Nationwide data are unavailable regarding changes in intensive care unit (ICU) outcomes and use of life support over the past 10 years, limiting understanding of practice changes.

To portray the epidemiology of US critical care before, during, and after the COVID-19 pandemic.

Retrospective cohort study of adult patients admitted to an ICU for any reason, using data from the 54 US health systems continuously contributing to the Epic Cosmos database from 2014-2023.

Patient demographics, COVID-19 status, and pandemic era.

In-hospital mortality unadjusted and adjusted for patient demographics, comorbidities, and illness severity; ICU length of stay; and receipt of life-support interventions, including mechanical ventilation and vasopressor medications.

Of 3 453 687 admissions including ICU care, median age was 65 (IQR, 53-75) years. Patients were 55.3% male; 17.3% Black and 6.1% Hispanic or Latino; and overall in-hospital mortality was 10.9%. The adjusted in-hospital mortality was elevated during the pandemic in COVID-negative (adjusted odds ratio [aOR], 1.3 [95% CI, 1.2-1.3]) and COVID-positive (aOR, 4.3 [95% CI, 3.8-4.8]) patients and returned to baseline by mid-2022. The median ICU length of stay was 2.1 (IQR, 1.1-4.2) days, with increases during the pandemic among COVID-positive patients (difference for COVID-positive vs COVID-negative patients, 2.0 days [95% CI, 2.0-2.1]). Rates of invasive mechanical ventilation were 23.2% (95% CI, 23.1%-23.2%) before the pandemic, increased to 25.8% (95% CI, 25.8%-25.9%) during the pandemic, and declined below prepandemic baseline thereafter (22.0% [95% CI, 21.9%-22.2%]). The use of vasopressors increased from 7.2% to 21.6% of ICU stays.

Pandemic-era increases in length of stay and adjusted in-hospital mortality among US ICU patients returned to recent historical baselines. Fewer patients are now receiving mechanical ventilation than prior to the pandemic, while more patients are administered vasopressor medications.

To assess the compliance and acceptance of a nurse-driven early weaning protocol from the initiation of spontaneous ventilation (SV) to extubation in patients with acute respiratory failure (ARF) in the intensive care unit (ICU).

This monocentric, prospective pilot study included patients admitted to the ICU with ARF and requiring invasive mechanical ventilation (IMV) for more than 48 h, between February 2021 and April 2024. The weaning protocol (WP) was initiated after a successful 30-minute SV trial with pressure support (PS). Every 3 h, nurses reduced PS by 2 cmH2O, fraction of inspired oxygen (FiO2) by 5%, and positive end-expiratory pressure (PEEP) according to a predefined protocol. When minimum PS and PEEP levels were reached, the patient was extubated after a successful T-tube test. The primary outcome was compliance with the WP assessed by the percentage of time spent in agreement with WP. The secondary outcome was nurse acceptance, assessed by an anonymous survey on a visual analogue scale from 0 to 10.

Of the 50 patients enrolled, 30 (60 %) had COVID-19 pneumonia. The median duration of IMV was 21 days per patient [IQR: 10-34], with a median WP duration of 11 days [IQR: 4-21.5]. Protocol compliance was 76 %. Thirty-two of 37 nurses (86 %) completed the survey and rated the acceptance of the WP as 8/10 [IQR: 7.75-9]. Workload was identified as a barrier to compliance with a median score of 5/10 [IQR: 2-7]. We reported 9/50 (18 %) extubation failures.

This nurse-driven protocol for early weaning of patients with ARF had good compliance and acceptance by the nurse team despite the COVID-19 pandemic health crisis.

It is essential to incorporate nursing feedback if we are to improve the protocols for ventilatory weaning patients in ICU.

As new SARS-CoV-2 variants emerge and as treatment of COVID-19 ARDS remains exclusively supportive, there is an unmet need to better characterize its different phenotypes to tailor personalized treatments. Clinical, biological, spirometric and CT data hardly allow deciphering of Heavy (H), Intermediate (I) and Light (L) phenotypes of COVID-19 ARDS and the implementation of tailored specific strategies (prone positioning, PEEP settings, recruitment maneuvers). We hypothesized that the ratio of two pivotal COVID-19 biomarkers (interleukin 6 [IL-6] and Krebs von den Lungen 6 [KL-6], related to inflammation and pneumocyte repair, respectively) would provide a biologic insight into the disease timeline allowing 1) to differentiate H, I and L phenotypes, 2) to predict outcome and 3) to reflect some of CT findings.

