Two-year outcomes, health care use, and costs of survivors of acute respiratory distress syndrome

Healthcare utilization 9 months pre- and post- COVID-19 hospitalization among patients discharged alive

BACKGROUND

Emerging evidence suggests that there is an increase in healthcare utilization (HCU) in patients due to Coronavirus Disease 2019 (COVID-19). We investigated the change in HCU pre and post hospitalization among patients discharged home from COVID-19 hospitalization for up to 9 months of follow up.

STUDY DESIGN AND METHODS

This retrospective study from a United States cohort used Optum® de-identified Clinformatics Data Mart; it included adults discharged home post hospitalization with primary diagnosis of COVID-19 between April 2020 and March 2021. We evaluated HCU of patients 9 months pre and post -discharge from index hospitalization. We defined HCU as emergency department (ED), inpatient, outpatient (office), rehabilitation/skilled nursing facility (SNF), telemedicine visits, and length of stay, expressed as number of visits per 10,000 person-days.

RESULTS

We identified 63,161 patients discharged home after COVID-19 hospitalization. The cohort of patients was mostly white (58.8%) and women (53.7%), with mean age 72.4 (SD± 12) years. These patients were significantly more likely to have increased HCU in the 9 months post hospitalization compared to the 9 months prior. Patients had a 47%, 67%, 65%, and 51% increased risk of ED (rate ratio 1.47; 95% CI 1.45-1.49; p < .0001), rehabilitation (rate ratio 1.67; 95% CI 1.61-1.73; p < .0001), office (rate ratio1.65; 95% CI 1.64-1.65; p < .0001), and telemedicine visits (rate ratio 1.5; 95% CI 1.48-1.54; p < .0001), respectively. We also found significantly different rates of HCU for women compared to men (women have higher risk of ED, rehabilitation, and telemedicine visits but a lower risk of inpatient visits, length of stay, and office visits than men) and for patients who received care in the intensive care unit (ICU) vs those who did not (ICU patients had increased risk of ED, inpatient, office, and telemedicine visits and longer length of stay but a lower risk of rehabilitation visits). Outpatient (office) visits were the highest healthcare service utilized post discharge (64.5% increase). Finally, the risk of having an outpatient visit to any of the specialties studied significantly increased post discharge. Interestingly, the risk of requiring a visit to pulmonary medicine was the highest amongst the specialties studied (rate ratio 3.35, 95% CI 3.26-3.45, p < .0001).

CONCLUSION

HCU was higher after index hospitalization compared to 9 months prior among patients discharged home post-COVID-19 hospitalization. The increases in HCU may be driven by those patients who received care in the ICU.

The effect of a selenium-based anti-inflammatory strategy on postoperative functional recovery in high-risk cardiac surgery patients - A nested sub-study of the sustain CSX trial

AIM

The cardiac surgery-related ischemia-reperfusion-related oxidative stress triggers the release of cytotoxic reactive oxygen and nitrogen species, contributing to organ failure and ultimately influencing patients' short- and long-term outcomes. Selenium is an essential co-factor for various antioxidant enzymes, thereby contributing to the patients' endogenous antioxidant and anti-inflammatory defense mechanisms. Given these selenium's pleiotropic functions, we investigated the effect of a high-dose selenium-based anti-inflammatory perioperative strategy on functional recovery after cardiac surgery.

MATERIALS AND METHODS

This prospective study constituted a nested sub-study of the SUSTAIN CSX trial, a double-blinded, randomized, placebo-controlled multicenter trial to investigate the impact of high-dose selenium supplementation on high-risk cardiac surgery patients' postoperative recovery. Functional recovery was assessed by 6-min walk distance, Short Form-36 (SF-36) and Barthel Index questionnaires.

KEY FINDINGS

174 patients were included in this sub-study. The mean age (SD) was 67.3 (8.9) years, and 78.7 % of the patients were male. The mean (SD) predicted 30-day mortality by the European System for Cardiac Operative Risk Evaluation II score was 12.6 % (9.4 %). There was no difference at hospital discharge and after three months in the 6-min walk distance between the selenium and placebo groups (131 m [IQR: not performed - 269] vs. 160 m [IQR: not performed - 252], p = 0.80 and 400 m [IQR: 299-461] vs. 375 m [IQR: 65-441], p = 0.48). The SF-36 and Barthel Index assessments also revealed no clinically meaningful differences between the selenium and placebo groups.

SIGNIFICANCE

A perioperative anti-inflammatory strategy with high-dose selenium supplementation did not improve functional recovery in high-risk cardiac surgery patients.

Prevalence, predictors, and outcomes of acute respiratory distress syndrome in severe stroke

OBJECTIVES

Patients with severe stroke are at high risk of developing acute respiratory distress syndrome (ARDS), but this severe complication was often under-diagnosed and rarely explored in stroke patients. We aimed to investigate the prevalence, early predictors, and outcomes of ARDS in severe stroke.

METHODS

This prospective study included consecutive patients admitted to neurological intensive care unit (neuro-ICU) with severe stroke, including acute ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. The incidence of ARDS was examined, and baseline characteristics and severity scores on admission were investigated as potential early predictors for ARDS. The in-hospital mortality, length of neuro-ICU stay, the total cost in neuro-ICU, and neurological functions at 90 days were explored.

RESULTS

Of 140 patients included, 35 (25.0%) developed ARDS. Over 90% of ARDS cases occurred within 1 week of admission. Procalcitonin (OR 1.310 95% CI 1.005-1.707, P = 0.046) and PaO2/FiO2 on admission (OR 0.986, 95% CI 0.979-0.993, P < 0.001) were independently associated with ARDS, and high brain natriuretic peptide (OR 0.994, 95% CI 0.989-0.998, P = 0.003) was a red flag biomarker warning that the respiratory symptoms may be caused by cardiac failure rather than ARDS. ARDS patients had longer stays and higher expenses in neuro-ICU. Among patients with ARDS, 25 (62.5%) were moderate or severe ARDS. All the patients with moderate to severe ARDS had an unfavorable outcome at 90 days.

CONCLUSIONS

ARDS is common in patients with severe stroke, with most cases occurring in the first week of admission. Procalcitonin and PaO2/FiO2 on admission are early predictors of ARDS. ARDS worsens both short-term and long-term outcomes. The conflict in respiratory support strategies between ARDS and severe stroke needs to be further studied.

Serum Mrp 8/14 as a Potential Biomarker for Predicting the Occurrence of Acute Respiratory Distress Syndrome Induced by Sepsis: A Retrospective Controlled Study

Background

To date, there are no studies regarding the Mrp 8/14 in predicting the occurrence of acute respiratory distress syndrome (ARDS) induced by sepsis. Thus, the objective of this study was to investigate the expression of Myeloid-related proteins 8 and 14 (Mrp 8/14) and its role in ARDS induced by sepsis.

Methods

A total of 168 septic patients were enrolled in the observational study. The baseline information and clinical outcomes were obtained retrospectively. Serum Mrp 8/14 level was determined by enzyme linked immunosorbent assay (ELISA). The patients were categorized into sepsis and ARDS group based on whether they developed ARDS during the intensive care unit (ICU) hospitalization.

Results

There was significant difference in the level of Mrp 8/14 between the sepsis group and ARDS groups (P < 0.05). Mrp 8/14 correlated positively with procalcitonin (PCT), interleukin-6 (IL-6), acute physiology and chronic health evaluation II (APACHE II) score, sequential organ failure assessment (SOFA) score on day 1, mechanical ventilation time, length of ICU stay and hospitalization expenses in ICU (all P < 0.05). Logistic regression analysis showed Mrp 8/14 was the independent factor for forecasting the occurrence of sepsis- induced ARDS (P < 0.05). The areas under receiver operating characteristic curves for Mrp 8/14 were higher than that of PCT, APACHE II score and SOFA score on day 1 (P < 0.05).

Conclusion

The serum Mrp 8/14 level at admission may be a potential marker for predicting the occurrence of ARDS induced by sepsis. Early detection of serum Mrp 8/14 could help clinicians to identify and evaluate the severity of ARDS induced by sepsis.

Intensive care unit follow-up clinic activities: a scoping review

The importance of ongoing post-discharge follow-up to prevent functional impairment in patients discharged from intensive care units (ICUs) is being increasingly recognized. Therefore, we conducted a scoping review, which included existing ICU follow-up clinic methodologies using the CENTRAL, MEDLINE, and CINAHL databases from their inception to December 2022. Data were examined for country or region, outpatient name, location, opening days, lead profession, eligible patients, timing of the follow-up, and assessment tools. Twelve studies were included in our review. The results obtained revealed that the methods employed by ICU follow-up clinics varied among countries and regions. The names of outpatient follow-up clinics also varied; however, all were located within the facility. These clinics were mainly physician or nurse led; however, pharmacists, physical therapists, neuropsychologists, and social workers were also involved. Some clinics were limited to critically ill patients with sepsis or those requiring ventilation. Ten studies reported the first outpatient visit 1-3 months after discharge. All studies assessed physical function, cognitive function, mental health, and the health-related quality of life. This scoping review revealed that an optimal operating format for ICU follow-up clinics needs to be established according to the categories of critically ill patients.

Physical and Cognitive Impairment in Acute Respiratory Failure

Recent research has brought renewed attention to the multifaceted physical and cognitive dysfunction that accompanies acute respiratory failure (ARF). This state-of-the-art review provides an overview of the evidence landscape encompassing ARF-associated neuromuscular and neurocognitive impairments. Risk factors, mechanisms, assessment tools, rehabilitation strategies, approaches to ventilator liberation, and interventions to minimize post-intensive care syndrome are emphasized. The complex interrelationship between physical disability, cognitive dysfunction, and long-term patient-centered outcomes is explored. This review highlights the need for comprehensive, multidisciplinary approaches to mitigate morbidity and accelerate recovery.

