Early mobilisation in critically ill COVID-19 patients: a subanalysis of the ESICM-initiated UNITE-COVID observational study

Background Early mobilisation (EM) is an intervention that may improve the outcome of critically ill patients. There is limited data on EM in COVID-19 patients and its use during the first pandemic wave. Methods This is a pre-planned subanalysis of the ESICM UNITE-COVID, an international multicenter observational study involving critically ill COVID-19 patients in the ICU between February 15th and May 15th, 2020. We analysed variables associated with the initiation of EM (within 72 h of ICU admission) and explored the impact of EM on mortality, ICU and hospital length of stay, as well as discharge location. Statistical analyses were done using (generalised) linear mixed-effect models and ANOVAs. Results Mobilisation data from 4190 patients from 280 ICUs in 45 countries were analysed. 1114 (26.6%) of these patients received mobilisation within 72 h after ICU admission; 3076 (73.4%) did not. In our analysis of factors associated with EM, mechanical ventilation at admission (OR 0.29; 95% CI 0.25, 0.35; p = 0.001), higher age (OR 0.99; 95% CI 0.98, 1.00; p ≤ 0.001), pre-existing asthma (OR 0.84; 95% CI 0.73, 0.98; p = 0.028), and pre-existing kidney disease (OR 0.84; 95% CI 0.71, 0.99; p = 0.036) were negatively associated with the initiation of EM. EM was associated with a higher chance of being discharged home (OR 1.31; 95% CI 1.08, 1.58; p = 0.007) but was not associated with length of stay in ICU (adj. difference 0.91 days; 95% CI − 0.47, 1.37, p = 0.34) and hospital (adj. difference 1.4 days; 95% CI − 0.62, 2.35, p = 0.24) or mortality (OR 0.88; 95% CI 0.7, 1.09, p = 0.24) when adjusted for covariates. Conclusions Our findings demonstrate that a quarter of COVID-19 patients received EM. There was no association found between EM in COVID-19 patients' ICU and hospital length of stay or mortality. However, EM in COVID-19 patients was associated with increased odds of being discharged home rather than to a care facility. Trial registration ClinicalTrials.gov: NCT04836065 (retrospectively registered April 8th 2021)

Clinical and organizational factors associated with mortality during the peak of first COVID-19 wave: the global UNITE-COVID study

8 páginasPurpose To accommodate the unprecedented number of critically ill patients with pneumonia caused by coronavirus disease 2019 (COVID-19) expansion of the capacity of intensive care unit (ICU) to clinical areas not previously used for critical care was necessary. We describe the global burden of COVID-19 admissions and the clinical and organizational characteristics associated with outcomes in critically ill COVID-19 patients. Methods Multicenter, international, point prevalence study, including adult patients with SARS-CoV-2 infection confirmed by polymerase chain reaction (PCR) and a diagnosis of COVID-19 admitted to ICU between February 15th and May 15th, 2020. Results 4994 patients from 280 ICUs in 46 countries were included. Included ICUs increased their total capacity from 4931 to 7630 beds, deploying personnel from other areas. Overall, 1986 (39.8%) patients were admitted to surge capacity beds. Invasive ventilation at admission was present in 2325 (46.5%) patients and was required during ICU stay in 85.8% of patients. 60-day mortality was 33.9% (IQR across units: 20%–50%) and ICU mortality 32.7%. Older age, invasive mechanical ventilation, and acute kidney injury (AKI) were associated with increased mortality. These associations were also confirmed specifically in mechanically ventilated patients. Admission to surge capacity beds was not associated with mortality, even after controlling for other factors. Conclusions ICUs responded to the increase in COVID-19 patients by increasing bed availability and staff, admitting up to 40% of patients in surge capacity beds. Although mortality in this population was high, admission to a surge capacity bed was not associated with increased mortality. Older age, invasive mechanical ventilation, and AKI were identified as the strongest predictors of mortality

Machine learning determination of motivators of terminal extubation during the transition to end-of-life care in intensive care unit

Procedural aspects of compassionate care such as the terminal extubation are understudied. We used machine learning methods to determine factors associated with the decision to extubate the critically ill patient at the end of life, and whether the terminal extubation shortens the dying process. We performed a secondary data analysis of a large, prospective, multicentre, cohort study, death prediction and physiology after removal of therapy (DePPaRT), which collected baseline data as well as ECG, pulse oximeter and arterial waveforms from WLST until 30 min after death. We analysed a priori defined factors associated with the decision to perform terminal extubation in WLST using the random forest method and logistic regression. Cox regression was used to analyse the effect of terminal extubation on time from WLST to death. A total of 616 patients were included into the analysis, out of which 396 (64.3%) were terminally extubated. The study centre, low or no vasopressor support, and good respiratory function were factors significantly associated with the decision to extubate. Unadjusted time to death did not differ between patients with and without extubation (median survival time extubated vs. not extubated: 60 [95% CI: 46; 76] vs. 58 [95% CI: 45; 75] min). In contrast, after adjustment for confounders, time to death of extubated patients was significantly shorter (49 [95% CI: 40; 62] vs. 85 [95% CI: 61; 115] min). The decision to terminally extubate is associated with specific centres and less respiratory and/or vasopressor support. In this context, terminal extubation was associated with a shorter time to death