This was a retrospective analysis of prospectively acquired data (COVID HUS cohort). Inclusion concerned any patient with severe COVID-19 pneumonia admitted to two intensive care units between March 1st and May 1st, 2020, in a high-density cluster of the first epidemic wave (Strasbourg University Hospital, France). Demographic, clinical, biological (standard, IL-6 [new generation ELISA], KL-6 [CLEIA technique]), spirometric (driving pressure, respiratory system compliance) and CT data were collected longitudinally. CT analysis included semi-automatic and automatic lung measurements and allowed segmentation of lung volumes into 4 (poorly aerated, non-aerated, overinflated and normally aerated) and 3 (ground-glass, restricted normally aerated, and overinflated) zones, respectively. The primary outcome was to challenge the IL-6/KL-6 ratio capacity to decipher the three COVID-19 ARDS phenotypes (H, I and L) defined on clinical, spirometric and radiologic grounds. Secondary outcomes were the analysis of the prognostic value of the IL-6/KL-6 ratio and its correlates with CT-acquired data. Multivariate analysis was based on principal component analysis. One hundred and forty-eight ventilated COVID-19 ICU patients from the COVID HUS cohort were assessed for eligibility and 77 were included in the full analysis. Most were male, all were under invasive mechanical ventilation and vasopressor therapy and displayed high severity scores (SAPSII: 48 [42-56]; SOFA: 8 [7-10]). The L, I and H COVID ARDS phenotypes were identified in 11, 15 and 48 patients, respectively. In three patients, the phenotype could not be defined precisely. Thirty patients (39%) died in the ICU and the number of ventilator-free days was 2 [0-2] days. The IL-6/KL-6 ratio was not significantly different between the L, I and H phenotypes and evolved according to similar patterns over time. Surviving and deceased patients displayed an inverse kinetic of KL-6. IL-6 and the IL-6/KL-6 ratio were linearly associated with ground-glass volume on semi-automatic and automatic CT lung measurements.

In our population of severe ventilated COVID ARDS patients, the IL-6/KL-6 ratio was not clue to differentiate the H, I and L phenotypes and tailor a personalized ventilatory approach. There was an interesting correlation between IL-6/KL-6 ratio and ground-glass volume as determined by automated lung CT analysis. Such correlation deserves more in-depth pathophysiological study, at best gathered from a prospective cohort with a larger sample size and histological analysis.

COVID HUS Trial registration number: NCT04405726.

Coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS) was an emergent syndrome that led to high volumes of critically ill ventilated patients. We explored influences on decision-making regarding management of COVID-19 ARDS mechanical ventilation to identify modifiable factors to improve preparedness for future pandemics.

A systematic review and small group interviews informed the development of an international questionnaire (UK, Italy, Germany and Netherlands) on factors influencing COVID-19 ARDS ventilation decision-making in critical care professionals. Participants ranked four themes in order of importance: disease (uncertainties around COVID-19 ARDS), contextual (cognitive strain), environmental (structural logistics) and team factors. Participants also ranked the subthemes within each theme. Thematic analysis was used to derive findings from qualitative data. Kruskal-Wallis, Mann-Whitney U and Kendall's tau were used for quantitative data analysis.

Patient factors (comorbidities, clinical/biochemical parameters) were the most studied influences in the extant literature on decision-making; uncertainty was one of the least studied. 371 critical care professionals responded to the questionnaire. Disease uncertainty (lack of applicable guidelines, unfamiliarity with pathophysiology) was ranked as the most important influence on ventilation decision-making for COVID-19 ARDS across regions, professions and experience levels (p<0.001). Participants expressed underconfidence in their decision-making (median score: 9/20); this was unaffected by experience (p=0.79) or profession (p=0.58). Qualitative findings supported and extended the initial proposed influences, including the impact of team factors (+ve) and resource limitations (-ve) on disease uncertainty.

Future pandemic preparedness programmes should target modifiable influences such as information sharing, teamworking and resource limitations to mitigate against the negative influence of uncertainty and thereby improve decision-making overall.