The Economic Burden of the COVID-19 Pandemic in State of Kuwait

Purpose

The main aim of this study is to estimate the provider's cost, patients' cost (home and institutional quarantine cost) and the total economic burden of COVID-19 for patients with PCR positive in Kuwait.

Patients and Methods

This cross-sectional and retrospective study identified the cost incurred for treating COVID-19 inpatients admitted to a General Hospital in Kuwait, a designated COVID-19 treatment center by the Kuwait Government during pandemic. A total of 485 COVID-19 patients were randomly selected from May 1st to September 31st, 2021. Data on sociodemographic information, length of stay (LOS), discharge status, and comorbidities were obtained from the patients' medical records. A step-down approach was done to estimate the healthcare provider cost per patient per admission. Patient cost (loss of productivity due to hospitalization, institutional and home quarantine) was calculated using human capital approach. The national economic burden of COVID-19 was estimated using costing data from a general hospital for the entire nation. The data were analyzed using the statistical software package SPSS version 25.

Results

In all, 485 COVID-19 patients were involved in the research. KD 2216 (USD 7,344) was the average cost per patient per admission. The ICU accounted for 20.6% of the total cost, the physician and nursing staff for 42.1%, and the laboratory services for 10.2%. The estimated annual cost of care for COVID-19 patients in Kuwait was KD 147.4 (USD 488.5) million, or 5.5% of the MOH budget for 2021, given that 9.03% (383,731) of the population had positive COVID-19 PCR results in 2021. The range of the estimated national economic burden, considering both the best and worst-case scenarios, is KD 73.6 (USD 244.2) million to KD 221.0 (USD 732.7) million.

Conclusion

COVID-19 poses a substantial financial strain on the healthcare system, estimated at 5.9% to 8.8% of the MOH's annual budget and 0.2% to 0.7% of Kuwait's GDP in 2021. To mitigate costs, prioritizing prevention and health education is crucial. Targeted strategies, such as workforce optimization, are needed to address high expenses. Policymakers and administrators should leverage these insights for enhanced efficiency and sustainability in future epidemic responses.

Psychological symptoms and health-related quality of life in intubated and non-intubated intensive care survivors: A multicentre, prospective observational cohort study

Objective

To compare long-term psychological symptoms and health-related quality of life (HRQOL) in intubated versus non-intubated ICU survivors.

Design

Prospective, multicentre observational cohort study.

Setting

Four tertiary medical-surgical ICUs in Australia.

Participants

Intubated and non-intubated adult ICU survivors.

Main outcome measures

Primary outcomes: clinically significant psychological symptoms at 3- and 12-month follow-up using Post-Traumatic Stress Syndrome-14 for post-traumatic stress disorder; Depression, Anxiety Stress Scales-21 for depression, anxiety, and stress. Secondary outcomes: HRQOL, using EuroQol-5D-5L questionnaire.

Results

Of the 133 ICU survivors, 54/116 (47 %) had at least one clinically significant psychological symptom (i.e., post-traumatic stress disorder, anxiety, depression, stress) at follow-up. Clinically significant scores for psychological symptoms were observed in 26 (39 %) versus 16 (32 %) at 3-months [odds ratio 1.4, 95 % confidence interval (0.66-3.13), p = 0.38]; 23 (37 %) versus 10 (31 %) at 12-months [odds ratio 1.3, 95 % confidence interval (0.53-3.31), p = 0.57] of intubated versus non-intubated survivors, respectively. Usual activities and mobility were the most commonly affected HRQOL dimension, with >30 % at 3 versus months and >20 % at 12-months of overall survivors reporting ≥ moderate problems. There was no difference between the groups in any of the EQ5D dimensions.

Conclusions

Nearly one-in-two (47 %) of the intubated and non-intubated ICU survivors reported clinically significant psychological symptoms at 3 and 12-month follow-ups. Overall, more than 30 % at 3-months and over 20 % at 12-months of the survivors in both groups had moderate or worse problems with their usual activities and mobility. The presence of psychological symptoms and HRQOL impairments was similar between the groups.

Long-term outcomes of patients supported with extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review and meta-analysis

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is increasingly used to support patients with severe acute respiratory distress syndrome (ARDS). The impact of ECMO on long-term outcomes of patients with severe ARDS is unclear.

METHODS

We searched electronic databases from inception to January 17th 2023. We selected clinical trials and observational studies reporting on long-term outcomes of patients supported with ECMO for ARDS. Health-related quality of life (HRQoL) was the primary outcome. Secondary outcomes included cognitive function, mental health, functional status, respiratory symptoms, and return to work.

RESULTS

Of the 7126 screened citations, 1 randomized clinical trial and 31 observational studies were included, of which 7 compared conventional mechanical ventilation (CMV) and ECMO. Overall quality of studies of the included studies was limited, with the majority being either low (45%) or fair (32%) quality. There was no significant difference in HRQoL measured with the SF-36 score between ECMO and CMV patients (physical component score [PCS]: mean difference 3.91 (- 6.22 to 14.05), mental component score [MCS] mean difference 1.33 (- 3.93 to 6.60)). There was no difference between cognitive function, mental health, functional status, and respiratory symptoms between ECMO and CMV, but data available for comparison were limited. There were high rates of disability for ECMO survivors with 49% of patients returning to work and 23% needing assistance at home on follow-up.

CONCLUSION

Survivors of ECMO for ARDS experience significant disability in multiple domains. Further studies are needed to examine the effect of ECMO on long-term outcomes of patients compared to CMV.

Post-intensive care syndrome follow-up system after hospital discharge: a narrative review

BACKGROUND

Post-intensive care syndrome (PICS) is the long-lasting impairment of physical functions, cognitive functions, and mental health after intensive care. Although a long-term follow-up is essential for the successful management of PICS, few reviews have summarized evidence for the efficacy and management of the PICS follow-up system.

MAIN TEXT

The PICS follow-up system includes a PICS follow-up clinic, home visitations, telephone or mail follow-ups, and telemedicine. The first PICS follow-up clinic was established in the U.K. in 1993 and its use spread thereafter. There are currently no consistent findings on the efficacy of PICS follow-up clinics. Under recent evidence and recommendations, attendance at a PICS follow-up clinic needs to start within three months after hospital discharge. A multidisciplinary team approach is important for the treatment of PICS from various aspects of impairments, including the nutritional status. We classified face-to-face and telephone-based assessments for a PICS follow-up from recent recommendations. Recent findings on medications, rehabilitation, and nutrition for the treatment of PICS were summarized.

CONCLUSIONS

This narrative review aimed to summarize the PICS follow-up system after hospital discharge and provide a comprehensive approach for the prevention and treatment of PICS.

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.

Protocol and statistical analysis plan for the identification and treatment of hypoxemic respiratory failure and acute respiratory distress syndrome with protection, paralysis, and proning: A type-1 hybrid stepped-wedge cluster randomised effectiveness-implementation study

Objective

To describe a study protocol and statistical analysis plan (SAP) for the identification and treatment of hypoxemic respiratory failure (HRF) and acute respiratory distress syndrome (ARDS) with protection, paralysis, and proning (TheraPPP) study prior to completion of recruitment, electronic data retrieval, and analysis of any data.

Design

TheraPPP is a stepped-wedge cluster randomised study evaluating a care pathway for HRF and ARDS patients. This is a type-1 hybrid effectiveness-implementation study design evaluating both intervention effectiveness and implementation; however primarily powered for the effectiveness outcome.

Setting

Seventeen adult intensive care units (ICUs) across Alberta, Canada.

Participants

We estimate a sample size of 18816 mechanically ventilated patients, with 11424 patients preimplementation and 7392 patients postimplementation. We estimate 2688 sustained ARDS patients within our study cohort.

Intervention

An evidence-based, stakeholder-informed, multidisciplinary care pathway called Venting Wisely that standardises diagnosis and treatment of HRF and ARDS patients.

Main outcome measures

The primary outcome is 28-day ventilator-free days (VFDs). The primary analysis will compare the mean 28-day VFDs preimplementation and postimplementation using a mixed-effects linear regression model. Prespecified subgroups include sex, age, HRF, ARDS, COVID-19, cardiac surgery, body mass index, height, illness acuity, and ICU volume.

Results

This protocol and SAP are reported using the Standard Protocol Items: Recommendations for Interventional Trials guidance and the Guidelines for the Content of Statistical Analysis Plans in Clinical Trials. The study received ethics approval and was registered (ClinicalTrials.gov-NCT04744298) prior to patient enrolment.

Conclusions

TheraPPP will evaluate the effectiveness and implementation of an HRF and ARDS care pathway.

Impact of COVID infection on lung function test and quality of life

Post-COVID-19 pulmonary sequalae are well-recognized early in the pandemic. Survivorship clinics are crucial for managing at-risk patients. However, it is unclear who requires pulmonary function test (PFT) and when PFTs should be performed. We aim to investigate for whom and how these interval PFTs should be performed. We performed a single-centre, prospective cohort study on COVID-19 survivors between 1st May 2020 and 31st April 2022. These patients were followed up at 6, 9 and 12 months with interval PFT and Short Form-36 (SF-36) Health Survey. Those with PFT defects were offered a computed tomography scan of the thorax. Of the 46 patients recruited, 17 (37%) had severe/critical illness. Compared to those with mild/moderate disease, these patients were more likely to experience DLCO defects (59% versus 17%, p = 0.005) and had lower SF-36 scores (mean physical component summary score of 45 ± 12 versus 52 ± 8, p = 0.046). These differences were most notable at 6 months, compared to the 9- and 12-months intervals. DLCO defects were also associated with older age, raised inflammatory markers and extensive CXR infiltrates. Besides interstitial-like abnormalities, obesity and undiagnosed lung conditions accounted for 39% of the PFT abnormalities. Interval PFTs can be performed earliest 6 months post-COVID-19. Patients with normal tests were unlikely to develop new abnormalities and would not require repeat PFTs. Abnormal PFTs can be followed-up with repeat PFTs 6 monthly until resolution. Non-COVID-19 differentials should be considered for persistent PFT abnormalities.

