; Parise M.; Masoni F.; Imbriani M.; Orlandi P.; Monetti F.; Dalpiaz G.; Golfieri R.; Ciccarese F.; Poerio A.; Muratore F.; Ferrari F.; Mughetti M.; Franchini L.; Neziri E.; Miceli M.; Minguzzi M.T.; Mellini L.; Piciucchi S.; Bartolucci M.Scaramuzzo G.; Gamberini L.; Tonetti T.; Zani G.; Ottaviani I.; Mazzoli C.A.; Capozzi C.; Giampalma E.; Bacchi Reggiani M.L.; Bertellini E.; Castelli A.; Cavalli I.; Colombo D.; Crimaldi F.; Damiani F.; Fusari M.; Gamberini E.; Gordini G.; Laici C.; Lanza M.C.; Leo M.; Marudi A.; Nardi G.; Papa R.; Potalivo A.; Russo E.; Taddei S.; Consales G.; Cappellini I.; Ranieri V.M.; Volta C.A.; Guerin C.; Spadaro S.; Tartaglione M.; Chiarini V.; Buldini V.; Coniglio C.; Moro F.; Barbalace C.; Citino M.; Cilloni N.; Giuntoli L.; Bellocchio A.; Matteo E.; Pizzilli G.; Siniscalchi A.; Tartivita C.; Matteo F.; Marchio A.; Bacchilega I.; Bernabe L.; Guarino S.; Mosconi E.; Bissoni L.; Viola L.; Meconi T.; Pavoni V.; Pagni A.; Pompa Cleta P.; Cavagnino M.; Malfatto A.; Adduci A.; Pareschi S.; Melegari G.; Maccieri J.; Marinangeli E.; Racca F.; Verri M.; Falo G.; Marangoni E.; Boni F.; Felloni G.; Baccarini F.D.; Terzitta M.; Maitan S.; Becherucci F.; Parise M.; Masoni F.; Imbriani M.; Orlandi P.; Monetti F.; Dalpiaz G.; Golfieri R.; Ciccarese F.; Poerio A.; Muratore F.; Ferrari F.; Mughetti M.; Franchini L.; Neziri E.; Miceli M.; Minguzzi M.T.; Mellini L.; Piciucchi S.; Bartolucci M

Factors influencing liberation from mechanical ventilation in coronavirus disease 2019: multicenter observational study in fifteen Italian ICUs

Background: A large proportion of patients with coronavirus disease 2019 (COVID-19) develop severe respiratory failure requiring admission to the intensive care unit (ICU) and about 80% of them need mechanical ventilation (MV). These patients show great complexity due to multiple organ involvement and a dynamic evolution over time; moreover, few information is available about the risk factors that may contribute to increase the time course of mechanical ventilation. The primary objective of this study is to investigate the risk factors associated with the inability to liberate COVID-19 patients from mechanical ventilation. Due to the complex evolution of the disease, we analyzed both pulmonary variables and occurrence of non-pulmonary complications during mechanical ventilation. The secondary objective of this study was the evaluation of risk factors for ICU mortality. Methods: This multicenter prospective observational study enrolled 391 patients from fifteen COVID-19 dedicated Italian ICUs which underwent invasive mechanical ventilation for COVID-19 pneumonia. Clinical and laboratory data, ventilator parameters, occurrence of organ dysfunction, and outcome were recorded. The primary outcome measure was 28 days ventilator-free days and the liberation from MV at 28 days was studied by performing a competing risks regression model on data, according to the method of Fine and Gray; the event death was considered as a competing risk. Results: Liberation from mechanical ventilation was achieved in 53.2% of the patients (208/391). Competing risks analysis, considering death as a competing event, demonstrated a decreased sub-hazard ratio for liberation from mechanical ventilation (MV) with increasing age and SOFA score at ICU admission, low values of PaO2/FiO2 ratio during the first 5 days of MV, respiratory system compliance (CRS) lower than 40 mL/cmH2O during the first 5 days of MV, need for renal replacement therapy (RRT), late-onset ventilator-associated pneumonia (VAP), and cardiovascular complications. ICU mortality during the observation period was 36.1% (141/391). Similar results were obtained by the multivariate logistic regression analysis using mortality as a dependent variable. Conclusions: Age, SOFA score at ICU admission, CRS, PaO2/FiO2, renal and cardiovascular complications, and late-onset VAP were all independent risk factors for prolonged mechanical ventilation in patients with COVID-19. Trial registration: NCT04411459