Low non-carbonic buffer power amplifies acute respiratory acid-base disorders in septic patients: an in-vitro study

Rationale: Septic patients have typically reduced concentrations of hemoglobin and albumin, the major components of non-carbonic buffer power(\u3b2). This could expose patients to high pH variations during acid-base disorders. Objectives: To compare, in-vitro, non-carbonic \u3b2 of septic patients with that of healthy volunteers, and evaluate its distinct components. Methods: Whole blood and isolated plasma of 18 septic patients and 18 controls were equilibrated with different CO2 mixtures. Blood gases, pH and electrolytes were measured. Non-carbonic \u3b2 and non-carbonic \u3b2 due to variations in Strong Ion Difference (\u3b2SID) were calculated for whole blood. Non-carbonic \u3b2 and non-carbonic \u3b2 normalized for albumin concentrations (\u3b2NORM) were calculated for isolated plasma. Representative values at pH=7.40 were compared. Albumin proteoforms were evaluated via two-dimensional electrophoresis. Measurements and main results: Hemoglobin and albumin concentrations were significantly lower in septic patients. Septic patients had lower non-carbonic \u3b2 both of whole blood (22.0\ub11.9 vs. 31.6\ub12.1 mmol/L, p<0.01) and plasma (0.5\ub11.0 vs. 3.7\ub10.8 mmol/L, p<0.01). Non-carbonic \u3b2SID was lower in patients (16.8\ub11.9 vs. 24.4\ub11.9 mmol/L, p<0.01) and strongly correlated with hemoglobin concentration (r=0.94, p<0.01). Non-carbonic \u3b2NORM was lower in patients (0.01 [-0.01 - 0.04] vs. 0.08 [0.06 - 0.09] mmol/g, p<0.01). Septic patients and controls showed different amounts of albumin proteoforms. Conclusions: Septic patients are exposed to higher pH variations for any given change in CO2 due to lower concentrations of non-carbonic buffers and, possibly, an altered buffering function of albumin. In both septic patients and healthy controls, electrolyte shifts are the major buffering mechanism during respiratory acid-base disorders

Clinical and organizational factors associated with mortality during the peak of first COVID-19 wave: the global UNITE-COVID study

Purpose: To accommodate the unprecedented number of critically ill patients with pneumonia caused by coronavirus disease 2019 (COVID-19) expansion of the capacity of intensive care unit (ICU) to clinical areas not previously used for critical care was necessary. We describe the global burden of COVID-19 admissions and the clinical and organizational characteristics associated with outcomes in critically ill COVID-19 patients. Methods: Multicenter, international, point prevalence study, including adult patients with SARS-CoV-2 infection confirmed by polymerase chain reaction (PCR) and a diagnosis of COVID-19 admitted to ICU between February 15th and May 15th, 2020. Results: 4994 patients from 280 ICUs in 46 countries were included. Included ICUs increased their total capacity from 4931 to 7630 beds, deploying personnel from other areas. Overall, 1986 (39.8%) patients were admitted to surge capacity beds. Invasive ventilation at admission was present in 2325 (46.5%) patients and was required during ICU stay in 85.8% of patients. 60-day mortality was 33.9% (IQR across units: 20%–50%) and ICU mortality 32.7%. Older age, invasive mechanical ventilation, and acute kidney injury (AKI) were associated with increased mortality. These associations were also confirmed specifically in mechanically ventilated patients. Admission to surge capacity beds was not associated with mortality, even after controlling for other factors. Conclusions: ICUs responded to the increase in COVID-19 patients by increasing bed availability and staff, admitting up to 40% of patients in surge capacity beds. Although mortality in this population was high, admission to a surge capacity bed was not associated with increased mortality. Older age, invasive mechanical ventilation, and AKI were identified as the strongest predictors of mortality

Correction to: Clinical and organizational factors associated with mortality during the peak of first COVID-19 wave: the global UNITE-COVID study.