CNP-miR146a Decreases Inflammation in Murine Acute Infectious Lung Injury

Acute respiratory distress syndrome (ARDS) has approximately 40% in-hospital mortality, and treatment is limited to supportive care. Pneumonia is the underlying etiology in many cases with unrestrained inflammation central to the pathophysiology. We have previously shown that CNP-miR146a, a radical scavenging cerium oxide nanoparticle (CNP) conjugated to the anti-inflammatory microRNA(miR)-146a, reduces bleomycin- and endotoxin-induced acute lung injury (ALI) by decreasing inflammation. We therefore hypothesized that CNP-miR146a would decrease inflammation in murine infectious ALI. Mice were injured with intratracheal (IT) MRSA or saline followed by treatment with IT CNP-miR146a or saline control. Twenty-four hours post-infection, bronchoalveolar lavage fluid (BALF) and whole lungs were analyzed for various markers of inflammation. Compared to controls, MRSA infection significantly increased proinflammatory gene expression (IL-6, IL-8, TNFα, IL-1β; p < 0.05), BALF proinflammatory cytokines (IL-6, IL-8, TNFα, IL-1β; p < 0.01), and inflammatory cell infiltrate (p = 0.03). CNP-miR146a treatment significantly decreased proinflammatory gene expression (IL-6, IL-8, TNFα, IL-1β; p < 0.05), bronchoalveolar proinflammatory protein leak (IL-6, IL-8, TNFα; p < 0.05), and inflammatory infiltrate (p = 0.01). CNP-miR146a decreases inflammation and improves alveolar-capillary barrier integrity in the MRSA-infected lung and has significant promise as a potential therapeutic for ARDS.

Autophagy ablation in skeletal muscles worsens sepsis-induced muscle wasting, impairs whole-body metabolism, and decreases survival

Septic patients frequently develop skeletal muscle wasting and weakness, resulting in severe clinical consequences and adverse outcomes. Sepsis triggers sustained induction of autophagy, a key cellular degradative pathway, in skeletal muscles. However, the impact of enhanced autophagy on sepsis-induced muscle dysfunction remains unclear. Using an inducible and muscle-specific Atg7 knockout mouse model (Atg7iSkM-KO), we investigated the functional importance of skeletal muscle autophagy in sepsis using the cecal ligation and puncture model. Atg7iSkM-KO mice exhibited a more severe phenotype in response to sepsis, marked by severe muscle wasting, hypoglycemia, higher ketone levels, and a decreased in survival as compared to mice with intact Atg7. Sepsis and Atg7 deletion resulted in the accumulation of mitochondrial dysfunction, although sepsis did not further worsen mitochondrial dysfunction in Atg7iSkM-KO mice. Overall, our study demonstrates that autophagy inactivation in skeletal muscles triggers significant worsening of sepsis-induced muscle and metabolic dysfunctions and negatively impacts survival.

Acute hypoxaemic respiratory failure after treatment with lower tidal volume ventilation facilitated by extracorporeal carbon dioxide removal: long-term outcomes from the REST randomised trial

INTRODUCTION

Lower tidal volume ventilation, facilitated by veno-venous extracorporeal carbon dioxide removal (vv-ECCO2R), does not improve 90-day mortality in patients with acute hypoxaemic respiratory failure (AHRF). The aim of this analysis was to evaluate the effect of this therapeutic strategy on long-term outcomes.

METHODS

This was a prespecified analysis of the REST trial, a UK-wide multicentre randomised clinical trial that compared lower tidal volume ventilation, facilitated by vv-ECCO2R (intervention), with standard care in the treatment of patients with moderate-to-severe AHRF. Mortality to 2 years was assessed, while respiratory function, post-traumatic stress disorder, cognitive function and health-related quality of life were evaluated in survivors at 1 year using standardised questionnaires.

RESULTS

Of 412 patients enrolled into the REST trial, 391 (95%) had 2-year mortality outcome data available. There was no difference in the time to death between intervention and standard care (HR 1.08 (0.81, 1.44); log-rank test p=0.61). 161 patients alive at 1 year provided at least one questionnaire response. There was no difference in respiratory function, post-traumatic stress disorder, cognitive dysfunction or health-related quality of life between patients allocated to intervention or standard care.

CONCLUSION

Lower-tidal volume ventilation facilitated by vv-ECCO2R does not affect 1-year mortality in patients with moderate-to-severe AHRF. Of the patients who provided questionnaire responses, there was no treatment effect on long-term respiratory function, post-traumatic stress disorder, cognitive dysfunction or health-related quality of life.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier: NCT02654327.

[Aftercare of ICU patients: A task for pneumology?]

As the number of patients treated in intensive care medicine increases, so does the number of those who suffer from the long-term consequences of critical illness and the consequences of a stay in an intensive care unit. For this group of patients with a post-intensive care syndrome (PICS), there are currently no specialized outpatient care structures that follow the hospital stay and possible follow-up treatment. A number of studies are researching the effectiveness of intensive care outpatient clinics nationally and internationally.After presenting the PICS and the associated complex need for care, this review article presents various model projects for outpatient follow-up care of critically ill patients. We discuss whether the field of pneumology is particularly suitable for the study of therapy control of complex clinical pictures since it has vast experience in the treatment of intensive care patients and the outpatient care of chronically ill patients.

Economic Burden of ICU-Hospitalized COVID-19 Patients: A Systematic Review and Meta-Analysis

The impact of the coronavirus disease 2019 (COVID-19) pandemic on the global economy is far-reaching and difficult to assess accurately. We aimed to systematically determine the magnitude of the costs and the economic burden of intensive care for hospitalized COVID-19 patients since the onset of the pandemic by means of a systematic review. We conducted a PRISMA 2020-compliant (protocol: PROSPERO CRD42022348741) systematic review by searching PubMed, EMBASE, and Web of Science for relevant literature. We included studies that presented costs based on a primary partial economic evaluation. Using the Consolidated Health Economic Evaluation Reporting Standards checklist and the population, intervention, control, and outcome criteria, we established the risk of bias in studies at the individual level. Daily cost per ICU admission and total cost per ICU patient of the original studies extracted. A random effect model was adopted for meta-analysis whenever possible. Of the 1,635 unique records identified, 14 studies related to ICU-hospitalized costs due to COVID-19 were eligible for inclusion. Included studies represented 93,721 hospitalized COVID-19 patients. Regarding total direct medical costs, the lowest cost per patient at ICU was observed in Turkey ($2,984.78 ± 2,395.93), while the highest was in Portugal ($51,358.52 ± 30,150.38). The Republic of Korea reported the highest length of stay of 29.4 days (±17.80), and the lowest is observed in India for nine days (±5.98). Our findings emphasize COVID-19's significance on health-economic outcomes. Limited research exists on the economic burden of COVID-19 in the ICU. Further studies on cost estimates can enhance data clarity, enabling informed analysis of healthcare costs and aiding efficient patient care organization by care providers and policymakers.

CNP-miR146a improves outcomes in a two-hit acute- and ventilator-induced lung injury model

Acute respiratory distress syndrome (ARDS) has high mortality (~40 %) and requires the lifesaving intervention of mechanical ventilation. A variety of systemic inflammatory insults can progress to ARDS, and the inflamed and injured lung is susceptible to ventilator-induced lung injury (VILI). Strategies to mitigate the inflammatory response while restoring pulmonary function are limited, thus we sought to determine if treatment with CNP-miR146a, a conjugate of novel free radical scavenging cerium oxide nanoparticles (CNP) to the anti-inflammatory microRNA (miR)-146a, would protect murine lungs from acute lung injury (ALI) induced with intratracheal endotoxin and subsequent VILI. Lung injury severity and treatment efficacy were evaluated via lung mechanical function, relative gene expression of inflammatory biomarkers, and lung morphometry (stereology). CNP-miR146a reduced the severity of ALI and slowed the progression of VILI, evidenced by improvements in inflammatory biomarkers, atelectasis, gas volumes in the parenchymal airspaces, and the stiffness of the pulmonary system.

Inhibition of a Microbiota-derived Peptide Ameliorates Established Acute Lung Injury

Acute lung injury is a clinical syndrome characterized by a diffuse lung inflammation that commonly evolves into acute respiratory distress syndrome and respiratory failure. The lung microbiota is involved in the pathogenesis of acute lung injury. Corisin, a proapoptotic peptide derived from the lung microbiota, plays a role in acute lung injury and acute exacerbation of pulmonary fibrosis. Preventive therapeutic intervention with a monoclonal anticorisin antibody inhibits acute lung injury in mice. However, whether inhibition of corisin with the antibody ameliorates established acute lung injury is unknown. Here, the therapeutic effectiveness of the anticorisin antibody in already established acute lung injury in mice was assessed. Lipopolysaccharide was used to induce acute lung injury in mice. After causing acute lung injury, the mice were treated with a neutralizing anticorisin antibody. Mice treated with the antibody showed significant improvement in lung radiological and histopathological findings, decreased lung infiltration of inflammatory cells, reduced markers of lung tissue damage, and inflammatory cytokines in bronchoalveolar lavage fluid compared to untreated mice. In addition, the mice treated with anticorisin antibody showed significantly increased expression of antiapoptotic proteins with decreased caspase-3 activation in the lungs compared to control mice treated with an irrelevant antibody. In conclusion, these observations suggest that the inhibition of corisin is a novel and promising approach for treating established acute lung injury.

