/pdf/clinical-characteristics-and-day-90-outcomes-of-4244-6bpmow2brz.pdf

Clinical characteristics and day-90 outcomes of 4244 ctritically ill adults with COVID-19: a prospective cohort study

Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome associated with COVID-19: a retrospective cohort study.

Mechanical power (MP) may unify variables known to be related to development of ventilator-induced lung injury. The aim of this study is to examine the association between MP and mortality in critically ill patients receiving invasive ventilation for at least 48 h. This is an analysis of data stored in the databases of the MIMIC–III and eICU. Critically ill patients receiving invasive ventilation for at least 48 h were included. The exposure of interest was MP. The primary outcome was in-hospital mortality. Data from 8207 patients were analyzed. Median MP during the second 24 h was 21.4 (16.2–28.1) J/min in MIMIC-III and 16.0 (11.7–22.1) J/min in eICU. MP was independently associated with in-hospital mortality [odds ratio per 5 J/min increase (OR) 1.06 (95% confidence interval (CI) 1.01–1.11); p = 0.021 in MIMIC-III, and 1.10 (1.02–1.18); p = 0.010 in eICU]. MP was also associated with ICU mortality, 30-day mortality, and with ventilator-free days, ICU and hospital length of stay. Even at low tidal volume, high MP was associated with in-hospital mortality [OR 1.70 (1.32–2.18); p < 0.001] and other secondary outcomes. Finally, there is a consistent increase in the risk of death with MP higher than 17.0 J/min. High MP of ventilation is independently associated with higher in-hospital mortality and several other outcomes in ICU patients receiving invasive ventilation for at least 48 h.

/pdf/mechanical-power-of-ventilation-is-associated-with-mortality-7m5sfdqgv6.pdf

Mechanical power of ventilation is associated with mortality in critically ill patients: an analysis of patients in two observational cohorts

To assess the effect of venovenous extracorporeal membrane oxygenation (ECMO) compared to conventional management in patients with severe acute respiratory distress syndrome (ARDS). We conducted a systematic review and individual patient data meta-analysis of randomised controlled trials (RCTs) performed after Jan 1, 2000 comparing ECMO to conventional management in patients with severe ARDS. The primary outcome was 90-day mortality. Primary analysis was by intent-to-treat. We identified two RCTs (CESAR and EOLIA) and combined data from 429 patients. On day 90, 77 of the 214 (36%) ECMO-group and 103 of the 215 (48%) control group patients had died (relative risk (RR), 0.75, 95% confidence interval (CI) 0.6–0.94; P = 0.013; I2 = 0%). In the per-protocol and as-treated analyses the RRs were 0.75 (95% CI 0.6–0.94) and 0.86 (95% CI 0.68–1.09), respectively. Rescue ECMO was used for 36 (17%) of the 215 control patients (35 in EOLIA and 1 in CESAR). The RR of 90-day treatment failure, defined as death for the ECMO-group and death or crossover to ECMO for the control group was 0.65 (95% CI 0.52–0.8; I2 = 0%). Patients randomised to ECMO had more days alive out of the ICU and without respiratory, cardiovascular, renal and neurological failure. The only significant treatment-covariate interaction in subgroups was lower mortality with ECMO in patients with two or less organs failing at randomization. In this meta-analysis of individual patient data in severe ARDS, 90-day mortality was significantly lowered by ECMO compared with conventional management.

/pdf/ecmo-for-severe-ards-systematic-review-and-individual-2ielr263m1.pdf

ECMO for severe ARDS: systematic review and individual patient data meta-analysis.

