Qualitative and quantitative muscle ultrasound changes in patients with COVID-19-related ARDS

Nutrition delivery and the relationship with changes in muscle mass in adult patients receiving extracorporeal membrane oxygenation: A retrospective observational study

BACKGROUND

Adverse changes in muscle health (size and quality) are common in patients receiving extracorporeal membrane oxygenation (ECMO). Nutrition delivery may attenuate such changes, yet the relationship with muscle health remains poorly understood. This study explored the association between energy and protein delivery and changes in muscle health measured using ultrasound from baseline to day 10 and 20 in patients receiving ECMO.

METHODS

A secondary analysis of data from a prospective study quantifying changes in muscle health using ultrasound in adults receiving ECMO was completed. Patients were eligible for inclusion if they were prescribed artificial nutrition within 3 days of enrolment and had >1 ultrasound measurement. The primary outcome was the association between protein delivery (grams delivered and percentage of targets received) and change in rectus femoris cross-sectional area (RF-CSA) till day 20. Secondary outcomes were the association between energy and protein delivery and change in RF-CSA till day 10, RF-echogenicity, and quadriceps muscle layer thickness to day 10 and 20. Associations were assessed using Spearman's rank correlation.

RESULTS

Twenty-three patients (age: 48 [standard deviation {SD}: 14], 44% male) were included. Mean energy and protein delivery were 1633 kcal (SD: 374 kcal) and 70 g (SD: 17 g) equating to 79% (SD: 19%) of energy and 73% (SD: 17%) of protein targets. No association was observed between protein delivery (r = 0.167; p = 0.495) or the percentage of targets received (r = 0.096; p = 0.694) and change in RF-CSA till day 20. No other significant associations were found between energy or protein delivery and change in RF-CSA, echogenicity, or quadriceps muscle layer thickness at any time point.

CONCLUSIONS

This exploratory study observed no association between nutrition delivery and changes in muscle health measured using ultrasound in patients receiving ECMO. Larger prospective studies are required to investigate the association between nutrition delivery and changes in muscle health in patients receiving ECMO.

Muscle Dysfunction and Functional Status in COVID-19 Patients during Illness and after Hospital Discharge

BACKGROUND

COVID-19 pneumonia is associated with SIRS and hypercatabolism. The aim of this study was to determine muscle loss during the acute phase of COVID-19 pneumonia and evaluate long-term sequelae in discharged patients.

METHODS

A total of 16 patients with COVID-19 pneumonia and respiratory insufficiency were included in the study. Selected parameters (weight, BMI, LBM = lean body mass, albumin, CRP, NLR = neutrophil-to-lymphocyte ratio, ultrasound measured thickness of rectus femoris muscle = US RF and rectus femoris + vastus intermedius = US RF + VI, handgrip strength, quality of life = EQ-5D questionnaire, and activities of daily living = Barthel's ADLs) were recorded on admission, discharge, and 1, 3, and 6 months after discharge.

RESULTS

The most significant changes were between hospital admission and discharge: US RF and RF + VI (-1.28 ± 1.97 mm, p = 0.046; -1.76 ± 2.94 mm, p = 0.05), EQ-5D score (14.6 ± 19.2, p = 0.02), and ADLs (17.1 ± 22.6; p = 0.02). There was a significant positive correlation between US RF + VI and handgrip strength (p = 0.014) and a negative correlation between weight and Barthel index (p = 0.012). There was an association between muscle function with an EQ-5D score and ADLs during outpatient check-ups, most noticeably between handgrip strength, US RF+VI, and ADLs (p = 0.08; p = 0.1, respectively). Conclusions: In patients with COVID-19 pneumonia, there is a significant reduction of health-related quality of life, impaired even 6 months after hospital discharge, influenced mainly by muscle loss. During the hospital stay, there was a significant muscle mass reduction. Ultrasound measurement of thigh muscle thickness may be a useful method to monitor muscle loss.

Bioimpedance-assessed muscle wasting and its relation to nutritional intake during the first week of ICU: a pre-planned secondary analysis of Nutriti Study

BACKGROUND

Muscle mass evaluation in ICU is crucial since its loss is related with long term complications, including physical impairment. However, quantifying muscle wasting with available bedside tools (ultrasound and bioimpedance analysis) must be more primarily understood. Bioimpedance analysis (BIA) provides estimates of muscle mass and phase angle (PA). The primary aim of this study was to evaluate muscle mass changes with bioimpedance analysis during the first 7 days after ICU admission. Secondary aims searched for correlations between muscular loss and caloric and protein debt.

METHODS

Patients with an expected ICU-stay ≥ 72 h and the need for artificial nutritional support were evaluated for study inclusion. BIA evaluation of muscle mass and phase angle were performed at ICU admission and after 7 days. Considering the difference between ideal caloric and protein targets, with adequate nutritional macronutrients delivered, we calculated the caloric and protein debt. We analyzed the potential correlation between caloric and protein debt and changes in muscle mass and phase angle.