COVID-19 does not influence functional status after ARDS therapy

RATIONALE

Health-related quality of life after surviving acute respiratory distress syndrome has come into focus in recent years, especially during the coronavirus disease 2019 pandemic.

OBJECTIVES

A total of 144 patients with acute respiratory distress syndrome caused by COVID-19 or of other origin were recruited in a randomized multicenter trial.

METHODS

Clinical data during intensive care treatment and data up to 180 days after study inclusion were collected. Changes in the Sequential Organ Failure Assessment score were used to quantify disease severity. Disability was assessed using the Barthel index on days 1, 28, 90, and 180.

MEASUREMENTS

Mortality rate and morbidity after 180 days were compared between patients with and without COVID-19. Independent risk factors associated with high disability were identified using a binary logistic regression.

MAIN RESULTS

The SOFA score at day 5 was an independent risk factor for high disability in both groups, and score dynamic within the first 5 days significantly impacted disability in the non-COVID group. Mortality after 180 days and impairment measured by the Barthel index did not differ between patients with and without COVID-19.

CONCLUSIONS

Resolution of organ dysfunction within the first 5 days significantly impacts long-term morbidity. Acute respiratory distress syndrome caused by COVID-19 was not associated with increased mortality or morbidity.

Prone Positioning for Acute Hypoxemic Respiratory Failure and ARDS: A Review

Prone positioning is an immediately accessible, readily implementable intervention that was proposed initially as a method for improvement in gas exchange > 50 years ago. Initially implemented clinically as an empiric therapy for refractory hypoxemia, multiple clinical trials were performed on the use of prone positioning in various respiratory conditions, cumulating in the landmark Proning Severe ARDS Patients trial, which demonstrated mortality benefit in patients with severe ARDS. After this trial and the corresponding meta-analysis, expert consensus and societal guidelines recommended the use of prone positioning for the management of severe ARDS. The ongoing COVID-19 pandemic has brought prone positioning to the forefront of medicine, including widespread implementation of prone positioning in awake, spontaneously breathing, nonintubated patients with acute hypoxemic respiratory failure. Multiple clinical trials now have been performed to investigate the safety and effectiveness of prone positioning in these patients and have enhanced our understanding of the effects of the prone position in respiratory failure. In this review, we discuss the physiologic features, clinical outcome data, practical considerations, and lingering questions of prone positioning.

Quality of Life in COVID-Related ARDS Patients One Year after Intensive Care Discharge (Odissea Study): A Multicenter Observational Study

BACKGROUND

Investigating the health-related quality of life (HRQoL) after intensive care unit (ICU) discharge is necessary to identify possible modifiable risk factors. The primary aim of this study was to investigate the HRQoL in COVID-19 critically ill patients one year after ICU discharge.

METHODS

In this multicenter prospective observational study, COVID-19 patients admitted to nine ICUs from 1 March 2020 to 28 February 2021 in Italy were enrolled. One year after ICU discharge, patients were required to fill in short-form health survey 36 (SF-36) and impact of event-revised (IES-R) questionnaire. A multivariate linear or logistic regression analysis to search for factors associated with a lower HRQoL and post-traumatic stress disorded (PTSD) were carried out, respectively.

RESULTS

Among 1003 patients screened, 343 (median age 63 years [57-70]) were enrolled. Mechanical ventilation lasted for a median of 10 days [2-20]. Physical functioning (PF 85 [60-95]), physical role (PR 75 [0-100]), emotional role (RE 100 [33-100]), bodily pain (BP 77.5 [45-100]), social functioning (SF 75 [50-100]), general health (GH 55 [35-72]), vitality (VT 55 [40-70]), mental health (MH 68 [52-84]) and health change (HC 50 [25-75]) describe the SF-36 items. A median physical component summary (PCS) and mental component summary (MCS) scores were 45.9 (36.5-53.5) and 51.7 (48.8-54.3), respectively, considering 50 as the normal value of the healthy general population. In all, 109 patients (31.8%) tested positive for post-traumatic stress disorder, also reporting a significantly worse HRQoL in all SF-36 domains. The female gender, history of cardiovascular disease, liver disease and length of hospital stay negatively affected the HRQoL. Weight at follow-up was a risk factor for PTSD (OR 1.02, p = 0.03).

CONCLUSIONS

The HRQoL in COVID-19 ARDS (C-ARDS) patients was reduced regarding the PCS, while the median MCS value was slightly above normal. Some risk factors for a lower HRQoL have been identified, the presence of PTSD is one of them. Further research is warranted to better identify the possible factors affecting the HRQoL in C-ARDS.

Use of Aerosolized Prostacyclins in Critically Ill Patients and Association With Clinical Outcomes

Aerosolized prostacyclins are frequently used in patients with severe acute respiratory distress syndrome and refractory hypoxia. Previous studies have shown improvement in oxygenation with use of pulmonary vasodilators such as iloprost and epoprostenol; however, there is no head-to-head comparison between these agents.

OBJECTIVES

To compare the effects of inhaled epoprostenol and inhaled iloprost in critically ill patients with refractory hypoxia.

DESIGN SETTING AND PARTICIPANTS

We performed a retrospective cohort analysis of patients admitted to the ICUs at the University of Oklahoma Health Sciences Center between 2015 and 2018. Adult patients who received aerosolized epoprostenol or iloprost for more than 4 hours were included in the analysis.

MAIN OUTCOMES AND MEASURES

The primary endpoint measured was to compare the change in Pao₂/Fio₂ ratio between patients treated with iloprost compared with epoprostenol. Secondary outcomes measured were 90-day in-hospital mortality and improvement in vasopressor requirements.

RESULTS

A total of 126 patients were included in the study, 95 of whom received iloprost (75%) and 31 patients (25%) received epoprostenol. There were significant improvements in Pao₂/Fio₂ ratio in both the iloprost and epoprostenol group. Patients in the epoprostenol group appeared to have a higher 90-day mortality compared with the iloprost group. However, our study was not powered to detect a mortality difference and this finding likely represents a sicker population in the epoprostenol group and prescription bias. The use of iloprost was associated with higher vasopressor requirements in the first 12 hours of administration, an association was not observed in the epoprostenol group.

CONCLUSIONS AND RELEVANCE

In this retrospective cohort analysis, use of both pulmonary vasodilators was associated with similar improvement in gas exchange. The mortality difference observed likely represents difference in severity of illness. Further studies are needed to corroborate these findings.

Days Spent at Home and Mortality After Critical Illness: A Cluster Analysis Using Nationwide Data

BACKGROUND

Beyond the question of short-term survival, days spent at home could be considered a patient-centered outcome in critical care trials.

RESEARCH QUESTION

What are the days spent at home and health care trajectories during the year after surviving critical illness?

STUDY DESIGN AND METHODS

Data were extracted on adult survivors spending at least 2 nights in a French ICU during 2018 who were treated with invasive mechanical ventilation or vasopressors or inotropes. Trauma, burn, organ transplant, stroke, and neurosurgical patients were excluded. Stays at home, death, and hospitalizations were reported before and after ICU stay, using state sequence analysis. An unsupervised clustering method was performed to identify cohorts based on post-ICU trajectories.

RESULTS

Of 77,132 ICU survivors, 89% returned home. In the year after discharge, these patients spent a median of 330 (interquartile range [IQR], 283-349) days at home. At 1 year, 77% of patients were still at home and 17% had died. Fifty-one percent had been re-hospitalized, and 10% required a further ICU admission. Forty-eight percent used rehabilitation facilities, and 5.7%, hospital at home. Three clusters of patients with distinct post-ICU trajectories were identified. Patients in cluster 1 (68% of total) survived and spent most of the year at home (338 [323-354] days). Patients in cluster 2 (18%) had more complex trajectories, but most could return home (91%), spending 242 (174-277) days at home. Patients in cluster 3 (14%) died, with only 37% returning home for 45 (15-90) days.

INTERPRETATION

Many patients had complex health care trajectories after surviving critical illness. Wide variations in the ability to return home after ICU discharge were observed between clusters, which represents an important patient-centered outcome.

MiCare study, an evaluation of structured, multidisciplinary and personalised post-ICU care on physical and psychological functioning, and quality of life of former ICU patients: a study protocol of a stepped-wedge cluster randomised controlled trial

INTRODUCTION

Over 70% of the intensive care unit (ICU) survivors suffer from long-lasting physical, mental and cognitive problems after hospital discharge. Post-ICU care is recommended by international guidelines, but evidence for cost-effectiveness lacks. The aim of this study is to evaluate the clinical effectiveness and cost-effectiveness of structured, multidisciplinary and personalised post-ICU care versus usual care on physical and psychological functioning and health-related quality of life (HRQoL) of ICU survivors, 1- and 2-year post-ICU discharge.

METHODS AND ANALYSIS

The MONITOR-IC post-ICU care study (MiCare study) is a multicentre stepped-wedge randomised controlled trial conducted in five hospitals. Adult patients at high risk for critical illness-associated morbidity post-ICU will be selected and receive post-ICU care, including an invitation to the post-ICU clinic 3 months after ICU discharge. A personalised long-term recovery plan tailored to patients' reported outcome measures will be made. 770 (intervention) and 1480 (control) patients will be included. Outcomes are 1- and 2-year HRQoL (EuroQol Instrument (EQ-5D-5L)), physical (fatigue and new physical problems), mental (anxiety, depression and post-traumatic stress disorder), and cognitive symptoms and cost-effectiveness. Medical data will be retrieved from patient records and cost data from health insurance companies.

ETHICS AND DISSEMINATION

Due to the lack of evidence, Dutch healthcare insurers do not reimburse post-ICU care. Therefore, evaluation of cost-effectiveness and integration in guidelines supports the evidence. Participation of several societies for physicians, nurses, paramedics, and patients and relatives in the project team increases the support for implementation of the intervention in clinical practice. Patients and relatives will be informed by the patient associations, hospitals and professional associations. Informing healthcare insurers about this project's results is important for the consideration for inclusion of post-ICU care in Dutch standard health insurance. The study is approved by the Radboud University Medical Centre research ethics committee (2021-13125).