Use of critical care resources during the first 2 weeks (February 24\u2013March 8, 2020) of the Covid-19 outbreak in Italy

Background: A Covid-19 outbreak developed in Lombardy, Veneto and Emilia-Romagna (Italy) at the end of February 2020. Fear of an imminent saturation of available ICU beds generated the notion that rationing of intensive care resources could have been necessary. Results: In order to evaluate the impact of Covid-19 on the ICU capacity to manage critically ill patients, we performed a retrospective analysis of the first 2 weeks of the outbreak (February 24\u2013March 8). Data were collected from regional registries and from a case report form sent to participating sites. ICU beds increased from 1545 to 1989 (28.7%), and patients receiving respiratory support outside the ICU increased from 4 (0.6%) to 260 (37.0%). Patients receiving respiratory support outside the ICU were significantly older [65 vs. 77 years], had more cerebrovascular (5.8 vs. 13.1%) and renal (5.3 vs. 10.0%) comorbidities and less obesity (31.4 vs. 15.5%) than patients admitted to the ICU. PaO2/FiO2 ratio, respiratory rate and arterial pH were higher [165 vs. 244; 20 vs. 24 breath/min; 7.40 vs. 7.46] and PaCO2 and base excess were lower [34 vs. 42 mmHg; 0.60 vs. 1.30] in patients receiving respiratory support outside the ICU than in patients admitted to the ICU, respectively. Conclusions: Increase in ICU beds and use of out-of-ICU respiratory support allowed effective management of the first 14 days of the Covid-19 outbreak, avoiding resource rationing

The role of the intensive care unit in real-time surveillance of emerging pandemics: the Italian GiViTI experience

The prompt availability of reliable epidemiological information on emerging pandemics is crucial for public health policy-makers. Early in 2013, a possible new H1N1 epidemic notified by an intensive care unit (ICU) to GiViTI, the Italian ICU network, prompted the re-activation of the real-time monitoring system developed during the 2009-2010 pandemic. Based on data from 216 ICUs, we were able to detect and monitor an outbreak of severe H1N1 infection, and to compare the situation with previous years. The timely and correct assessment of the severity of an epidemic can be obtained by investigating ICU admissions, especially when historical comparisons can be made

Health-related quality of life profiles, trajectories, persistent symptoms and pulmonary function one year after ICU discharge in invasively ventilated COVID-19 patients, a prospective follow-up study