Several studies found an association between COVID-19 incidence, cumulated over the first pandemic wave, and the risk of death for infected individuals. They attributed this association to hospital overload. We studied this association across the French departments using 82,467 serological samples and a hierarchical Bayesian model with spatial smoothing. In high-incidence areas, we hypothesized that hospital overload would increase infection fatality rate (IFR) without increasing infection hospitalization rate (IHR). The analyses were adjusted for intensive care beds per capita, age of the population, and diabetes prevalence (as a surrogate for obesity). We found that increasing departmental incidence from 3 to 9% rose IFR from 0.42 to 1.14% (difference 0.72%, 95% CI 0.49-1.01%), and IHR from 1.66 to 3.61% (difference 1.94%, 95% CI 1.18-2.80%). An increase in incidence from 6 to 12% in people under 60 was associated with an increased proportion of people over 60 among those infected, from 11.6 to 17.4% (difference 5.8%, 95% CI 2.9-8.8%). Higher incidence increased the risk of death for infected individuals and their risk of hospitalization by the same magnitude. These findings could be explained by a higher age among infected individuals in high-incidence areas, rather by than hospital overload.

Respiratory sequelae, induced by lung injury, reduced muscle strength, and nutritional disturbance, are common in hospitalized patients with coronavirus disease 2019 (COVID-19). Therefore, optimal treatment is essential for reducing the mortality in severe forms of the disease and critically ill patients. Pulmonary rehabilitation (PR) has been used in many chronic respiratory diseases, but the role of early PR in severe and critically ill COVID-19 patients remains to be fully understood.

Hospitalized severe to critically ill COVID-19 patients were recruited from Beijing Chaoyang Hospital between December 1, 2022, and June 30, 2023. In all, we recruited 272 patients, with 39 in the PR group and 233 in the control group. The PR intervention consisted of the prone position, airway clearance therapy (ACT), and resistance respiratory training (RRT). The primary outcome was the composite disease progression outcome rate, defined as death or intensive care unit (ICU) admission. Adverse events (AEs) and serious adverse events (SAEs) were recorded in the PR group. Inverse probability of treatment weighting (IPTW) and propensity score matching (PSM) was used to balance confounding bias, generating weighting cohort and matched cohort.

The rate of the primary outcome was lower in the PR group (28.2% [11/39] in the PR group vs. 48.9% [114/233] in the control group). Significant differences were observed in both the original and weighting cohorts. Subgroup analyses showed that receiving ≥ 2 types of PR, receiving RRT, length from admission to intervention ≤ 4 days, and baseline P/F ≤ 150 mmHg were associated with lower rates of progression. Total rates of 2.6% (1/39) for AEs and 10.26% (4/39) for SAEs were reported.

Early pulmonary rehabilitation may prevent disease progression and reduce mortality in patients with severe COVID-19. These findings may be helpful for formulating an optimal rehabilitation strategy.

The evidence supporting the benefit on clinical outcomes of prone positioning during veno-venous extracorporeal membrane oxygenation (V-V ECMO) for acute hypoxemic respiratory failure remains inconclusive. We aimed to assess the association of prone positioning, compared to no prone positioning, with 28-day mortality and other clinical outcomes in different patient subgroups.

A systematic review and meta-analysis of randomized and non-randomized controlled trials (RCTs) using a random-effects model was conducted. An electronic database search up to September 1st, 2024 was performed (PROSPERO CRD42024517602). The RoB 2 and ROBINS-I tools were used for risk of bias assessments.

We analyzed two RCTs and 20 non-RCTs (3,465 patients). Compared to no prone positioning, the use of prone positioning was associated with lower 28-day (odds ratio [OR] 0.64, 95% confidence interval [CI] 0.42-0.98, p = 0.040, I2 = 66%, low certainty of evidence [CoE]) and hospital mortality (OR 0.67, 95% CI 0.54-0.83, p < 0.001, I2 = 39%, low CoE), despite fewer 28-day ventilator-free days and longer ECMO duration. Younger age (p = 0.005), a higher sequential organ failure assessment (SOFA) score (p = 0.022), non-Covid-19 etiology (p = 0.003), and lower rates of prone positioning before cannulation (p = 0.049) were associated with a greater benefit from prone positioning.

In this analysis, among patients supported with V-V ECMO for acute hypoxemic respiratory failure, we observed improved 28-day and hospital mortality in those who received prone positioning, compared to those who did not. However, these findings do not imply causation. Further research is needed to clarify the role of prone positioning in this population.