TRIAL REGISTRATION NUMBER

NCT05066984.

Health outcomes in people 2 years after surviving hospitalisation with COVID-19: a longitudinal cohort study

BACKGROUND

With the ongoing COVID-19 pandemic, growing evidence shows that a considerable proportion of people who have recovered from COVID-19 have long-term effects on multiple organs and systems. A few longitudinal studies have reported on the persistent health effects of COVID-19, but the follow-up was limited to 1 year after acute infection. The aim of our study was to characterise the longitudinal evolution of health outcomes in hospital survivors with different initial disease severity throughout 2 years after acute COVID-19 infection and to determine their recovery status.

METHODS

We did an ambidirectional, longitudinal cohort study of individuals who had survived hospitalisation with COVID-19 and who had been discharged from Jin Yin-tan Hospital (Wuhan, China) between Jan 7 and May 29, 2020. We measured health outcomes 6 months (June 16-Sept 3, 2020), 12 months (Dec 16, 2020-Feb 7, 2021), and 2 years (Nov 16, 2021-Jan 10, 2022) after symptom onset with a 6-min walking distance (6MWD) test, laboratory tests, and a series of questionnaires on symptoms, mental health, health-related quality of life (HRQoL), return to work, and health-care use after discharge. A subset of COVID-19 survivors received pulmonary function tests and chest imaging at each visit. Age-matched, sex-matched, and comorbidities-matched participants without COVID-19 infection (controls) were introduced to determine the recovery status of COVID-19 survivors at 2 years. The primary outcomes included symptoms, modified British Medical Research Council (mMRC) dyspnoea scale, HRQoL, 6MWD, and return to work, and were assessed in all COVID-19 survivors who attended all three follow-up visits. Symptoms, mMRC dyspnoea scale, and HRQoL were also assessed in controls.

FINDINGS

2469 patients with COVID-19 were discharged from Jin Yin-tan Hospital between Jan 7 and May 29, 2020. 1192 COVID-19 survivors completed assessments at the three follow-up visits and were included in the final analysis, 1119 (94%) of whom attended the face-to-face interview 2 years after infection. The median age at discharge was 57·0 years (48·0-65·0) and 551 (46%) were women. The median follow-up time after symptom onset was 185·0 days (IQR 175·0-197·0) for the visit at 6 months, 349·0 days (337·0-360·0) for the visit at 12 months, and 685·0 days (675·0-698·0) for the visit at 2 years. The proportion of COVID-19 survivors with at least one sequelae symptom decreased significantly from 777 (68%) of 1149 at 6 months to 650 (55%) of 1190 at 2 years (p<0·0001), with fatigue or muscle weakness always being the most frequent. The proportion of COVID-19 survivors with an mMRC score of at least 1 was 168 (14%) of 1191 at 2 years, significantly lower than the 288 (26%) of 1104 at 6 months (p<0·0001). HRQoL continued to improve in almost all domains, especially in terms of anxiety or depression: the proportion of individuals with symptoms of anxiety or depression decreased from 256 (23%) of 1105 at 6 months to 143 (12%) 1191 at 2 years (p<0·0001). The proportion of individuals with a 6MWD less than the lower limit of the normal range declined continuously in COVID-19 survivors overall and in the three subgroups of varying initial disease severity. 438 (89%) of 494 COVID-19 survivors had returned to their original work at 2 years. Survivors with long COVID symptoms at 2 years had lower HRQoL, worse exercise capacity, more mental health abnormality, and increased health-care use after discharge than survivors without long COVID symptoms. COVID-19 survivors still had more prevalent symptoms and more problems in pain or discomfort, as well as anxiety or depression, at 2 years than did controls. Additionally, a significantly higher proportion of survivors who had received higher-level respiratory support during hospitalisation had lung diffusion impairment (43 [65%] of 66 vs 24 [36%] of 66, p=0·0009), reduced residual volume (41 [62%] vs 13 [20%], p<0·0001), and total lung capacity (26 [39%] vs four [6%], p<0·0001) than did controls.

INTERPRETATION

Regardless of initial disease severity, COVID-19 survivors had longitudinal improvements in physical and mental health, with most returning to their original work within 2 years; however, the burden of symptomatic sequelae remained fairly high. COVID-19 survivors had a remarkably lower health status than the general population at 2 years. The study findings indicate that there is an urgent need to explore the pathogenesis of long COVID and develop effective interventions to reduce the risk of long COVID.

SIRT1-mediated p53 deacetylation inhibits ferroptosis and alleviates heat stress-induced lung epithelial cells injury

OBJECTIVE

Acute lung injury (ALI) is a common complication of heat stroke (HS) and a direct cause of death. However, the mechanism underlying ALI following HS remains unclear.

METHOD

To investigate whether ferroptosis is involved in HS-ALI. We established a HS model of mice and mouse lung epithelial-2 cells (MLE-2). The severity of lung injury was measured by H&E staining, the wet-to-dry lung weight ratio, and Transmission electron microscopy. Potential markers of ferroptosis Fe²⁺, malondialdehyde (MDA), hydroxynonenal (4-HNE) and lipid peroxidation were detected. The percentages of cell death and viability induced by HS were assessed by LDH and CCK8 assays. SLC7A11, ACSL4, GPX4, SIRT1, p53, and p53 K382 acetylation levels were measured by Western blot.

RESULTS

The administration of ferroptosis inhibitor ferrostatin-1(Fer-1) could significantly ameliorate lung injury, inhibiting levels of MDA and 4-HNE, and ameliorating HS-induced increased ACSL4, decreased SLC7A11 and GPX4, suggesting ferroptosis was involved in HS-induced ALI in vivo and in vitro. Moreover, SIRT1 expression decreased, and p53 K382 acetylation levels increased in MLE-2 cells. Activation of SIRT1 could improve lung epithelial ferroptosis caused by HS in vivo ang in vitro. Besides, the activation of SIRT1 could significantly reduce the p53 K382 acetylation levels, suggesting that activation of SIRT1 could prevent ferroptosis via inhibiting p53 acetylation.

CONCLUSION

These findings substantiate the vital role of the SIRT1/p53 axis in mediating ferroptosis in HS-ALI, suggesting that targeting SIRT1 may represent a novel therapeutic strategy to ameliorate ALI during HS.

Assessment of Patient Health-Related Quality of Life and Functional Outcomes in Pediatric Acute Respiratory Distress Syndrome

OBJECTIVES

To describe health-related quality of life (HRQL) and functional outcomes in pediatric acute respiratory distress syndrome (ARDS) and to determine risk factors associated with poor outcome defined as death or severe reduction in HRQL at 28 days or ICU discharge.

DESIGN

Prospective multisite cohort-outcome study conducted between 2019 and 2020.

SETTING

Eight academic PICUs in the United States.

PATIENTS

Children with ARDS based on standard criteria.

INTERVENTIONS

Patient characteristics and illness severity were collected during PICU admission. Parent proxy-report measurements were obtained at baseline, day 28/ICU discharge, month 3, and month 9, utilizing Pediatric Quality of Life Inventory and Functional Status Scale (FSS). A composite outcome evaluated using univariate and multivariate analysis was death or severe reduction in HRQL (>25% reduction in the Pediatric Quality of Life Inventory at day 28/ICU discharge.

MEASUREMENTS AND MAIN RESULTS

This study enrolled 122 patients with a median age of 3 years (interquartile range, 1-12 yr). Common etiologies of ARDS included pneumonia ( n = 63; 52%) and sepsis ( n = 27; 22%). At day 28/ICU discharge, half (50/95; 53%) of surviving patients with follow-up data reported a greater than 10% decrease in HRQL from baseline, and approximately one-third of participants ( n = 19/61; 31%) reported a greater than 10% decrease in HRQL at 9 months. Trends in FSS were similar. Of 104 patients with data, 47 patients (45%) died or reported a severe decrease of greater than 25% in HRQL at day 28/ICU discharge. Older age was associated with an increased risk of death or severe reduction in HRQL (odds ratio, 1.08; CI, 1.01-1.16).

CONCLUSIONS

Children with ARDS are at risk for deterioration in HRQL and FSS that persists up to 9 months after ARDS. Almost half of children with ARDS experience a poor outcome including death or severe reduction in HRQL at day 28/ICU discharge.

Real-time seizure detection in paediatric intensive care patients: the RESET child brain protocol

INTRODUCTION

Approximately 20%-40% of comatose children with risk factors in intensive care have electrographic-only seizures; these go unrecognised due to the absence of continuous electroencephalography (EEG) monitoring (cEEG). Utility of cEEG with high-quality assessment is currently limited due to high-resource requirements. New software analysis tools are available to facilitate bedside cEEG assessment using quantitative EEG (QEEG) trends. The primary aim of this study is to describe accuracy of interpretation of QEEG trends by paediatric intensive care unit (PICU) nurses compared with cEEG assessment by neurologist (standard clinical care) in children at risk of seizures and status epilepticus utilising diagnostic test statistics. The secondary aims are to determine time to seizure detection for QEEG users compared with standard clinical care and describe impact of confounders on accuracy of seizure detection.

METHODS AND ANALYSIS

This will be a single-centre, prospective observational cohort study evaluating a paediatric QEEG programme utilising the full 19 electrode set. The setting will be a 36-bed quaternary PICU with medical, cardiac and general surgical cases. cEEG studies in PICU patients identified as 'at risk of seizures' will be analysed. Trained bedside clinical nurses will interpret the QEEG. Seizure events will be marked as seizures if >3 QEEG criteria occur. Post-hoc dedicated neurologists, who remain blinded to the QEEG analysis, will interpret the cEEG. Determination of standard test characteristics will assess the primary hypothesis. To calculate 95% (CIs) around the sensitivity and specificity estimates with a CI width of 10%, the sample size needed for sensitivity is 80 patients assuming each EEG will have approximately 9 to 18 1-hour epochs.