RESULTS

72 patients from September 1st to October 30th, 2019 and from August 1st to October 30th, 2021 were included in the final statistical analysis. Median age was 68 [59-77] years, mainly men (72%) admitted due to respiratory failure (25%), and requiring invasive mechanical ventilation for 7 [4-10] days. Median ICU stay was 8 [6-12] days. Bioimpedance data at ICU admission and after 7 days showed that MM and PA resulted significantly reduced after 7 days of critically illness, 34.3 kg vs 30.6 kg (p < 0.0001) and 4.90° vs 4.35° (p = 0.0004) respectively. Mean muscle loss was 3.84 ± 6.7 kg, accounting for 8.4% [1-14] MM reduction. Correlation between caloric debt (r = 0.14, p = 0.13) and protein debt (r = 0.18, p = 0.13) with change in MM was absent. Similarly, no correlation was found between caloric debt (r = -0.057, p = 0.631) and protein debt (r = -0.095, p = 0.424) with changes in PA.

CONCLUSIONS

bioimpedance analysis demonstrated that muscle mass and phase angle were significantly lower after 7 days in ICU. The total amount of calories and proteins does not correlate with changes in muscle mass and phase angle.

A High Respiratory Drive Is Associated with Weaning Failure in Patients with COVID-19-Associated Acute Respiratory Distress Syndrome: The Role of the Electrical Activity of the Diaphragm

BACKGROUND

Mechanical ventilation is the main supportive treatment of severe cases of COVID-19-associated ARDS (C-ARDS). Weaning failure is common and associated with worse outcomes. We investigated the role of respiratory drive, assessed by monitoring the electrical activity of the diaphragm (EAdi), as a predictor of weaning failure.

METHODS

Consecutive, mechanically ventilated patients admitted to the ICU for C-ARDS with difficult weaning were enrolled. Blood gas, ventilator, and respiratory mechanic parameters, as well as EAdi, were recorded at the time of placement of EAdi catheter, and then after 1, 2, 3, 7, and 10 days, and compared between patients with weaning success and weaning failure.

RESULTS

Twenty patients were enrolled: age 66 (60-69); 85% males; PaO2/FiO2 at admission 148 (126-177) mmHg. Thirteen subjects (65%) were classified as having a successful weaning. A younger age (OR(95%CI): 0.02 (0.01-0.11) per year), a higher PaO2/FiO2 ratio (OR(95%CI): 1.10 (1.01-1.21) per mmHg), and a lower EAdi (OR(95%CI): 0.16 (0.08-0.34) per μV) were associated with weaning success.

CONCLUSION

In critically ill patients with moderate-severe C-ARDS and difficult weaning from mechanical ventilation, a successful weaning was associated with a lower age, a higher oxygenation, and a lower respiratory drive, as assessed at the bedside via EAdi monitoring.

Prolonged intensive care: muscular functional, and nutritional insights from the COVID-19 pandemic

During the coronavirus disease 2019 (COVID-19) pandemic, clinical staff learned how to manage patients enduring extended stays in an intensive care unit (ICU). COVID-19 patients requiring critical care in an ICU face a high risk of experiencing prolonged intensive care (PIC). The use of invasive mechanical ventilation in individuals with severe acute respiratory distress syndrome can cause numerous complications that influence both short-term and long-term morbidity and mortality. Those risks underscore the importance of proactively addressing functional complications. Mitigating secondary complications unrelated to the primary pathology of admission is imperative in minimizing the risk of PIC. Therefore, incorporating strategies to do that into daily ICU practice for both COVID-19 patients and those critically ill from other conditions is significantly important.

Prognostic Value of Diaphragmatic Ultrasound in Patients Admitted for COVID-19 Pneumonia

Introduction

COVID-19 pneumonia results in an impairment of the diaphragmatic musculature that influences the development of respiratory failure during the patient's hospitalization. Diaphragmatic ultrasound is a useful, non-invasive, and accessible tool for measuring the function of this muscle.

Objective

Assessing the morphological and functional ultrasound status of the diaphragm in patients admitted within the first 24 h for COVID-related pneumonia and its association with hospital morbidity and mortality (NCT05805579).

Material and methods

Observational, prospective cohort study that included 68 patients admitted for COVID-19 pneumonia with respiratory failure. Diaphragmatic ultrasound was performed within the first 24 h of admission to the pulmonology ward. Clinical, analytical, and ultrasound variables were collected: excursion, thickness, and diaphragmatic shortening fraction (DSF). DSF < 20% was used to define diaphragmatic dysfunction (DD). Patients who showed favorable progression and were managed on the ward (HCONV) were compared to those who required admission to the respiratory monitoring unit (RMU).

Results

A total of 68 patients were included, of which 22 (32.35%) were admitted to the RMU. Diaphragmatic excursion at maximum volume was higher in the HCONV group compared to the RMU group (58.41 ± 17.83 vs. 50.03 ± 16.23; p = 0.123). Diaphragmatic dysfunction (DD) was observed in 21 (30.88%) patients, with a higher prevalence in the RMU group than in the HCONV group (15 (68.18%) vs. 6 (13.04%); p = 0.0001). In the multivariate analysis, age and DSF at admission were the best predictors of failure to discharge.

Conclusions

Performing diaphragmatic ultrasound to assess mobility and DSF within the first 24 h of admission for COVID-19 pneumonia proves valuable in determining short-term progression and the need for admission to a respiratory monitoring unit.