none112siBackground: Health-related quality of life (HRQoL) impairment is often reported among COVID-19 ICU survivors, and little is known about their long-term outcomes. We evaluated the HRQoL trajectories between 3 months and 1 year after ICU discharge, the factors influencing these trajectories and the presence of clusters of HRQoL profiles in a population of COVID-19 patients who underwent invasive mechanical ventilation (IMV). Moreover, pathophysiological correlations of residual dyspnea were tested. Methods: We followed up 178 survivors from 16 Italian ICUs up to one year after ICU discharge. HRQoL was investigated through the 15D instrument. Available pulmonary function tests (PFTs) and chest CT scans at 1 year were also collected. A linear mixed-effects model was adopted to identify factors associated with different HRQoL trajectories and a two-step cluster analysis was performed to identify HRQoL clusters. Results: We found that HRQoL increased during the study period, especially for the significant increase of the physical dimensions, while the mental dimensions and dyspnea remained substantially unchanged. Four main 15D profiles were identified: full recovery (47.2%), bad recovery (5.1%) and two partial recovery clusters with mostly physical (9.6%) or mental (38.2%) dimensions affected. Gender, duration of IMV and number of comorbidities significantly influenced HRQoL trajectories. Persistent dyspnea was reported in 58.4% of patients, and weakly, but significantly, correlated with both DLCO and length of IMV. Conclusions: HRQoL impairment is frequent 1 year after ICU discharge, and the lowest recovery is found in the mental dimensions. Persistent dyspnea is often reported and weakly correlated with PFTs alterations. Trial registration: NCT04411459.mixedGamberini L.; Mazzoli C.A.; Prediletto I.; Sintonen H.; Scaramuzzo G.; Allegri D.; Colombo D.; Tonetti T.; Zani G.; Capozzi C.; Dalpiaz G.; Agnoletti V.; Cappellini I.; Melegari G.; Damiani F.; Fusari M.; Gordini G.; Laici C.; Lanza M.C.; Leo M.; Marudi A.; Papa R.; Potalivo A.; Montomoli J.; Taddei S.; Mazzolini M.; Ferravante A.F.; Nicali R.; Ranieri V.M.; Russo E.; Volta C.A.; Spadaro S.; Tartaglione M.; Chiarini V.; Buldini V.; Coniglio C.; Moro F.; Orlando S.; Fecarotti D.; Cilloni N.; Giuntoli L.; Bellocchio A.; Matteo E.; Pizzilli G.; Siniscalchi A.; Tartivita C.; Cavalli I.; Castelli A.; Marchio A.; Bacchilega I.; Bernabe L.; Facondini F.; Morini L.; Bissoni L.; Viola L.; Meconi T.; Pavoni V.; Venni A.; Pagni A.; Cleta P.P.; Cavagnino M.; Guzzo A.; Malfatto A.; Adduci A.; Pareschi S.; Bertellini E.; Maccieri J.; Marinangeli E.; Racca F.; Verri M.; Falo G.; Marangoni E.; Ottaviani I.; Boni F.; Felloni G.; Baccarini F.D.; Terzitta M.; Maitan S.; Tutino L.; Senzi A.; Consales G.; Becherucci F.; Imbriani M.; Orlandi P.; Candini S.; Golfieri R.; Ciccarese F.; Poerio A.; Muratore F.; Ferrari F.; Mughetti M.; Giampalma E.; Franchini L.; Neziri E.; Miceli M.; Minguzzi M.T.; Mellini L.; Piciucchi S.; Monari M.; Valli M.; Daniele F.; Ferioli M.; Nava S.; Lazzari Agli L.A.; Valentini I.; Bernardi E.; Balbi B.; Contoli M.; Padovani M.; Oldani S.; Ravaglia C.; Goti P.Gamberini L.; Mazzoli C.A.; Prediletto I.; Sintonen H.; Scaramuzzo G.; Allegri D.; Colombo D.; Tonetti T.; Zani G.; Capozzi C.; Dalpiaz G.; Agnoletti V.; Cappellini I.; Melegari G.; Damiani F.; Fusari M.; Gordini G.; Laici C.; Lanza M.C.; Leo M.; Marudi A.; Papa R.; Potalivo A.; Montomoli J.; Taddei S.; Mazzolini M.; Ferravante A.F.; Nicali R.; Ranieri V.M.; Russo E.; Volta C.A.; Spadaro S.; Tartaglione M.; Chiarini V.; Buldini V.; Coniglio C.; Moro F.; Orlando S.; Fecarotti D.; Cilloni N.; Giuntoli L.; Bellocchio A.; Matteo E.; Pizzilli G.; Siniscalchi A.; Tartivita C.; Cavalli I.; Castelli A.; Marchio A.; Bacchilega I.; Bernabe L.; Facondini F.; Morini L.; Bissoni L.; Viola L.; Meconi T.; Pavoni V.; Venni A.; Pagni A.; Cleta P.P.; Cavagnino M.; Guzzo A.; Malfatto A.; Adduci A.; Pareschi S.; Bertellini E.; Maccieri J.; Marinangeli E.; Racca F.; Verri M.; Falo G.; Marangoni E.; Ottaviani I.; Boni F.; Felloni G.; Baccarini F.D.; Terzitta M.; Maitan S.; Tutino L.; Senzi A.; Consales G.; Becherucci F.; Imbriani M.; Orlandi P.; Candini S.; Golfieri R.; Ciccarese F.; Poerio A.; Muratore F.; Ferrari F.; Mughetti M.; Giampalma E.; Franchini L.; Neziri E.; Miceli M.; Minguzzi M.T.; Mellini L.; Piciucchi S.; Monari M.; Valli M.; Daniele F.; Ferioli M.; Nava S.; Lazzari Agli L.A.; Valentini I.; Bernardi E.; Balbi B.; Contoli M.; Padovani M.; Oldani S.; Ravaglia C.; Goti P

Hospitals with and without neurosurgery: a comparative study evaluating the outcome of patients with traumatic brain injury