ETHICS AND DISSEMINATION

The study has received approval by the Children's Health Queensland Human Research Ethics Committee (HREC/19/QCHQ/58145). Results will be made available to the funders, critical care survivors and their caregivers, the relevant societies, and other researchers.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ANZCTR) 12621001471875.

A multicentre evaluation exploring the impact of an integrated health and social care intervention for the caregivers of ICU survivors

Background

Caregivers and family members of Intensive Care Unit (ICU) survivors can face emotional problems following patient discharge from hospital. We aimed to evaluate the impact of a multi-centre integrated health and social care intervention, on caregiver and family member outcomes.

Methods

This study evaluated the impact of the Intensive Care Syndrome: Promoting Independence and Return to Employment (InS:PIRE) programme across 9 sites in Scotland. InS:PIRE is an integrated health and social care intervention. We compared caregivers who attended this programme with a contemporary control group of ICU caregivers (usual care cohort), who did not attend.

Results

The primary outcome was anxiety measured via the Hospital Anxiety and Depression Scale at 12 months post-hospital discharge. Secondary outcome measures included depression, carer strain and clinical insomnia. A total of 170 caregivers had data available at 12 months for inclusion in this study; 81 caregivers attended the InS:PIRE intervention and completed outcome measures at 12 months post-hospital discharge. In the usual care cohort of caregivers, 89 completed measures. The two cohorts had similar baseline demographics. After adjustment, those caregivers who attended InS:PIRE demonstrated a significant improvement in symptoms of anxiety (OR: 0.42, 95% CI: 0.20–0.89, p = 0.02), carer strain (OR: 0.39; 95% CI: 0.16–0.98 p = 0.04) and clinical insomnia (OR: 0.40; 95% CI: 0.17–0.77 p < 0.001). There was no significant difference in symptoms of depression at 12 months.

Conclusions

This multicentre evaluation has shown that caregivers who attended an integrated health and social care intervention reported improved emotional health and less symptoms of insomnia, 12 months after the delivery of the intervention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04014-z.

Outcomes of critically ill COVID-19 survivors and caregivers: a case study-centred narrative review

PURPOSE

Critical illness is a transformative experience for both patients and their family members. For COVID-19 patients admitted to the intensive care unit (ICU), survival may be the start of a long road to recovery. Our knowledge of the post-ICU long-term sequelae of acute respiratory distress syndrome (ARDS) and severe acute respiratory syndrome (SARS) may inform our understanding and management of the long-term effects of COVID-19.

SOURCE

We identified international and Canadian epidemiologic data on ICU admissions for COVID-19, COVID-19 pathophysiology, emerging ICU practice patterns, early reports of long-term outcomes, and federal support programs for survivors and their families. Centred around an illustrating case study, we applied relevant literature from ARDS and SARS to contextualize knowledge within emerging COVID-19 research and extrapolate findings to future long-term outcomes.

PRINCIPAL FINDINGS

COVID-19 is a multisystem disease with unknown long-term morbidity and mortality. Its pathophysiology is distinct and unique from ARDS, SARS, and critical illness. Nevertheless, based on initial reports of critical care management for COVID-19 and the varied injurious supportive practices employed in the ICU, patients and families are at risk for post-intensive care syndrome. The distinct incremental risk of COVID-19 multiple organ dysfunction is unknown. The risk of mood disorders in family members may be further exacerbated by imposed isolation and stigma.

CONCLUSION

Emerging literature on COVID-19 outcomes suggests some similarities with those of ARDS/SARS and prolonged mechanical ventilation. The pathophysiology of COVID-19 is presented here in the context of early outcome data and to inform an agenda for longitudinal research for patients and families.

Aspirin as a Treatment for ARDS: A Randomized, Placebo-Controlled Clinical Trial

BACKGROUND

There is no pharmacologic treatment for ARDS. Platelets play an important role in the pathophysiology of ARDS. Preclinical, observational, and clinically relevant models of ARDS indicate aspirin as a potential therapeutic option.

RESEARCH QUESTION

Is enteral aspirin (75 mg, once daily) safe and effective in improving surrogate outcomes in adult patients with ARDS?

STUDY DESIGN AND METHODS

This randomized, double-blind (patient and investigator), allocation-concealed, placebo-controlled phase 2 trial was conducted in five UK ICUs. Patients fulfilling the Berlin definition of ARDS were randomly assigned at a 1:1 ratio to receive enteral aspirin (75 mg) or placebo, for a maximum of 14 days, using a computer-generated randomization schedule, with variable block size, stratified by vasopressor requirement. The primary end point was oxygenation index (OI) on day 7. Secondary outcomes included safety parameters and other respiratory physiological markers. Analyses were by intention to treat.

RESULTS

The trial was stopped early, due to slow recruitment, after 49 of a planned 60 patients were recruited. Twenty-four patients were allocated to aspirin and 25 to placebo. There was no significant difference in day 7 OI [aspirin group: unadjusted mean, 54.4 (SD 26.8); placebo group: 42.4 (SD 25); mean difference, 12.0; 95% CI, -6.1 to 30.1; P = .19]. Aspirin did not significantly impact the secondary outcomes. There was no difference in the number of adverse events between the groups (13 in each; OR, 1.04; 95% CI, 0.56-1.94; P = .56).

INTERPRETATION

Aspirin was well tolerated but did not improve OI or other physiological outcomes; a larger trial is not feasible in its current design.

TRIAL REGISTRATION

ClinicalTrials.gov; No.: NCT02326350; URL: www.

CLINICALTRIALS

gov.

Cigarette Smoke Exposure and Acute Respiratory Distress Syndrome in Sepsis: Epidemiology, Clinical Features, and Biologic Markers

Rationale: Cigarette smoke exposure is associated with an increased risk of developing acute respiratory distress syndrome (ARDS) in trauma, transfusion, and nonpulmonary sepsis. It is unknown whether this relationship exists in the general sepsis population. Furthermore, it is unknown if patients with ARDS have differences in underlying biology based on smoking status. Objectives: To assess the relationship between cigarette smoke exposure and ARDS in sepsis and identify tobacco-related biomarkers of lung injury. Methods: We studied a prospective cohort of 592 patients with sepsis from 2009 to 2017. Plasma cotinine and urine NNAL [urine 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol] were measured to categorize smoking status. Plasma biomarkers of inflammation and lung injury were measured, including in a smaller cohort of trauma patients with ARDS to increase generalizability. Measurements and Main Results: Passive and active smoking were associated with increased odds of developing ARDS in patients with sepsis. Among patients with sepsis and ARDS, active cigarette smokers were younger and had lower severity of illness than nonsmokers. Patients with ARDS with cigarette smoke exposure had lower plasma levels of IL-8 (P = 0.01) and sTNFR-1 (soluble tumor necrosis factor 1; P = 0.01) compared with those without exposure. Similar biomarker patterns were observed in blunt trauma patients with ARDS. Conclusions: Passive and active smoking are associated with an increased risk of developing ARDS in patients with pulmonary and nonpulmonary sepsis. Among patients with ARDS, those with cigarette smoke exposure have less systemic inflammation, while active smokers also have lower severity of illness compared with nonsmokers, suggesting that smoking contributes to biological heterogeneity in ARDS.

Improving physical function of patients following intensive care unit admission (EMPRESS): protocol of a randomised controlled feasibility trial

INTRODUCTION

Physical rehabilitation delivered early following admission to the intensive care unit (ICU) has the potential to improve short-term and long-term outcomes. The use of supine cycling together with other rehabilitation techniques has potential as a method of introducing rehabilitation earlier in the patient journey. The aim of the study is to determine the feasibility of delivering the designed protocol of a randomised clinical trial comparing a protocolised early rehabilitation programme including cycling with usual care. This feasibility study will inform a larger multicentre study.

METHODS AND ANALYSIS

90 acute care medical patients from two mixed medical-surgical ICUs will be recruited. We will include ventilated patients within 72 hours of initiation of mechanical ventilation and expected to be ventilated a further 48 hours or more. Patients will receive usual care or usual care plus two 30 min rehabilitation sessions 5 days/week.Feasibility outcomes are (1) recruitment of one to two patients per month per site; (2) protocol fidelity with >75% of patients commencing interventions within 72 hours of mechanical ventilation, with >70% interventions delivered; and (3) blinded outcome measures recorded at three time points in >80% of patients. Secondary outcomes are (1) strength and function, the Physical Function ICU Test-scored measured on ICU discharge; (2) hospital length of stay; and (3) mental health and physical ability at 3 months using the WHO Disability Assessment Schedule 2. An economic analysis using hospital health services data reported with an embedded health economic study will collect and assess economic and quality of life data including the Hospital Anxiety and Depression Scales core, the Euroqol-5 Dimension-5 Level and the Impact of Event Score.

ETHICS AND DISSEMINATION

The study has ethical approval from the South Central Hampshire A Research Ethics Committee (19/SC/0016). All amendments will be approved by this committee. An independent trial monitoring committee is overseeing the study. Results will be made available to critical care survivors, their caregivers, the critical care societies and other researchers.

TRIAL REGISTRATION NUMBER

NCT03771014.