High-flow nasal oxygen (HFNO) is frequently used to treat patients with acute hypoxemic respiratory failure (AHRF) due to viral pneumonia, including COVID-19. However, its clinical effect compared to conventional oxygen therapy (COT) remains largely unexplored in patients with a do not intubate (DNI) order. We aimed to assess whether HFNO compared to COT is associated with improved clinical outcomes in hospitalized patients with AHRF due to COVID-19 and a DNI order.

This analysis included patients with a DNI order and SARS-CoV-2 infection, selected from three observational studies, who were treated with COT only or HFNO. The primary endpoint was in-hospital mortality, the secondary endpoint was hospital length of stay (LOS). The effect of HFNO vs. COT was assessed using multivariable regression, accounting for pre-selected confounders.

Between March 2020 and September 2021, 116 patients received HFNO and 110 patients received COT. Median age was 78 [72-83], and 78% of the patients had a Clinical Frailty Scale score of 4 to 9. In-hospital mortality was 64% for HFNO and 71% for COT (p = 0.29), with an adjusted odds ratio of 0.72 (95% confidence interval [0.34-1.54], p = 0.40). Hospital LOS was 11 [6-18] days for HFNO, and 7 [4-12] days for COT (p < 0.001), with a remaining difference after adjusting for confounders (p < 0.01).

The lack of survival benefit and increased hospital LOS should be taken into account when considering HFNO for patients with a DNI order, suffering from AHRF due to viral pneumonia, like COVID-19.

HFNO-COVID-19 study: DTR, NL9067 (Dutch Trial Registry), registration date: 27-11-2020.

The objective of this study is to develop and validate a predictive model for mortality among severe COVID-19 patients who are candidates for inter-hospital transfer. A multicenter prospective observational study was conducted between 1 January 2021 and 30 April 2021 (third and fourth pandemic waves) in regional coordination centers of the Emergency Medical Services of eight Spanish autonomous communities. Hospitalized patients with severe COVID-19 transferred to other hospitals were included. Clinical variables from the initial evaluation, the triage score, and in-hospital mortality rates were collected. A Lasso-type regression analysis was performed to fit the mortality predictive model and its performance was evaluated by a leave-one-out cross-validation. Subsequently, the regional mass triage (MATER) score was created. 1,018 transferred patients were included, with a mean age of 62.3 years (SD 12), of whom 65.1% were male and 89.6% were admitted to an Intensive Care Unit. In-hospital mortality was 23.0%. The MATER score included six variables and presented good discrimination ability with an area under the curve of 0.79 (95% CI 0.77-0.81) and a good calibration with a Brier score of 0.135. The MATER score successfully predicted the mortality rate of severe COVID-19 patients and can be helpful in decision-making for triage and transfer prioritization in mass critical care surges.

The incidence of obesity among patients admitted to the intensive care unit (ICU) is increasing, and pneumonia remains the leading cause of acute respiratory distress syndrome (ARDS). The association of obesity on both short- and long-term outcomes in patients with pneumonia-induced ARDS has been the subject of only limited research.

We conducted a retrospective analysis of a prospective cohort consisting of ARDS patients who had microbiologically confirmed pneumonia and a PaO2/FiO2 ratio ≤ 150 mmHg. Patients were assessed for mortality at 28 days, 90 days, and at 1 year from the diagnosis of ARDS and compared between obese defined by a body mass index (BMI) ≥ 30 kg.m2 and non-obese patients. Models were adjusted for age, sex, COPD, coronary artery disease, immunodepression, severity score and acute kidney injury on admission to the ICU, severity of ARDS (PaO2/FiO2 ratio ≤ 100 mmHg), severe hypercapnia (PaCO2 ≥ 50 mmHg), ventilatory ratio and plateau pressure the first day of ARDS, influenza, COVID-19, pneumocystosis, and bacteria involved in pneumonia. We also investigated the continuous spectrum of BMI on the risk of mortality.

