Abstract:Summary
Background
Widely varying mortality rates of critically ill Coronavirus disease 19 (COVID-19) patients in the world highlighted the need for local surveillance of baseline characteristics, treatment strategies and outcome. We compared two periods of the COVID-19 pandemic to identify important differences in characteristics and therapeutic measures and their influence on the outcome of critically ill COVID-19 patients.
Methods
This mu… Show more
“…This discrepancy may be largely attributed to older age, a higher number of comorbidities, more frequent coexistence of frailty, and greater severity of the disease expressed as a higher SOFA score at admission in the COVIP study sample. Nevertheless, such a high NIV failure rate was expected since elderly ICU patients have a particularly grim prognosis [24]. Therefore, in order to avoid unnecessary invasive procedures and futile suffering of the patients, LST limitations are commonly introduced during hospitalization.…”
Background
Noninvasive ventilation (NIV) is a promising alternative to invasive mechanical ventilation (IMV) with a particular importance amidst the shortage of intensive care unit (ICU) beds during the COVID-19 pandemic. We aimed to evaluate the use of NIV in Europe and factors associated with outcomes of patients treated with NIV.
Methods
This is a substudy of COVIP study—an international prospective observational study enrolling patients aged ≥ 70 years with confirmed COVID-19 treated in ICU. We enrolled patients in 156 ICUs across 15 European countries between March 2020 and April 2021.The primary endpoint was 30-day mortality.
Results
Cohort included 3074 patients, most of whom were male (2197/3074, 71.4%) at the mean age of 75.7 years (SD 4.6). NIV frequency was 25.7% and varied from 1.1 to 62.0% between participating countries. Primary NIV failure, defined as need for endotracheal intubation or death within 30 days since ICU admission, occurred in 470/629 (74.7%) of patients. Factors associated with increased NIV failure risk were higher Sequential Organ Failure Assessment (SOFA) score (OR 3.73, 95% CI 2.36–5.90) and Clinical Frailty Scale (CFS) on admission (OR 1.46, 95% CI 1.06–2.00). Patients initially treated with NIV (n = 630) lived for 1.36 fewer days (95% CI − 2.27 to − 0.46 days) compared to primary IMV group (n = 1876).
Conclusions
Frequency of NIV use varies across European countries. Higher severity of illness and more severe frailty were associated with a risk of NIV failure among critically ill older adults with COVID-19. Primary IMV was associated with better outcomes than primary NIV.
Clinical Trial RegistrationNCT04321265, registered 19 March 2020, https://clinicaltrials.gov.
“…This discrepancy may be largely attributed to older age, a higher number of comorbidities, more frequent coexistence of frailty, and greater severity of the disease expressed as a higher SOFA score at admission in the COVIP study sample. Nevertheless, such a high NIV failure rate was expected since elderly ICU patients have a particularly grim prognosis [24]. Therefore, in order to avoid unnecessary invasive procedures and futile suffering of the patients, LST limitations are commonly introduced during hospitalization.…”
Background
Noninvasive ventilation (NIV) is a promising alternative to invasive mechanical ventilation (IMV) with a particular importance amidst the shortage of intensive care unit (ICU) beds during the COVID-19 pandemic. We aimed to evaluate the use of NIV in Europe and factors associated with outcomes of patients treated with NIV.
Methods
This is a substudy of COVIP study—an international prospective observational study enrolling patients aged ≥ 70 years with confirmed COVID-19 treated in ICU. We enrolled patients in 156 ICUs across 15 European countries between March 2020 and April 2021.The primary endpoint was 30-day mortality.
Results
Cohort included 3074 patients, most of whom were male (2197/3074, 71.4%) at the mean age of 75.7 years (SD 4.6). NIV frequency was 25.7% and varied from 1.1 to 62.0% between participating countries. Primary NIV failure, defined as need for endotracheal intubation or death within 30 days since ICU admission, occurred in 470/629 (74.7%) of patients. Factors associated with increased NIV failure risk were higher Sequential Organ Failure Assessment (SOFA) score (OR 3.73, 95% CI 2.36–5.90) and Clinical Frailty Scale (CFS) on admission (OR 1.46, 95% CI 1.06–2.00). Patients initially treated with NIV (n = 630) lived for 1.36 fewer days (95% CI − 2.27 to − 0.46 days) compared to primary IMV group (n = 1876).
Conclusions
Frequency of NIV use varies across European countries. Higher severity of illness and more severe frailty were associated with a risk of NIV failure among critically ill older adults with COVID-19. Primary IMV was associated with better outcomes than primary NIV.