Ultrasonographic Features of Muscular Weakness and Muscle Wasting in Critically Ill Patients

Muscle wasting begins as soon as in the first week of one's ICU stay and patients with multi-organ failure lose more muscle mass and suffer worse functional impairment as a consequence. Muscle wasting and weakness are mainly characterized by a generalized, bilateral lower limb weakness. However, the impairment of the respiratory and/or oropharyngeal muscles can also be observed with important consequences for one's ability to swallow and cough. Muscle wasting represents the result of the disequilibrium between breakdown and synthesis, with increased protein degradation relative to protein synthesis. It is worth noting that the resulting functional disability can last up to 5 years after discharge, and it has been estimated that up to 50% of patients are not able to return to work during the first year after ICU discharge. In recent years, ultrasound has played an increasing role in the evaluation of muscle. Indeed, ultrasound allows an objective evaluation of the cross-sectional area, the thickness of the muscle, and the echogenicity of the muscle. Furthermore, ultrasound can also estimate the thickening fraction of muscle. The objective of this review is to analyze the current understanding of the pathophysiology of acute skeletal muscle wasting and to describe the ultrasonographic features of normal muscle and muscle weakness.

Muscle ultrasound and its application to point-of-care ultrasonography: a narrative review

Technological advances of hand-held ultrasound devices and educational programmes for their use, such as point-of-care ultrasonography (POCUS) training, have contributed to the increasing application of these devices in clinical practice. With the greater impact of frailty and sarcopenia in aging societies, attention is being focused on the use of ultrasound for skeletal muscle assessment. In this narrative review, we discuss how ultrasound can be applied to skeletal muscle assessment, especially that of the quadriceps muscle, in clinical practice. Muscle thickness by ultrasound has been shown to have good reliability and validity for the evaluation of muscle size, and echo intensity has been used to evaluate muscle quality. Muscle ultrasound has not only been useful to diagnose sarcopenia in various settings, but has also been validated to predict health-related outcomes such as death and functional disability. Recommended methods for muscle ultrasound was published recently, and the results of future studies are expected to be comparable. Although several challenging issues with muscle ultrasound remain, if it could be incorporated into educational programmes such as POCUS training, more clinicians may be able to use ultrasound for skeletal muscle assessment in the future.KEY MESSAGESThe evolution of hand-held ultrasound devices enables physicians to perform ultrasound at the bedside as part of regular medical examinations.Muscle ultrasound is considered an effective tool for evaluating muscle size and quality, and has been studied in various settings.More clinicians may be able to evaluate skeletal muscle assessment with the development of educational programmes on muscle ultrasound in the future.

Nutritional support and prevention of post-intensive care syndrome: the Italian SIAARTI survey

BACKGROUND

Malnutrition and muscle wasting are common in ICU patients and predict adverse patient-centered outcomes. The Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care (SIAARTI) conducted a nationwide survey to identify the nutritional practices in the Italian ICUs and to plan future, training interventions to improve the national clinical practice.

METHODS

Nationwide online survey, involving Italian ICUs, developed by experts affiliated with SIAARTI. Invitations to participate were distributed through emails and social networks. Data were collected over a period of three months (October 1 to December 31, 2022) during 2022.

RESULTS

One hundred full responses from participating ICUs were collected. The number of beds is < 10 in most ICUs and > 20 in 11 ICUs. Most ICUs (87%) are mixed, cardiac (5%), neurosurgical (4%), or pediatric ICUs (1%). Although the nutritional program is widely prescribed based on the patients' general evaluation, 52 ICUs (52%) do not perform nutritional risk evaluation at admission in case of > 24-h stay. Daily caloric intake is mainly based on the 25 kcal/kg equation; otherwise, the Harris-Benedict formula is mostly used, whereas indirect calorimetry is less used. Most clinicians apply a personalized nutritional approach to organ failure. Most ICUs have a nutritional management protocol, and enteral nutrition (EN) is frequently started within 2 days from admission, while supplemental parenteral nutrition is used when EN is insufficient by most clinicians. The EN administered seems to correspond to that prescribed, but it is stopped if the gastric residual gastric is > 300-500 ml in most ICUs.

CONCLUSION

Prescription, route, and mode of administration of nutritional support seem to be in line with international recommendations, while suggestions on the tools for assessing the nutritional risk and monitoring efficacy and complications seem far less followed. Future national clinical studies are necessary to investigate the optimal nutritional and metabolic management of critically ill patients and the correspondence with the results of this survey on actual practices.

Assessment of body composition in adults hospitalized with acute COVID-19: a scoping review

Introduction

Body composition (BC) assessment can supply accurate information for in-hospital nutritional evaluation. The aim of this study was to explore in the literature how the studies assessed BC, for what purpose, and investigate the role of BC findings in COVID-19 hospitalized patients' outcomes.

Methods

A scoping review was conducted according to the methodology available on the Joanna Briggs Institute website. We used the PCC acronym for the systematic search (population: adults with COVID-19, concept: assessment of BC, context: hospital setting) and performed it on PubMed, Scopus, and the Web of Science on 16 September 2022. Eligibility criteria consisted of the utilization of BC assessment tools in COVID-19 patients. Studies in which BC was solely measured with anthropometry (perimeters and skinfolds) were excluded. No language restriction was applied.