Hospital re-admission after critical care survival: a systematic review and meta-analysis

Survivors of critical illness frequently require increased healthcare resources after hospital discharge. We undertook a systematic review and meta-analysis to assess hospital re-admission rates following critical care admission and to explore potential re-admission risk factors. We searched the MEDLINE, Embase and CINAHL databases on 05 March 2020. Our search strategy incorporated controlled vocabulary and text words for hospital re-admission and critical illness, limited to the English language. Two reviewers independently applied eligibility criteria and assessed quality using the Newcastle Ottawa Score checklist and extracted data. The primary outcome was acute hospital re-admission in the year after critical care discharge. Of the 8851 studies screened, 87 met inclusion criteria and 41 were used within the meta-analysis. The analysis incorporated data from 3,897,597 patients and 741,664 re-admission episodes. Pooled estimates for hospital re-admission after critical illness were 16.9% (95%CI: 13.3-21.2%) at 30 days; 31.0% (95%CI: 24.3-38.6%) at 90 days; 29.6% (95%CI: 24.5-35.2%) at six months; and 53.3% (95%CI: 44.4-62.0%) at 12 months. Significant heterogeneity was observed across included studies. Three risk factors were associated with excess acute care rehospitalisation one year after discharge: the presence of comorbidities; events during initial hospitalisation (e.g. the presence of delirium and duration of mechanical ventilation); and subsequent infection after hospital discharge. Hospital re-admission is common in survivors of critical illness. Careful attention to the management of pre-existing comorbidities during transitions of care may help reduce healthcare utilisation after critical care discharge. Future research should determine if targeted interventions for at-risk critical care survivors can reduce the risk of subsequent rehospitalisation.

Impact of protocol-based physiotherapy on insulin sensitivity and peripheral glucose metabolism in critically ill patients

BACKGROUND

The impact of physiotherapy on insulin sensitivity and peripheral glucose metabolism in critically ill patients is not well understood.

METHODS

This pooled analysis investigates the impact of different physiotherapeutic strategies on insulin sensitivity in critically ill patients. We pooled data from two previous trials in adult patients with sequential organ failure assessment score (SOFA)≥ 9 within 72 h of intensive care unit (ICU) admission, who received hyperinsulinaemic euglycaemic (HE) clamps. Patients were divided into three groups: standard physiotherapy (sPT, n = 22), protocol-based physiotherapy (pPT, n = 8), and pPT with added muscle activating measures (pPT+, n = 20). Insulin sensitivity index (ISI) was determined by HE clamp. Muscle metabolites lactate, pyruvate, and glycerol were measured in the M. vastus lateralis via microdialysis during the HE clamp. Histochemical visualization of glucose transporter-4 (GLUT4) translocation was performed in surgically extracted muscle biopsies. All data are reported as median (25th/75th percentile) (trial registry: ISRCTN77569430 and ISRCTN19392591/ethics approval: Charité-EA2/061/06 and Charité-EA2/041/10).

RESULTS

Fifty critically ill patients (admission SOFA 13) showed markedly decreased ISIs on Day 17 (interquartile range) 0.029 (0.022/0.048) (mg/min/kg)/(mU/L) compared with healthy controls 0.103 (0.087/0.111), P < 0.001. ISI correlated with muscle strength measured by medical research council (MRC) score at first awakening (r = 0.383, P = 0.026) and at ICU discharge (r = 0.503, P = 0.002). Different physiotherapeutic strategies showed no effect on the ISI [sPT 0.029 (0.019/0.053) (mg/min/kg)/(mU/L) vs. pPT 0.026 (0.023/0.041) (mg/min/kg)/(mU/L) vs. pPT+ 0.029 (0.023/0.042) (mg/min/kg)/(mU/L); P = 0.919]. Regardless of the physiotherapeutic strategy metabolic flexibility was reduced. Relative change of lactate/pyruvate ratio during HE clamp is as follows: sPT 0.09 (-0.13/0.27) vs. pPT 0.07 (-0.16/0.31) vs. pPT+ -0.06 (-0.19/0.16), P = 0.729, and relative change of glycerol concentration: sPT -0.39 (-0.8/-0.12) vs. pPT -0.21 (-0.33/0.07) vs. pPT+ -0.21 (-0.44/-0.03), P = 0.257. The majority of ICU patients showed abnormal localization of GLUT4 with membranous GLUT4 distribution in 37.5% (3 of 8) of ICU patients receiving sPT, in 42.9% (3 of 7) of ICU patients receiving pPT, and in 53.8% (7 of 13) of ICU patients receiving pPT+ (no statistical testing possible).

CONCLUSIONS

Our data suggest that a higher duration of muscle activating measures had no impact on insulin sensitivity or metabolic flexibility in critically ill patients with sepsis-related multiple organ failure.

Acute respiratory distress syndrome readmissions: A nationwide cross-sectional analysis of epidemiology and costs of care

Background

Acute Respiratory Distress Syndrome affects approximately 10% of patients admitted to intensive care units internationally, with as many as 40%-52% of patients reporting re-hospitalization within one year.

Research question/aim

To describe the epidemiology of patients with acute respiratory distress syndrome who require 30-day readmission, and to describe associated costs.

Study design and methods

A cross-sectional analysis of the 2016 Healthcare Cost and Utilization Project’s Nationwide Readmission Database, which is a population-based administrative database which includes discharge data from U.S. hospitals. Inclusion criteria: hospital discharge records for adults age > 17 years old, with a diagnosis of ARDS on index admission, with associated procedure codes for endotracheal intubation and/or invasive mechanical ventilation, who were discharged alive. Primary exposure is adult hospitalization for meeting criteria as described. The primary outcome measure is 30-day readmission rate, as well as patient characteristics and time distribution of readmissions.

Results

Nationally, 25,170 admissions meeting criteria were identified. Index admission mortality rate was 37.5% (95% confidence interval [CI], 36.2–38.8). 15,730 records of those surviving hospitalization had complete discharge information. 30-day readmission rate was 18.4%, with 14% of total readmissions occurring within 2 calendar days of discharge; these early readmissions had higher mortality risk (odds ratio 1.82, 95% CI 1.05–6.56) compared with readmission in subsequent days. For the closest all-cause readmission within 30 days, the mean cost was $26,971, with a total national cost of over $75.6 million.

Interpretation

Thirty-day readmission occurred in 18.4% of patients with acute respiratory distress syndrome in this sample, and early readmission is strongly associated with increased mortality compared to late readmission. Further research is needed to clarify whether the rehospitalizations or associated mortalities are preventable.

Healthcare Utilization and Costs in Sepsis Survivors in Germany-Secondary Analysis of a Prospective Cohort Study

Background: Survivors of sepsis often face long-term sequelae after intensive care treatment. Compared to the period of hospitalization, little is known about the ambulatory healthcare utilization in sepsis patients. The study evaluated healthcare utilization and associated costs of sepsis care including allied health professions after initial hospitalization. Methods: Secondary analysis was performed on data in 210 sepsis patients prospectively enrolled from nine intensive care study centers across Germany. Data was collected via structured surveys among their Primary care (Family-) physicians (PCPs) within the first month after discharge from ICU (baseline) and again at 6, 12 and 24 months after discharge, each relating to the period following the last survey. Costs were assessed by standardized cost unit rates from a health care system’s perspective. Changes in healthcare utilization and costs over time were calculated using the Wilcoxon rank-sum test. Results: Of the 210 patients enrolled, 146 (69.5%) patients completed the 24 months follow-up. In total, 109 patients were hospitalized within the first 6 months post-intensive care. Mean total direct costs per patient at 0–6 months were €17,531 (median: €6047), at 7–12 months €9029 (median: €3312), and at 13–24 months €18,703 (median: €12,828). The largest contributor to the total direct costs within the first 6 months was re-hospitalizations (€13,787 (median: €2965). After this first half year, we observed a significant decline in inpatient care costs for re-hospitalizations (p ≤ 0.001). PCPs were visited by more than 95% of patients over 24 months. Conclusions: Sepsis survivors have high health care utilization. Hospital readmissions are frequent and costly. Highest costs and hospitalizations were observed in more than half of patients within the first six months post-intensive care. Among all outpatient care providers, PCPs were consulted most frequently. Clinical impact: Sepsis survivors have a high healthcare utilization and related costs which persist after discharge from hospital. Within outpatient care, possible needs of sepsis survivors as physiotherapy or psychotherapy seem not to be met appropriately. Development of sepsis aftercare programs for early detection and treatment of complications should be prioritized.

Lung function improves after delayed treatment with CNP-miR146a following acute lung injury

Acute respiratory distress syndrome (ARDS) is a highly morbid pulmonary disease characterized by hypoxic respiratory failure. Its pathogenesis is characterized by unrestrained oxidative stress and inflammation, with long-term sequelae of pulmonary fibrosis and diminished lung function. Unfortunately, prior therapeutic ARDS trials have failed and therapy is limited to supportive measures. Free radical scavenging cerium oxide nanoparticles (CNP) conjugated to the anti-inflammatory microRNA-146a (miR146a), termed CNP-miR146a, have been shown to prevent acute lung injury in a pre-clinical model. In this study, we evaluated the potential of delayed treatment with CNP-miR146a at three or seven days after injury to rescue the lung from acute injury. We found that intratracheal CNP-miR146a administered three days after injury lowers pulmonary leukocyte infiltration, reduce inflammation and oxidative stress, lower pro-fibrotic gene expression and collagen deposition in the lung, and ultimately improve pulmonary function.

Post-Intensive Care Syndrome in Survivors from Critical Illness including COVID-19 Patients: A Narrative Review

Current achievements in medical science and technological advancements in intensive care medicine have allowed better support of critically ill patients in intensive care units (ICUs) and have increased survival probability. Post-intensive care syndrome (PICS) is a relatively new term introduced almost 10 years ago, defined as "new or worsening impairments in physical, cognitive, or mental health status arising after critical illness and persisting beyond acute care hospitalization". A significant percentage of critically ill patients suffer from PICS for a prolonged period of time, with physical problems being the most common. The exact prevalence of PICS is unknown, and many risk factors have been described well. Coronavirus disease 2019 (COVID-19) survivors seem to be at especially high risk for developing PICS. The families of ICU survivors can also be affected as a response to the stress suffered during the critical illness of their kin. This separate entity is described as PICS family (PICS-F). A multidisciplinary approach is warranted for the treatment of PICS, involving healthcare professionals, clinicians, and scientists from different areas. Improving outcomes is both challenging and imperative for the critical care community. The review of the relevant literature and the study of the physical, cognitive, and mental sequelae could lead to the prevention and timely management of PICS and the subsequent improvement of the quality of life for ICU survivors.