PURPOSE: To accommodate the unprecedented number of critically ill patients with pneumonia caused by coronavirus disease 2019 (COVID-19) expansion of the capacity of intensive care unit (ICU) to clinical areas not previously used for critical care was necessary. We describe the global burden of COVID-19 admissions and the clinical and organizational characteristics associated with outcomes in critically ill COVID-19 patients. METHODS: Multicenter, international, point prevalence study, including adult patients with SARS-CoV-2 infection confirmed by polymerase chain reaction (PCR) and a diagnosis of COVID-19 admitted to ICU between February 15th and May 15th, 2020. RESULTS: 4994 patients from 280 ICUs in 46 countries were included. Included ICUs increased their total capacity from 4931 to 7630 beds, deploying personnel from other areas. Overall, 1986 (39.8%) patients were admitted to surge capacity beds. Invasive ventilation at admission was present in 2325 (46.5%) patients and was required during ICU stay in 85.8% of patients. 60-day mortality was 33.9% (IQR across units: 20%–50%) and ICU mortality 32.7%. Older age, invasive mechanical ventilation, and acute kidney injury (AKI) were associated with increased mortality. These associations were also confirmed specifically in mechanically ventilated patients. Admission to surge capacity beds was not associated with mortality, even after controlling for other factors. CONCLUSIONS: ICUs responded to the increase in COVID-19 patients by increasing bed availability and staff, admitting up to 40% of patients in surge capacity beds. Although mortality in this population was high, admission to a surge capacity bed was not associated with increased mortality. Older age, invasive mechanical ventilation, and AKI were identified as the strongest predictors of mortality. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s00134-022-06705-1

the global UNITE-COVID study

Funding Information: AE, FD, GDP, LG, VG, AJ, JK, AL, JM, SNM, MO, MP, MC declare no conflicts of interest. MG reports speaking fees from Baxter and Philips. TDC is supported by Research Foundation Flanders (Grant nr G085920N). MA reports Research Grant from GE, Honoraria from Fisher and Paykel, Pfizer, Orion and Gilead. GC reports grants, personal fees as Speakers’ Bureau Member and Advisory Board Member from Integra and Neuroptics, all outside the submitted work. ACM is supported by a Clinician Scientist Fellowship from the Medical Research Council (MR/V006118/1). SE declares no financial COIs and the following non-financial disclosures: Cochrane editor, American Society of Anesthesiologist data review board member. LF reports research funding from NIHR, Baxter, Ortho-Clinical Diagnostics, Exthera Medical and lecture fees from Baxter, Fresenius, Paion, all outside the submitted work. GG received payment for lectures from Getinge, Draeger Medical, Fisher&Paykel, Biotest, MSD, Gilead and unrestricted research grants from Fisher&Paykel and MSD (all unrelated to the present work). MCMD declares potential conflict of interest with BD. PP declares potential conflicts of interest with Pfizer, MSD and Gilead. SJS reports personal fees from Springer-Verlag, GmbH (Vienna, Austria) for educational commitments grants and non-financial support from ESICM (Bruxelles, Belgium), Fresenius (Germany), Liberate Medical LLC (Crestwood, USA), STIMIT AG (Nidau, Switzerland) Reactive Robotics GmbH (Munich, Germany) as well as from Technical University of Munich, Germany, from national (e.g. DGAI) and international (e.g. ESICM) medical societies (or their congress organizers) in the field of anesthesiology and intensive care, all outside the submitted work; SJS holds stocks in small amounts from Alphabeth Inc., Bayer AG, Rhön-Klinikum AG, and Siemens AG. These did not have any influence on this study. AW reports Honorarium for delivery of educational material for Vygon, GE. JLT declares potential conflict of interest with Getinge. JDW has consulted for Pfizer, MSD (honoraria paid to institution), and is a senior clinical investigator funded by the Research Foundation Flanders (FWO, Ref. 1881020N).Purpose: To accommodate the unprecedented number of critically ill patients with pneumonia caused by coronavirus disease 2019 (COVID-19) expansion of the capacity of intensive care unit (ICU) to clinical areas not previously used for critical care was necessary. We describe the global burden of COVID-19 admissions and the clinical and organizational characteristics associated with outcomes in critically ill COVID-19 patients. Methods: Multicenter, international, point prevalence study, including adult patients with SARS-CoV-2 infection confirmed by polymerase chain reaction (PCR) and a diagnosis of COVID-19 admitted to ICU between February 15th and May 15th, 2020. Results: 4994 patients from 280 ICUs in 46 countries were included. Included ICUs increased their total capacity from 4931 to 7630 beds, deploying personnel from other areas. Overall, 1986 (39.8%) patients were admitted to surge capacity beds. Invasive ventilation at admission was present in 2325 (46.5%) patients and was required during ICU stay in 85.8% of patients. 60-day mortality was 33.9% (IQR across units: 20%–50%) and ICU mortality 32.7%. Older age, invasive mechanical ventilation, and acute kidney injury (AKI) were associated with increased mortality. These associations were also confirmed specifically in mechanically ventilated patients. Admission to surge capacity beds was not associated with mortality, even after controlling for other factors. Conclusions: ICUs responded to the increase in COVID-19 patients by increasing bed availability and staff, admitting up to 40% of patients in surge capacity beds. Although mortality in this population was high, admission to a surge capacity bed was not associated with increased mortality. Older age, invasive mechanical ventilation, and AKI were identified as the strongest predictors of mortality.publishersversionpublishe