Of 603 patients, 227 patients (37.6%) were obese. Obesity was associated with female gender (p = 0.009), hypertension (p < 0.001), diabetes mellitus (p < 0.001), COVID-19 pneumonia (p = 0.008), and PaO2/FiO2 ratio ≤ 100 mmHg (p = 0.006). Obesity was independently associated with lower mortality at 28 days (adjusted Odds Ratio (OR) 0.55, 95% confident interval (CI) 0.33-0.90, p = 0.02) but not at 90 days (adjusted OR 0.70, 95% CI 0.45-1.09, p = 0.11) nor at 1 year from the diagnosis of ARDS (adjusted OR 0.73, 95% CI 0.47-1.13, p = 0.16). Mortality at 28 days was significantly lower in obese patients than in non-obese patients when propensity score matching was used (15.2% versus 22%, p = 0.04). BMI was also independently associated with lower mortality at 28 days (p = 0.038) but not with mortality at 90 days (p = 0.12) and 1 year (p = 0.12).

Our results suggest that in patients with pneumonia-related ARDS, obesity is independently associated with better survival at 28 days but not at 90 days and 1 year from the diagnosis of ARDS.

Introduction Survivors of prolonged severe COVID-19 who are treated at ICUs are at risk for physical and psychological complications, including lung injury and multi-organ dysfunction. As the number of survivors of severe COVID-19 increases, it is necessary to understand the trajectory of the disease and the patient care needed after discharge from the ICU. This study tries to efficiently assess the long-term clinical sequelae among patients with prolonged severe COVID-19 who were admitted to the ICU, one year after their discharge. The parameters tested included the chronic obstructive pulmonary disease assessment test (CAT) score, pulmonary function tests, and laboratory data. Materials and methods The study population included 454 patients who were followed up one year after surviving ICU admission for severe COVID-19. All the patients who presented with signs and symptoms to the hospital were examined further. They underwent the necessary investigations, assessments, and systemic examinations. The results of all the laboratory and radiological investigations were reviewed. During the SARS-CoV-2 pandemic, all the patient details were entered into a hospital information management system from which the data was retrieved. Mean with standard deviation (SD) or median or interquartile ranges (IQR) were used to assess the continuous variables, whereas numbers and percentages were used for categorical variables. Statistical significance was calculated by the Chi-square test. Results The median age of the study population was 64 (IQR 57-74) years and 64.7% (294/454) were male patients. The median follow-up time was 367 days. During the follow-up period, 14.9% (68/454) of the patients were readmitted to the ICU. The mean length of hospital stay was 12 days (IQR 8-20 days). Among the readmitted patients (n=68), 17.6% (12/68) were on mechanical ventilation and the remaining 82.3% (56/68) received oxygen therapy. One patient underwent extracorporeal membrane oxygenation. The hospital mortality rate observed among these ICU survivors was 10.2%. The Health-Related Quality of Life (HRQOL) score at baseline i.e. before the ICU admission (52.5 (SD, 9.2); p<0.001) was better than that observed at the one-year follow-up (44.3 (SD, 9.5); p<0.001). Moreover, the clinical frailty scale and cognitive symptoms were significantly different at the follow up assessment versus the baseline (p<0.001). The proportion of patients with a grade of 0-2 on the Modified Medical Research Council (mMRC) dyspnea scale was almost similar at baseline and the one-year follow-up, whereas a breathlessness grade of 3-4 on the scale was observed in 39.8% of the study population. Conclusion The management of ICU survivors after severe COVID requires a multi-disciplinary approach. It includes preventive measures and rehabilitation services along with appropriate treatment strategies to relieve the residual symptoms.

The optimal use of tracheostomy in COVID-19 patients is debated, and considerable uncertainties on the frequency, timing, and outcomes of tracheostomy remain. The objective was to study the frequency and timing of tracheostomy in a real-world population of critically ill COVID-19 patients. The secondary aim was to study whether early tracheostomy was associated with days alive and out of intensive care unit (ICU), days free of invasive mechanical ventilation (IMV), 60-day mortality, ventilator weaning rate, and ICU discharge rate compared to late tracheostomy.

The study is a retrospective two-center cohort study. All COVID-19 patients admitted to critical care in the Region Östergötland County Council, Sweden, between March 2020 and September 2021 were included. Early (≤10 days from tracheal intubation) and late (>10 days) tracheostomy were compared. Through the Swedish intensive care registry, 249 mechanically ventilated COVID-19-positive patients ≥18 years old with respiratory failure were included. The pre-defined primary outcomes were the frequency and timing of tracheostomy. Secondary outcomes were days free of mechanical ventilation and intensive care, ICU discharge rate, ventilator weaning rate, and 60-day mortality.