Rationale: Current practices regarding mechanical ventilation in patients treated with extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome are unknown.Objectives: To report current practices regarding mechanical ventilation in patients treated with ECMO for severe acute respiratory distress syndrome (ARDS) and their association with 6-month outcomes.Methods: This was an international, multicenter, prospective cohort study of patients undergoing ECMO for ARDS during a 1-year period in 23 international ICUs.Measurements and Main Results: We collected demographics, daily pre- and per-ECMO mechanical ventilation settings and use of adjunctive therapies, ICU, and 6-month outcome data for 350 patients (mean ± SD pre-ECMO PaO2/FiO2 71 ± 34 mm Hg). Pre-ECMO use of prone positioning and neuromuscular blockers were 26% and 62%, respectively. Vt (6.4 ± 2.0 vs. 3.7 ± 2.0 ml/kg), plateau pressure (32 ± 7 vs. 24 ± 7 cm H2O), driving pressure (20 ± 7 vs. 14 ± 4 cm H2O), respiratory rate (26 ± 8 vs. 14 ± 6 breaths/min), and mechanical power (26.1 ± 12.7 vs. 6.6 ± 4.8 J/min) were markedly reduced after ECMO initiation. Six-month survival was 61%. No association was found between ventilator settings during the first 2 days of ECMO and survival in multivariable analysis. A time-varying Cox model retained older age, higher fluid balance, higher lactate, and more need for renal-replacement therapy along the ECMO course as being independently associated with 6-month mortality. A higher Vt and lower driving pressure (likely markers of static compliance improvement) across the ECMO course were also associated with better outcomes.Conclusions: Ultraprotective lung ventilation on ECMO was largely adopted across medium- to high-case volume ECMO centers. In contrast with previous observations, mechanical ventilation settings during ECMO did not impact patients' prognosis in this context.

https://www.atsjournals.org/doi/pdf/10.1164/rccm.201806-1094OC

Mechanical Ventilation Management During Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome. An International Multicenter Prospective Cohort

RESUMO Objetivo: Avaliar a eficacia do cateter nasal de alto fluxo na prevencao de intubacao e reintubacao de pacientes criticos em comparacao com oxigenoterapia convencional ou ventilacao nao invasiva. Metodos: Esta revisao sistematica foi realizada por meio de busca eletronica em bancos de dados incluindo trabalhos publicados entre 1966 e abril de 2018. O desfecho primario foi a necessidade de intubacao ou reintubacao. Os desfechos secundarios foram escalonamento de terapia, mortalidade no seguimento mais longo, mortalidade hospitalar e necessidade de ventilacao nao invasiva. Resultados: Dezessete estudos com 3.978 pacientes foram incluidos. Nao houve reducao na necessidade de intubacao ou reintubacao (OR 0,72; IC95% 0,52 - 1,01; p = 0,056). Nao houve diferenca no escalonamento de terapia (OR 0,80; IC95% 0,59 - 1,08; p = 0,144), na mortalidade no seguimento mais longo (OR 0,94; IC95% 0,70 - 1,25; p = 0,667), na mortalidade hospitalar (OR 0,84; IC95% 0,56 - 1,26; p = 0,391) ou na necessidade de ventilacao nao invasiva (OR 0,64; IC95% 0,39 - 1,05, p = 0,075). Na analise sequencial de ensaios, o numero de eventos incluidos foi menor que o tamanho otimo de informacao, com erro tipo I global > 0,05. Conclusao: No presente estudo e no cenario avaliado, o cateter nasal de alto fluxo nao foi associado com reducao na necessidade de intubacao ou reintubacao em pacientes criticos.

/pdf/the-effects-of-high-flow-nasal-cannula-on-intubation-and-re-34pqu9hmjw.pdf

The effects of high-flow nasal cannula on intubation and re-intubation in critically ill patients: a systematic review, meta-analysis and trial sequential analysis

Mechanical power during mechanical ventilation of critically ill patients

Daily multidisciplinary clinical rounds involving physicians, nurses, respiratory therapists, nutritionists and clinical pharmacists improve the quality and outcomes of ICUs [1]. However, data regarding performance of these clinical rounds in an open-ICU model are limited.

/pdf/appraisal-of-the-daily-clinical-rounds-performed-in-an-open-zchtztazz3.pdf

Denise Carnieli Cazati

Papers

Mechanical power of ventilation is associated with mortality in critically ill patients: an analysis of patients in two observational cohorts

The effects of high-flow nasal cannula on intubation and re-intubation in critically ill patients: a systematic review, meta-analysis and trial sequential analysis

Mechanical power during mechanical ventilation of critically ill patients

Appraisal of the daily clinical rounds performed in an open and general ICU