Background: We leveraged the data of the international CREACTIVE consortium to investigate whether the outcome of traumatic brain injury (TBI) patients admitted to intensive care units (ICU) in hospitals without on-site neurosurgical capabilities (no-NSH) would differ had the same patients been admitted to ICUs in hospitals with neurosurgical capabilities (NSH). Methods: The CREACTIVE observational study enrolled more than 8000 patients from 83 ICUs. Adult TBI patients admitted to no-NSH ICUs within 48 h of trauma were propensity-score matched 1:3 with patients admitted to NSH ICUs. The primary outcome was the 6-month extended Glasgow Outcome Scale (GOS-E), while secondary outcomes were ICU and hospital mortality. Results: A total of 232 patients, less than 5% of the eligible cohort, were admitted to no-NSH ICUs. Each of them was matched to 3 NSH patients, leading to a study sample of 928 TBI patients where the no-NSH and NSH groups were well-balanced with respect to all of the variables included into the propensity score. Patients admitted to no-NSH ICUs experienced significantly higher ICU and in-hospital mortality. Compared to the matched NSH ICU admissions, their 6-month GOS-E scores showed a significantly higher prevalence of upper good recovery for cases with mild TBI and low expected mortality risk at admission, along with a progressively higher incidence of poor outcomes with increased TBI severity and mortality risk. Conclusions: In our study, centralization of TBI patients significantly impacted short- and long-term outcomes. For TBI patients admitted to no-NSH centers, our results suggest that the least critically ill can effectively be managed in centers without neurosurgical capabilities. Conversely, the most complex patients would benefit from being treated in high-volume, neuro-oriented ICUs

The prognostic importance of chronic end-stage diseases in geriatric patients admitted to 163 Italian ICUs

BACKGROUND: The number of elderly patients undergoing major surgical interventions and then needing admission to intensive care unit (ICU) grows steadily. We investigated this issue in a cohort of 232,278 patients admitted in five years (2011-2015) to 163 Italian general ICUs. METHODS: Surgical patients older than 75 registered in the GiViTI MargheritaPROSAFE project were analyzed. The impact on hospital mortality of important chronic conditions (severe COPD, NYHA class IV, dementia, end-stage renal disease, cirrhosis with portal hypertension) was investigated with two prognostic models developed yearly on patients staying in the ICU less or more than 24 hours. RESULTS: 44,551 elderly patients (19.2%) underwent emergency (47.3%) or elective surgery (52.7%). At least one severe comorbidity was present in 14.6% of them, yielding a higher hospital mortality (32.4%, vs. 21.1% without severe comorbidity). In the models for patients staying in the ICU 24 hours or more, cirrhosis, NYHA class IV, and severe COPD were constant independent predictors of death (adjusted odds ratios [ORs] range 1.67-1.97, 1.54-1.91, and 1.34-1.50, respectively), while dementia was statistically significant in four out of five models (adjusted ORs 1.23-1.28). End-stage renal disease, instead, never resulted to be an independent prognostic factor. For patients staying in the ICU less than 24 hours, chronic comorbidities were only occasionally independent predictors of death. CONCLUSIONS: Our study confirms that elderly surgical patients represent a relevant part of all ICUs admissions. About one of seven bear at least one severe chronic comorbidity, that, excluding end-stage renal disease, are all strong independent predictors of hospital death

Prosafe: a european endeavor to improve quality of critical care medicine in seven countries

BACKGROUND: long-lasting shared research databases are an important source of epidemiological information and can promote comparison between different healthcare services. Here we present ProsaFe, an advanced international research network in intensive care medicine, with the focus on assessing and improving the quality of care. the project involved 343 icUs in seven countries. all patients admitted to the icU were eligible for data collection. MetHoDs: the ProsaFe network collected data using the same electronic case report form translated into the corresponding languages. a complex, multidimensional validation system was implemented to ensure maximum data quality. individual and aggregate reports by country, region, and icU type were prepared annually. a web-based data-sharing system allowed participants to autonomously perform different analyses on both own data and the entire database. RESULTS: The final analysis was restricted to 262 general ICUs and 432,223 adult patients, mostly admitted to Italian units, where a research network had been active since 1991. organization of critical care medicine in the seven countries was relatively similar, in terms of staffing, case mix and procedures, suggesting a common understanding of the role of critical care medicine. conversely, icU equipment differed, and patient outcomes showed wide variations among countries. coNclUsioNs: ProsaFe is a permanent, stable, open access, multilingual database for clinical benchmarking, icU self-evaluation and research within and across countries, which offers a unique opportunity to improve the quality of critical care. its entry into routine clinical practice on a voluntary basis is testimony to the success and viability of the endeavor