Of 319 identified patients (70% men), 249 (78%) underwent endotracheal intubation. Of these, 145 (58%) underwent tracheostomy and 99 (68%) were performed early. Tracheostomy patients (vs. non-tracheostomy) had fewer IMV-free days and ICU-free days (27 [0-43] vs. 52 [43-55], p < .001, and 24 [0-40] vs. 49 [41-52], p < .001). Late (vs. early) tracheostomy patients had fewer IMV- and ICU-free days (16 [0-31] vs. 36 [0-47], p < .001 and 8 [0-28] vs. 32 [0-44], p < .001). Early tracheostomy (vs. late) was associated with a significantly higher ICU discharge rate (adjusted HR = 0.59, 95% CI [0.40-0.86], p = .006), but not with the weaning rate (adjusted HR = 0.64, 95% CI [0.12-3.32], p = .5) or 60-day mortality (adjusted HR = 1.27, 95% CI [0.61-2.67], p = .5).

Tracheostomy is common in critically ill COVID-19 patients. In patients predicted to need a tracheostomy at some point, early, rather than late, tracheostomy might be a means to reduce the time spent in ICU. However, we do not have sufficient evidence to suggest that early tracheostomy reduces mortality or weaning rates, compared with late tracheostomy.

Despite an increased risk for adverse outcomes from SARS-CoV-2 infection among individuals with type 1 diabetes (T1D), vaccine hesitancy persists due to safety concerns including dysglycemia. The impact of booster vaccination on individuals using automated insulin delivery (AID) systems remains unclear.

We used continuous glucose monitoring (CGM) data from 53 individuals with T1D using insulin pump therapy who received their third and/or fourth COVID-19 vaccination. CGM data from the 14 days before and 3 and 7 days after each vaccination were compared. The primary outcome was glucose time in range (TIR) (70-180 mg/dL) 3 and 7 days post-vaccination compared with the 14 days prior. Secondary outcomes included other CGM metrics such as time below range (< 70 mg/dL), time above range (> 180 mg/dL), mean glucose, co-efficient of variation and average total daily insulin.

The cohort comprised 53 adults (64% women, 64% AID), totaling 74 vaccination periods (84% Pfizer-BioNTech boosters), mean ± SD age 40.0 ± 15.9 years, duration of diabetes 26.0 ± 15.4 years. There was no significant difference between pre-vaccination TIR (61.0%±18.5) versus 3 (60.5%±22.8) and 7 days post-vaccination (60.2%±21.8; p = 0.79). Level 1 hypoglycemia, time in range 54-69 mg/dL, was lower 3 (1.1%±1.7) and 7 days post-vaccination (1.1%±1.6), compared with 14 days pre-vaccination (1.4%±1.4; p = 0.021).

The study provides evidence that SARS-CoV-2 booster vaccination does not acutely worsen glycemia in people with T1D receiving insulin pump therapy.

This study compared the efficacy of therapeutic anticoagulation guided by anti-Xa levels vs. a D-dimer-based protocol in ICU patients with COVID-19. Given the heightened risk of thrombosis despite anticoagulation therapy in some cases, we hypothesised that anti-Xa measurement improves anticoagulation effectiveness and clinical outcomes in this population. We retrospectively analysed data from ICU patients at COVID Hospital Karaburma between April 2020 and December 2021. The primary outcome was the incidence of failed noninvasive ventilation necessitating intubation. Secondary endpoints included mortality rates, thromboembolic and bleeding complications, and anticoagulation effectiveness assessed by antifactor Xa activity. The analysis included 395 patients - 137 in the anti-Xa group and 258 in the D-dimer group. The D-dimer group showed a higher rate of failed noninvasive ventilation requiring intubation (65.7% vs. 50%, P  = 0.009). The overall mortality was 48.3%, significantly higher in the D-dimer group (52.7%) compared to the anti-Xa group (40.1%, P  = 0.02). Thromboembolic complications were lower in the anti-Xa group (2.9%) than in the D-dimer group (9.7%, P  = 0.014), with no significant difference in bleeding. Following the first LMWH administration, 70.8% of patients had anti-Xa levels below the therapeutic and 11.7% below the prophylactic range. Anti-Xa-guided anticoagulation improves survival and reduces thromboembolic complications compared to D-dimer-based treatment without increasing bleeding risk. This study highlights the potential of the anti-Xa assay in managing anticoagulation in critically ill COVID-19 patients. Our findings provide a foundation for future research on using anti-Xa measurements as a guiding tool to optimise anticoagulation therapy in other critically ill populations.