Clinical Trial RegistrationNCT04321265, registered 19 March 2020, https://clinicaltrials.gov.
“…Experience gained during the first wave and specific therapies have been associated to a better outcome among critically ill Covid-19 patients admitted during second waves across the world. [20][21][22] Among these therapies, the introduction of corticosteroids have been associated to a lower proportion of patients requiring invasive mechanical ventilation and to reduced mortality. [25] Interestingly, despite implementation of a protocol for corticosteroids in our ICU, we did not found difference of mortality between both waves.…”
There are currently no data regarding characteristics of critically ill patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) variant of concern (VOC) 20H/501Y.V2. We therefore aimed to describe changes of characteristics in critically ill patients with Covid-19 between the first and the second wave when viral genome sequencing indicated that VOC was largely dominant in Mayotte Island (Indian Ocean). Consecutive patients with Covid-19 and over 18 years admitted in the unique intensive care unit (ICU) of Mayotte during wave 2 were compared with an historical cohort of patients admitted during wave 1. We performed a LR comparing wave 1 and wave 2 as outcomes. To complete analysis, we built a Random Forest model (RF), that is, a machine learning classification tool- using the same variable set as that of the LR. We included 156 patients, 41 (26.3%) and 115 (73.7%) belonging to the first and second waves respectively. Univariate analysis did not find difference in demographic data or in mortality. Our multivariate LR found that patients in wave 2 had less fever (absence of fever aOR 5.23, 95% confidence interval (CI) 1.89–14.48,
p
= .001) and a lower simplified acute physiology score (SAPS II) (aOR 0.95, 95% CI 0.91–0.99,
p
= .007) at admission; at 24 hours, the need of invasive mechanical ventilation was higher (aOR 3.49, 95% CI 0.98–12.51,
p
= .055) and pO2/FiO2 ratio was lower (aOR 0.99, 95 % CI 0.98–0.99,
p
= .03). Patients in wave 2 had also an increased risk of ventilator-associated pneumonia (VAP) (aOR 4.64, 95% CI 1.54–13.93,
p
= .006). Occurrence of VAP was also a key variable to classify patients between wave 1 and wave 2 in the variable importance plot of the RF model. Our data suggested that VOC 20H/501Y.V2 could be associated with a higher severity of respiratory failure at admission and a higher risk for developing VAP. We hypothesized that the expected gain in survival brought by recent improvements in critical care management could have been mitigated by increased transmissibility of the new lineage leading to admission of more severe patients. The immunological role of VOC 20H/501Y.V2 in the propensity for VAP requires further investigations.
“…Die invasive maschinelle Beatmung (ohne ARDS) geht mit einer 3‑fachen Erhöhung des Risikos für eine AKI einher [ 3 , 34 ]. Kohortenstudien zeigten bei COVID-19 ebenfalls einen Zusammenhang zwischen der Rate an invasiver Beatmung und der Häufigkeit von AKI [ 24 , 42 ]. Einige (retrospektive) Studien lieferten sogar Hinweise, dass der Effekt der mechanischen Beatmung auf die Nierenfunktion ausgeprägter ist als in Nicht-COVID-19-Vergleichsgruppen [ 18 ].…”
Section: Pathogeneseunclassified
“…Vergleiche der ersten beiden Wellen zeigen zu Beginn (hohe Rate an invasiver Beatmung) auch deutlich höhere AKI-Raten und einen Rückgang der AKI-Inzidenz im Verlauf der Pandemie (Abb. 1 , [ 11 , 42 ]). …”
ZusammenfassungEine mit der Coronaviruserkrankung 2019 (COVID-19) assoziierte Nierenschädigung ist vor allem bei Intensivpatient:innen ein häufiges Phänomen. Das Virus selbst dürfte im Sinne eines direkten Befalls der Niere nur in geringem Ausmaß eine Rolle spielen, die mit einer schweren COVID-19-Erkrankungen assoziierte pathologische Entzündungsreaktion dagegen sehr wohl. Einen wesentlichen Einfluss haben die Folgen der invasiven Beatmung und das durch COVID-19 verursachte Acute Respiratory Distress Syndrome (ARDS). Hohe Beatmungsdrücke wirken sich negativ auf die Nierenperfusion aus und können so zur Entstehung einer AKI beitragen. Die durch das ARDS verursachte Entzündungsreaktion sowie die für COVID-19 typische endotheliale Dysfunktion in Kombination mit einer Hyperkoagulabilität sind weitere Faktoren, die die Nierenfunktion negativ beeinflussen können.
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