The health-related quality of life in patients with post-COVID-19 after hospitalization: a systematic review

Symptoms in post-COVID-19 patients who require hospitalization can persist for months, significantly affecting their health-related quality of life (HRQoL). Thus, the present study aimed to discuss the main findings regarding HRQoL in post-COVID-19 patients who required hospitalization. An electronic search was performed in the MEDLINE, EMBASE, CINAHL, Web of Science, LILACS, and Scopus databases, without date and language restrictions, until July 2021. Twenty-four articles were included in the analysis. It seems that HRQoL partially improved soon after hospital discharge, although the negative impact on HRQoL may persist for months. The physical and mental aspects are affected because patients report pain, discomfort, anxiety, and depression. The HRQoL of COVID-19 infected patients was worse than that of uninfected patients. Additionally, HRQoL seemed worse in patients admitted to the intensive care unit than in those who remained in the ward. Improvements in HRQoL after hospital discharge are independent of imaging improvement, and there seems to be no association between HRQoL after hospital discharge and disease severity on hospital admission. Many factors have been identified as determinants of HRQoL, with women and advanced age being the most related to worse HRQOL, followed by the duration of invasive mechanical ventilation and the need for intensive care. Other factors included the presence and number of comorbidities, lower forced vital capacity, high body mass index, smoking history, undergraduate education, and unemployment. In conclusion, these findings may aid in clinical management and should be considered in the aftercare of patients.

Intensive Care Unit-acquired Neuromuscular Weakness: A Prospective Study on Incidence, Clinical Course, and Outcomes

Background

Neuromuscular weakness may manifest subsequent to critical illness in intensive care unit (ICU) patients. This weakness termed as “ICU-acquired weakness” (ICUAW) has a significant bearing on the length of mechanical ventilation, duration of ICU stays, long-term disability, and survival rate. Early identification of ICUAW helps in planning appropriate strategies, as well as in predicting the prognosis and long-term outcomes of these patients.

Aims and objectives

To identify the incidence of new-onset neuromuscular weakness developing among patients admitted in the ICU (ICUAW) and study its clinical course and impact on the duration of ICU stay.

Methods

This prospective observational study evaluated patients admitted to the ICU over a period of 1 year and 3 months (November 1, 2015, to January 31, 2017). All patients fulfilling the inclusion and exclusion criteria were evaluated with the Medical Research Council (MRC) score for muscle strength. Patients with an average score <4 were diagnosed with ICUAW. Included patients were examined on alternate days to study the clinical progression of the weakness till ICU discharge or death of the patient. The duration of ICU stay was noted.

Results and conclusion

The study revealed a significant association of ICUAW with age, Acute Physiology And Chronic Health Evaluation (APACHE II) Score, duration of mechanical ventilation, and ICU mortality. The incidence of the weakness was found to be 7.83% among the patients who survived and 50% among those patients who did not survive critical illness.

How to cite this article

Baby S, George C, Osahan NM. Intensive Care Unit-acquired Neuromuscular Weakness: A Prospective Study on Incidence, Clinical Course, and Outcomes. Indian J Crit Care Med 2021;25(9):1006–1012.

Incidence, Time Course and Influence on Quality of Life of Intensive Care Unit-Acquired Weakness Symptoms in Long-Term Intensive Care Survivors

PURPOSE

Intensive care unit-acquired weakness (ICUAW) can manifest as muscle weakness or neuropathy-like symptoms, with diagnosis remaining a challenge. Uncertainties surround the long-term cause and sequelae. Therefore, the purpose was to assess incidence, time course and long-term influence on quality of life (QoL) of symptoms in ICU survivors.

METHODS

After ethical approval and registration (www.drks.de: DRKS00011593), in a single-center cohort study all patients admitted to the ICU in 2007-2017 in a German university hospital were screened. Out of 1,860 patients (≥7d ICU care including ventilation support for ≥72 h, at least 6mo-10y after ICU) 636 were deceased, 912 survivors were contacted.

RESULTS

149 former patients (age: 63.5 ± 13.1y; males: 73%; duration in ICU: 20.8 ± 15.7d; duration of ventilation: 16.5 ± 13.7 h; time post-ICU: 4.4 ± 2.7y, 5-10y: 43%) consented to be interviewed concerning occurrence, duration, recovery and consequences of ICUAW-associated muscle weakness or neuropathy-like symptoms after ICU. In 75% at least 1 persistent or previous symmetrical symptom was reported (myopathy-like muscle weakness: 43%; neuropathy-like symptoms: 13%; both: 44%) and rated as incidence of ICUAW. However, only 18% of participants had received an ICUAW diagnosis by their physicians, although 62% had persistent symptoms up to 10y after ICU (5-10y: 46%). Only 37% of participants reported a complete recovery of symptoms, significantly associated with an initially low number of symptoms after ICU (p < 0.0001), myopathy-like symptoms (p = 0.024), and younger age at the time of ICU admission (55.7 ± 13.1 vs. 62.6 ± 10.6y, p < 0.001). ICUAW still impaired the QoL at the time of the interview in 74% of affected survivors, with 30% reporting severe impairment.

CONCLUSION

ICUAW symptoms were disturbingly common in the majority of long-term survivors, indicating that symptoms persist up to 10y and frequently impair QoL. However, only a small number of patients had been diagnosed with ICUAW. Trial registry: Deutsches Register Klinischer Studien (DRKS), https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00011593, registration number: DRKS00011593.

Timing of ARDS Resolution (TARU): A Pragmatic Clinical Assessment of ARDS Resolution in the ICU

Purpose

Lack of a pragmatic outcome measures for acute respiratory distress syndrome (ARDS) resolution is a barrier to meaningful interventional trials of novel treatments. We evaluated a pragmatic, electronic health record (EHR)-based approach toward the clinical assessment of a novel outcome measure: ICU ARDS resolution.

Methods

We conducted a retrospective observational cohort study evaluating adult patients with moderate–severe ARDS admitted to the medical intensive care unit (ICU) at Mayo Clinic in Rochester, MN, from January 2001 through December 2010. We compared the association of ICU ARDS resolution vs non-resolution with mortality. ICU ARDS resolution was defined as improvement in P/F > 200 for at least 48 h or (if arterial blood gas unavailable) SpO₂:FiO₂ (S/F) > 235, or discharge prior to 48 h from first P/F > 200 without subsequent decline in P/F, as documented in EHR.

Results

Of the 254 patients included, ICU ARDS resolution was achieved in 179 (70%). Hospital mortality was lower in patients who met ICU ARDS resolution criteria as compared to those who did not (23% vs. 41%, p < 0.01). After adjusting for age, gender, and illness severity, the patients who met ICU ARDS resolution criteria had lower odds of hospital mortality [odds ratio 0.47, 95% CI 0.25–0.86; p = 0.015].

Conclusion

The electronic health record-based pragmatic measure of ICU ARDS resolution is associated with patient outcomes and may serve as an intermediate outcome assessing novel mechanistic treatments.

The Cost of ARDS: A Systematic Review

BACKGROUND

ARDS is an inflammatory condition of the lungs and is a common condition in adult ICUs. The resources required and costs of care for patients with ARDS are significant because of the severity of the illness and extended ICU lengths of stay.

RESEARCH QUESTION

What are the costs associated with ARDS?

STUDY DESIGN AND METHODS

We systematically searched the literature through April 29, 2021, for articles relevant to ARDS and costs. MEDLINE, Embase, Central, and EconLit databases were searched, and articles that reported on cost data from an original publication in adult patients with ARDS were included. Two authors independently assessed articles for inclusion and extracted data elements related to costs, methodology, health-care system type, economic perspective, and clinical data. Publication quality was assessed using a modified version of the Quality of Health Economic Studies Instrument.

RESULTS

Four thousand six hundred sixty-three publications were found, of which 110 were included for full-text review (κ = 0.72). A total of 22 publications (49,483 patients) were suitable for data extraction. The publications represented a broad range of health-care systems, economic perspectives, costing methodology, and time frames. Mean inpatient costs ranged from $8,476 (2021 US dollars [USD]) to $547,974 (2021 USD) and were highest in publications of lower quality and in American health systems and were associated with trauma cohorts. Outpatient costs were highest in publications with higher readmission rates, longer durations of follow-up, and in American health systems.

INTERPRETATION

A wide range of costing data is available for ARDS. A comprehensive synthesis of this literature frames the reasons for this and allows estimates to reflect the context in which they were assessed. This information will be of value to researchers and administrators interested in the economics of caring for patients with ARDS.

TRIAL REGISTRY

PROSPERO; No.: CRD42020192487.

Acute respiratory distress syndrome

Acute respiratory distress syndrome (ARDS) is an acute respiratory illness characterised by bilateral chest radiographical opacities with severe hypoxaemia due to non-cardiogenic pulmonary oedema. The COVID-19 pandemic has caused an increase in ARDS and highlighted challenges associated with this syndrome, including its unacceptably high mortality and the lack of effective pharmacotherapy. In this Seminar, we summarise current knowledge regarding ARDS epidemiology and risk factors, differential diagnosis, and evidence-based clinical management of both mechanical ventilation and supportive care, and discuss areas of controversy and ongoing research. Although the Seminar focuses on ARDS due to any cause, we also consider commonalities and distinctions of COVID-19-associated ARDS compared with ARDS from other causes.