Results

Fifty-five studies were eligible for the review. Out of the 55 studies, 36 used computed tomography (CT), 13 used bioelectrical impedance (BIA), and 6 used ultrasound (US). No studies with D3-creatinine, 24  h urine excretion, dual-energy X-ray absorptiometry, or magnetic resonance were retrieved. BC was mainly assessed to test associations with adverse outcomes such as disease severity and mortality.

Discussion

Studies assessing BC in hospitalized patients with COVID-19 used mainly CT and BIA and associated the parameters with severity and mortality. There is little evidence of BC being assessed by other methods, as well as studies on BC changes during hospitalization.

Extended prone positioning for intubated ARDS: a review

During the COVID-19 pandemic, several centers had independently reported extending prone positioning beyond 24 h. Most of these centers reported maintaining patients in prone position until significant clinical improvement was achieved. One center reported extending prone positioning for organizational reasons relying on a predetermined fixed duration. A recent study argued that a clinically driven extension of prone positioning beyond 24 h could be associated with reduced mortality. On a patient level, the main benefit of extending prone positioning beyond 24 h is to maintain a more homogenous distribution of the gas-tissue ratio, thus delaying the increase in overdistention observed when patients are returned to the supine position. On an organizational level, extending prone positioning reduces the workload for both doctors and nurses, which might significantly enhance the quality of care in an epidemic. It might also reduce the incidence of accidental catheter and tracheal tube removal, thereby convincing intensive care units with low incidence of ARDS to prone patients more systematically. The main risk associated with extended prone positioning is an increased incidence of pressure injuries. Up until now, retrospective studies are reassuring, but prospective evaluation is needed.

Prevalence and clinical implications of abnormal body composition phenotypes in patients with COVID-19: a systematic review

BACKGROUND

The impact of body composition (BC) abnormalities on coronavirus disease 2019 (COVID-19) outcomes remains to be determined.

OBJECTIVE

We summarized the evidence on BC abnormalities and their relationship with adverse clinical outcomes in patients with COVID-19.

METHODS

A systematic search was conducted up until September 26, 2022 for observational studies using BC techniques to quantify skeletal muscle mass (or related compartments), muscle radiodensity or echo intensity, adipose tissue (AT, or related compartments), and phase angle (PhA) in adults with COVID-19. Methodological quality of studies was assessed using the Newcastle-Ottawa Scale. A synthesis without meta-analysis was conducted to summarize the prevalence of BC abnormalities and their significant associations with clinical outcomes.

RESULTS

We included 62 studies (69.4% low risk of bias) with 12 to 1,138 participants, except three with up to 490,301 participants. Using computed tomography and different cut-offs, prevalence ranged approximately from 22-90% for low muscle mass, 12-85% for low muscle radiodensity, 16-70% for high visceral AT. Using bioelectrical impedance analysis (BIA), prevalence of high fat mass was 51% and low PhA was 22-88%. Mortality was inversely related to PhA (3/4 studies) and positively related to intramuscular AT (4/5 studies), muscle echo intensity (2/2 studies), and BIA-estimated fat mass (2/2 studies). Intensive care unit admission was positively related to visceral AT (6/7 studies) and total AT (2/3 studies). Disease severity and hospitalization outcomes were positively related to intramuscular AT (2/2 studies). Inconsistent associations were found for the rest of BC measures and hospitalization outcomes.

CONCLUSIONS

Abnormalities in BC were prevalent in patients with COVID-19. Although conflicting associations were observed among certain BC abnormalities and clinical outcomes, higher muscle echo intensity (reflective of myosteatosis) and lower PhA were more consistently associated with greater mortality risk. Likewise, high IMAT and VAT were associated with mortality and ICU admission, respectively.

Update on Lean Body Mass Diagnostic Assessment in Critical Illness

Acute critical illnesses can alter vital functions with profound biological, biochemical, metabolic, and functional modifications. Despite etiology, patient's nutritional status is pivotal to guide metabolic support. The assessment of nutritional status remains complex and not completely elucidated. Loss of lean body mass is a clear marker of malnutrition; however, the question of how to investigate it still remains unanswered. Several tools have been implemented to measure lean body mass, including a computed tomography scan, ultrasound, and bioelectrical impedance analysis, although such methods unfortunately require validation. A lack of uniform bedside measurement tools could impact the nutrition outcome. Metabolic assessment, nutritional status, and nutritional risk have a pivotal role in critical care. Therefore, knowledge about the methods used to assess lean body mass in critical illnesses is increasingly required. The aim of the present review is to update the scientific evidence regarding lean body mass diagnostic assessment in critical illness to provide the diagnostic key points for metabolic and nutritional support.

Characterization of muscle mass, strength and mobility of critically ill patients with SARS-CoV-2 pneumonia: Distribution by sex, age, days on mechanical ventilation, and muscle weakness

Objective: Quantify and categorize by sex, age, and time spent on mechanical ventilation (MV), the decline in skeletal muscle mass, strength and mobility in critically ill patients infected with SARS-CoV-2 and requiring mechanical ventilation while at intensive care unit (ICU). Design: Prospective observational study including participants recruited between June 2020 and February 2021 at Hospital Clínico Herminda Martin (HCHM), Chillán, Chile. The thickness of the quadriceps muscle was evaluated by ultrasonography (US) at intensive care unit admission and awakening. Muscle strength and mobility were assessed, respectively, through the Medical Research Council Sum Score (MRC-SS) and the Functional Status Score for the Intensive Care Unit Scale (FSS-ICU) both at awakening and at ICU discharge. Results were categorized by sex (female or male), age (<60 years old or ≥60 years old) and time spent on MV (≤10 days or >10 days). Setting: Intensive care unit in a public hospital. Participants: 132 participants aged 18 years old or above (women n = 49, 60 ± 13 years; men n = 85, 59 ± 12 years) admitted to intensive care unit with a confirmed diagnosis of severe SARS-CoV-2 and requiring MV for more than 48 h were included in the study. Patients with previous physical and or cognitive disorders were excluded. Interventions: Not applicable. Results: Muscle thickness have significantly decreased during intensive care unit stay, vastus intermedius (-11%; p = 0.025), rectus femoris (-20%; p < 0.001) and total quadriceps (-16%; p < 0.001). Muscle strength and mobility were improved at intensive care unit discharge when compared with measurements at awakening in intensive care unit (time effect, p < 0.001). Patients ≥60 years old or on MV for >10 days presented greater muscle loss, alongside with lower muscle strength and mobility. Conclusion: Critically ill patients infected with SARS-CoV-2 and requiring MV presented decreased muscle mass, strength, and mobility during their intensive care unit stay. Factors associated with muscle mass, such as age >60 years and >10 days of MV, exacerbated the critical condition and impaired recovery.

Ultrasonographic findings in long COVID: A cross-sectional study of 312 patients

Background

Fatigue and muscle weakness are common complaints in COVID-19 survivors. However, little is still known about the skeletal muscle qualitative and quantitative characteristics after hospitalization due to moderate and severe COVID-19.

Objectives

To assess rectus femoris and vastus intermedius muscle thickness (MT) and rectus femoris echo intensity (EI) and to establish its association with demographic, clinical, functional, and inflammatory parameters in long COVID patients after hospital discharge.

Methods

Cross-sectional study with 312 COVID-19 patients (53.53% male; age: 54.59 ± 13.50 years), with a laboratory-confirmed diagnosis of COVID-19. Patients were assessed 3-11 months after hospital discharge. We evaluated MT of the right rectus femoris and vastus intermedius and EI of the right rectus femoris using a portable ultrasound system, 6-13 MHz, broadband linear transducer. We corrected EI using the subcutaneous fat thickness. Ultrasonographic parameters were tested in association with demographic (sex and age); functional (Handgrip strength measurement, Timed Up and Go, 1 min Sit-to-Stand test, EuroQoL-5 Dimensions-5 Levels, World Health Organization Disability Assessment Schedule (WHODAS 2.0), Post-COVID-19 Functional Status, Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT), Medical Research Council (MRC) sum score, Borg Dyspnea Scale, MRC Dyspnea score, Visual Analogue Scale (VAS), Epworth Sleepiness Scale, Insomnia Severity Index, Functional Independence Measurement (FIM), and Functional Oral Intake Scale); clinical (length of hospital stay, intubation, and presence of comorbidities such as systemic hypertension, diabetes, obesity, chronic obstructive pulmonary disease, asthma), and inflammatory data assessed by the C-reactive protein and D-dimer serum concentrations.

Results

Rectus femoris MT was associated with age, handgrip strength, Epworth Sleepiness Scale, and subcutaneous fat thickness (r² = 27.51%; p < 0.0001). Vastus intermedius MT was associated with age, pain intensity, handgrip strength, Epworth Sleepiness scale, FIM, and time since hospital discharge (r² = 21.12%; p < 0.0001). Rectus femoris EI was significantly associated with the male sex, TUG, Epworth Sleepiness Scale, and C-Reactive Protein levels (r² = 44.39%; p < 0.0001). Mean MT of rectus femoris and vastus intermedius are significantly different (p < 0.001).

Conclusion

After hospital discharge, long COVID patients present qualitative and quantitative skeletal muscle characteristics associated with a combination of demographic, clinical, and functional parameters.

Relationship Between Skeletal Muscle Quality and Hospital-Acquired Disability in Patients With Sepsis Admitted to the ICU: A Pilot Study

Early risk assessment of functional decline in patients with sepsis is clinically challenging. Recently, there is increasing interest in the nonvolitional evaluation of skeletal muscle quality.

OBJECTIVES

The aim of this study was to assess the relationship between skeletal muscle quality and functional decline after intensive care.

DESIGN SETTING AND PARTICIPANTS

This pilot study was a single-center prospective observational study conducted from March 2021 to February 2022. We included consecutive patients with sepsis who were admitted to our ICU.

MAIN OUTCOMES AND MEASURES

The primary outcome was hospital-acquired disability (HAD), which is defined as a decrease in the Barthel index score of at least 5 points from pre-hospital to hospital discharge. Muscle quality was assessed by: 1) muscle echogenicity with ultrasound and 2) phase angle (PhA) with bioelectrical impedance analysis, both of which were measured on ICU days less than 3, 3-5, 5-7, 7-10, and 10-14. We compared longitudinal changes in muscle echogenicity and PhA between the HAD and non-HAD groups using two-way repeated measures analysis of variance with mixed models.

RESULTS

Among the 22 patients, 7 (31.8%) had HAD. Muscle echogenicity was higher in the HAD group than in the non-HAD group (p < 0.001); however, no interaction effects were found between the two groups (p = 0.189). PhA showed a main effect on each evaluation day in patients (p = 0.040) and a significant interaction effect between the groups, including an early decreased pattern in the HAD group (p = 0.036).

CONCLUSIONS AND RELEVANCE

Higher muscle echogenicity and a decreased PhA pattern are related to HAD. Noninvasive assessment of muscle quality using ultrasound and bioelectrical impedance analysis may be useful in predicting the functional prognosis of patients with sepsis.

Association of nitrogen balance trajectories with clinical outcomes in critically ill COVID-19 patients: A retrospective cohort study

BACKGROUND & AIMS

The intensity and duration of the catabolic phase in COVID-19 patients can differ between survivors and non-survivors. The purpose of the study was to assess the determinants of, and association between, nitrogen balance trajectories and outcome in critically ill COVID-19 patients.

METHODS

This retrospective monocentric observational study involved patients admitted to the intensive care unit (ICU) of the University Hospital of Clermont Ferrand, France, from January 2020 to May 2021 for COVID-19 pneumonia. Patients were excluded if referred from another ICU, if their ICU length of stay was <72 h, or if they were treated with renal replacement therapy during the first seven days after ICU admission. Data were collected prospectively at admission and during ICU stay. Death was recorded at the end of ICU stay. Comparisons of the time course of nitrogen balance according to outcome were analyzed using two-way ANOVA. At days 3, 5, 7, 10 and 14, uni- and multivariate logistic regression analyses were performed to assess the impact of a non-negative nitrogen-balance on ICU death. To investigate the relationships between nitrogen balance, inflammatory markers and protein intake, linear and non-nonlinear models were run at days 3, 5 and 7, and the amount of protein intake necessary to reach a neutral nitrogen balance was calculated. Subgroup analyses were carried out according to BMI, age, and sex.

RESULTS

99 patients were included. At day 3, a similar negative nitrogen balance was observed in survivors and non-survivors: -16.4 g/d [-26.5, -3.3] and -17.3 g/d [-22.2, -3.8] (p = 0.54). The trajectories of nitrogen balance over time thus differed between survivors and non-survivors (p = 0.01). In survivors, nitrogen balance increased over time, but decreased from day 2 to day 6 in non-survivors, and thereafter increased slowly up to day 14. At days 5 and 7, a non-negative nitrogen-balance was protective from death. Administering higher protein amounts was associated with higher nitrogen balance.

CONCLUSION

We report a prolonged catabolic state in COVID patients that seemed more pronounced in non-survivors than in survivors. Our study underlines the need for monitoring urinary nitrogen excretion to guide the amount of protein intake required by COVID-19 patients.

Predictors of Sarcopenia in Outpatients with Post-Critical SARS-CoV2 Disease. Nutritional Ultrasound of Rectus Femoris Muscle, a Potential Tool

Background and Objectives: The loss of muscle mass in post-critical COVID-19 outpatients is difficult to assess due to the limitations of techniques and the high prevalence of obesity. Ultrasound is an emerging technique for evaluating body composition. The aim is to evaluate sarcopenia and its risk factors, determining ultrasound usefulness as a potential tool for this purpose according to established techniques, such as the bioimpedance vector analysis (BIVA), handgrip strength, and timed up-and-go test. Methods: This is a transversal study of 30 post-critical COVID-19 outpatients. We evaluated nutritional status by ultrasound (Rectus Femoris-cross-sectional-area (RF-CSA), thickness, and subcutaneous-adipose-tissue), BIVA, handgrip strength, timed up-and-go test, and clinical variables during admission. Results: According to The European Society for Clinical Nutrition and Metabolism and the European Association for the Study of Obesity (ESPEN&EASO) Consensus for Sarcopenic and Obesity, in terms of excess fat mass and decreased lean mass, the prevalence of class-1 sarcopenic obesity was 23.4% (n = 7), and class-2 sarcopenic obesity was 33.3% (n = 10) in our study. A total of 46.7% (n = 14) of patients had a handgrip strength below the 10th percentile, and 30% (n = 9) achieved a time greater than 10s in the timed up-and-go test. There were strong correlations between the different techniques that evaluated the morphological (BIVA, Ultrasound) and functional measurements of muscle. Intensive care unit stay, mechanical ventilation, and age all conditioned the presence of sarcopenia in COVID-19 outpatients (R2 = 0.488, p = 0.002). Predictive models for sarcopenic diagnosis based on a skeletal muscle index estimation were established by RF-CSA (R2 0.792, standard error of estimate (SEE) 1.10, p < 0.001), muscle-thickness (R2 0.774, SEE 1.14, p < 0.001), and handgrip strength (R2 0.856, SEE 0.92, p < 0.001). RF-CSA/weight of 5.3 cm2/kg × 100 was the cut-off value for predicting sarcopenia in post-critical COVID-19 outpatients, with 88.2 sensitivity and 69.2% specificity. Conclusion: More than half of the post-critical COVID-19 survivors had sarcopenic obesity and functional impairment of handgrip strength. Intensive care unit stay, age, and mechanical ventilation all predict sarcopenia. An ultrasound, when applied to the assessment of body composition in post-critical COVID-19 patients, provided the possibility of assessing sarcopenia in this population.

Nutrition support for critically ill patients during the COVID-19 pandemic: the Italian SIAARTI survey

Background

Critically ill, COVID-19 patients are characterized by a hypermetabolic state and a reduced food intake and are at high risk of malnutrition and lean body mass loss. An appropriate metabolic-nutritional intervention aims to reduce complications and improve the clinical outcomes. We conducted a cross-sectional, multicenter, observational, nationwide online survey involving Italian Intensivists to assess the nutritional practices in critically ill patients with COVID-19.

Results

A group of experts in nutrition of the Italian Society of Anaesthesia Analgesia Resuscitation and Intensive Care (SIAARTI) developed a 24-item questionnaire; the 9000 members of the Society were invited to participate through emails and social networks. Data was collected from June 1 to August 1, 2021.

A total of 545 responses were collected: 56% in northern, 25% in central, and 20% in southern Italy. Artificial nutrition support is directly handled by intensivists in > 90 of the cases; the nutritional status is assessed as suggested by the guidelines in more than 70% of the cases, and a form of nutrition support is started within the first 48 h from ICU admission by > 90% of the respondents. Nutritional targets are reached in 4–7 days in > 75% of the cases, mainly by the enteral route. Indirect calorimetry, muscle ultrasound, and bioimpedance analysis are used by a limited part of the interviewees. Only about a half of the respondents reported the nutritional issues in the ICU discharge summary.

Conclusions

This survey among Italian Intensivists during the COVID-19 epidemic showed how the beginning, progression, and route of nutritional support adhere to international recommendations, while recommendations on the tools to set the target and monitor the efficacy of the metabolic support are less followed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s44158-022-00063-6.

The Possible Impact of COVID-19 on Respiratory Muscles Structure and Functions: A Literature Review

The impact of SARS-CoV-2 infection on respiratory muscle functions is an important area of recent enquiry. COVID-19 has effects on the respiratory muscles. The diaphragm muscle is perturbed indirectly due to the mechanical-ventilation-induced-disuse, but also by direct mechanisms linked with SARS-CoV-2 viral infection. In this sense, a deeper understanding of the possible links between COVID-19 and alterations in structure and functions of the respiratory muscles may increase the success rate of preventive and supportive strategies. Ultrasound imaging alongside respiratory muscle strength tests and pulmonary function assessment are valid approaches to the screening and monitoring of disease, for mild to severe patients. The aim of the present review is to highlight the current literature regarding the links between COVID-19 and respiratory muscle functions. We examine from the pathophysiological aspects of disease, up to approaches taken to monitor and rehabilitate diseased muscle. We hope this work will add to a greater understanding of the pathophysiology and disease management of respiratory muscle pathology subsequent to SARS-CoV-2 infection.

Sonographic Evaluation of Muscle Echogenicity for the Detection of Intensive Care Unit-Acquired Weakness: A Pilot Single-Center Prospective Cohort Study

Qualitative assessment by the Heckmatt scale (HS) and quantitative greyscale analysis of muscle echogenicity were compared for their value in detecting intensive care unit-acquired weakness (ICU-AW). We performed muscle ultrasound (MUS) of eight skeletal muscles on day 3 and day 10 after ICU admission. We calculated the global mean greyscale score (MGS), the global mean z-score (MZS) and the global mean Heckmatt score (MHS). Longitudinal outcome was defined by the modified Rankin scale (mRS) and Barthel index (BI) after 100 days. In total, 652 ultrasound pictures from 38 critically ill patients (18 with and 20 without ICU-AW) and 10 controls were analyzed. Patients with ICU-AW had a higher MHS on day 10 compared to patients without ICU-AW (2.6 (0.4) vs. 2.2 (0.4), p = 0.006). The MHS was superior to ROC analysis (cut-off: 2.2, AUC: 0.79, p = 0.003, sensitivity 86%, specificity 60%) in detecting ICU-AW compared to MGS and MZS on day 10. The MHS correlated with the Medical Research Council sum score (MRC-SS) (r = −0.45, p = 0.004), the mRS (r = 0.45; p = 0.007) and BI (r = −0.38, p = 0.04) on day 100. Qualitative MUS analysis seems superior to quantitative greyscale analysis of muscle echogenicity for the detection of ICU-AW.

What Do We Need to Know About Musculoskeletal Manifestations of COVID-19?: A Systematic Review

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COVID-19 is a disease that is challenging science, health-care systems, and humanity. An astonishingly wide spectrum of manifestations of multi-organ damage, including musculoskeletal, can be associated with SARS-CoV-2.

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In the acute phase of COVID-19, fatigue, myalgia, and arthralgia are the most common musculoskeletal symptoms.

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Post-COVID-19 syndrome is a group of signs and symptoms that are present for >12 weeks. The associated musculoskeletal manifestations are fatigue, arthralgia, myalgia, new-onset back pain, muscle weakness, and poor physical performance.

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Data on COVID-19 complications are growing due to large absolute numbers of cases and survivors in these 2 years of the pandemic. Additional musculoskeletal manifestations encountered are falls by the elderly, increased mortality after hip fracture, reduced bone mineral density and osteoporosis, acute sarcopenia, rhabdomyolysis, Guillain-Barré syndrome, muscle denervation atrophy, fibromyalgia, rheumatological disease triggering, septic arthritis, adhesive capsulitis, myositis, critical illness myopathy, onset of latent muscular dystrophy, osteonecrosis, soft-tissue abscess, urticarial vasculitis with musculoskeletal manifestations, and necrotizing autoimmune myositis.

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A wide range of signs and symptoms involving the musculoskeletal system that affect quality of life and can result in a decrease in disability-adjusted life years. This powerful and unpredictable disease highlights the importance of multimodality imaging, continuing education, and multidisciplinary team care to support preventive measures, diagnosis, and treatment.

Human skeletal muscle size with ultrasound imaging: a comprehensive review

Skeletal muscle size is an important factor in assessing adaptation to exercise training and detraining, athletic performance, age-associated atrophy and mobility decline, clinical conditions associated with cachexia, and overall skeletal muscle health. Magnetic resonance (MR) imaging and computed tomography (CT) are widely accepted as the gold standard methods for skeletal muscle size quantification. However, it is not always feasible to use these methods (e.g., field studies, bedside studies, large cohort studies). Ultrasound has been available for skeletal muscle examination for more than 50 years and the development, utility, and validity of ultrasound imaging are underappreciated. It is now possible to use ultrasound in situations where MR and CT imaging are not suitable. This review provides a comprehensive summary of ultrasound imaging and human skeletal muscle size assessment. Since the first study in 1968, more than 600 articles have used ultrasound to examine the cross-sectional area and/or volume of 107 different skeletal muscles in more than 27,500 subjects of various ages, health status, and fitness conditions. Data from these studies, supported by decades of technological developments, collectively show that ultrasonography is a valid tool for skeletal muscle size quantification. Considering the wide-ranging connections between human health and function and skeletal muscle mass, the utility of ultrasound imaging will allow it to be employed in research investigations and clinical practice in ways not previously appreciated or considered.

Association of Gastric Antrum Echodensity and Acute Gastrointestinal Injury in Critically Ill Patients

(1) Background: Acute muscle inflammation leads to increased sonographic echodensity. We developed a technique to characterize the echodensity of the gastric antrum wall and assess its feasibility in evaluating the severity of acute gastrointestinal injury (AGI); (2) Methods: The B-mode images of the gastric antrum of each enrolled patient were obtained daily by point-of-care ultrasound (POCUS). The 50th percentile, 85th percentile, and mean value of the grayscale distribution according to histogram analysis (ED50, ED85, and EDmean, respectively) were used to characterize the gastric antrum echodensity. Consistency and correlation analyses were performed to evaluate the feasibility and reproducibility of gastric antrum echodensity measurement. The association of gastric antrum echodensity with the severity of AGI and its ability to predict feeding intolerance (FI) were analyzed; (3) Results: In total, 206 POCUS images of 43 patients were analyzed. The gastric antrum echodensity measurements had sufficient intra- and inter-investigator reliabilities (intraclass correlation coefficient >0.9 for all parameters). The ED50 showed a significant upward trend as AGI severity increased, as well as ED85 and EDmean (p for trend <0.001, respectively). Patients who experienced FI had a higher ED50 (67.8 vs. 56.1, p = 0.02), ED85 (85.6 vs. 71.2, p = 0.01), and EDmean (70.3 vs. 57.6, p = 0.01) upon enteral feeding initiation; (4) Conclusions: Measurement of gastric antrum echodensity was technically feasible and reproducible in ventilated patients. Increased gastric antrum echodensity was associated with greater severity of AGI. Patients with higher gastric antrum echodensity upon enteral nutrition initiation via a nasogastric tube were more likely to develop FI.

Muscle Evaluation and Hospital-Associated Disability in Acute Hospitalized Older Adults

OBJECTIVES

We aimed to examine the association of muscle evaluation, including muscle ultrasound, with hospital-associated disability (HAD), focusing on ADL categories.

DESIGN

A prospective observational cohort study.

SETTING AND PARTICIPANTS

We recruited patients aged 65 years or older who were admitted to the geriatric ward of an acute hospital between October 2019 and September 2021.

MEASUREMENTS

Handgrip strength, bioimpedance analyzer-determined skeletal muscle mass, bilateral thigh muscle thickness (BATT), and the echo intensity of the rectus femoris on muscle ultrasound were performed as muscle assessments. HAD was evaluated separately for mobility impairments and self-care impairments.

RESULTS

In total, 256 individuals (mean age, 85.2 years; male sex, 41.8%) were analyzed. HAD in mobility was more common than HAD in self-care (37.5% vs. 30.0%). Only BATT was independently associated with HAD in mobility in multiple logistic regression analysis. There was no significant association between muscle indicators and HAD in self-care.

CONCLUSION

A lower BATT was associated with a higher prevalence of HAD in mobility, suggesting the need to reconsider muscle assessment methods in hospitalized older adults. In addition, approaches other than physical may be required, such as psychosocial and environmental interventions to improve HAD in self-care.