The COVID-19 pandemic may have compounded social disparities in access to healthcare, with possible deleterious consequences on the functional prognosis of patients after a stay in the intensive care unit (ICU). In the previous RECOVIDS study, we reported that despite comparable pulmonary sequelae and similar access to rehabilitation, socio-economically "vulnerable" patients had lower quality of life at 6 months after an ICU stay. We aimed to describe the barriers to, and facilitators of participation in rehabilitation, among patients from the RECOVIDS study, regardless of their socio-economic situation.

Qualitative study using semi-structured interviews with adult patients admitted to ICU for PCR-proven SARS-CoV-2 infection, and who had acute respiratory distress syndrome (ARDS) or had received high flow nasal oxygen. In addition, patients had to have been living at home for the month prior to the interview and had to be proficient in French. Eligible patients were randomly selected, aiming to select the same number of socially deprived and non-socially-deprived patients. Interviews were transcribed for thematic analysis.

In total, 31 interviews were performed from 10/2021 to 01/2022; 16 with socially deprived, and 15 with non-deprived participants. Average age was 65.2 (±11.6) years. Four themes emerged from the analysis of the interviews, namely: (1) the impact of the patient's professional and socio-economic situation; (2) the feeling that age and socio-economic situation influence access to rehabilitation; (3) a perception that the healthcare system was saturated, and that inequalities exist in access to rehabilitation resources; (4) perception of previous own health and expectations of post-resuscitation health status.

A precarious socio-economic situation has a substantial impact on access to rehabilitation after ICU admission for ARDS caused by COVID-19. It represents a barrier to rehabilitation through the combined action of various social determinants that deserve to be detected early, in order to take appropriate action to ensure that the most socially vulnerable individuals can benefit from access to rehabilitation.

Background: Prone positioning in mechanically ventilated patients with severe ARDS is associated with reduced mortality. COVID-19 causes variable pulmonary involvement in some patients suffering from severe respiratory failure and ARDS. Although proning in the COVID-19 patient population is increasingly common, more data are needed to fully understand its utility in those with ARDS due to COVID-19. Methods: We conducted a single-center retrospective study, inclusive of 100 consecutive subjects intubated for ARDS from COVID-19, admitted to the ICU from September 2020 to December 2020. Data were collected daily from time of intubation for 7 d along with 30-d outcomes. Results: The study included a total of 53 subjects proned and 47 nonproned during their hospitalization. Proned subjects had a mean age of 61.8 years and 56.6% were male, compared with a mean age of 66.3 years and 57.4% male in the nonproned group. Age, sex, other baseline characteristics, and treatments were similar between groups, except that proned subjects had a higher body mass index than nonproned subjects (34.1 ± 7.5 vs 30.5 ± 7.4, kg/m2 P = .02) and lower initial P/F ratios (119.1 ± 54.5 vs 154.0 ± 92.7 mm Hg, P = .047). Proned subjects received more neuromuscular blockade (OR 6.63, 95% CI 3.25-13.12, P < .001) and higher sedation levels (two sedatives: OR = 3.00, 95% CI 1.77-5.08; ≥3 sedatives: OR = 7.13, 95% CI 3.96-12.81) with similar ICU stays, ventilator days, newly initiated renal replacement therapy, and 30-d outcomes including being alive, out of the ICU, or discharged from the hospital when compared with nonproned subjects. There were a total of 15 (28.3%) complications related to proning. Proned subjects were reintubated significantly less than the nonproned group (1.9% vs 19.1%, P = .006). Conclusions: Proning mechanically ventilated COVID-19 subjects was associated with more frequent use of neuromuscular blockade and sedation, and lower rates of re-intubation, for respiratory failure when compared with nonproned subjects.

Rationale: The optimal strategy to prevent reintubation in patients with obesity remains uncertain. Objectives: We aimed to determine whether noninvasive ventilation (NIV) with active humidification is superior to a high-flow nasal cannula (HFNC) in preventing reintubation in patients with obesity at intermediate risk. Methods: We conducted a randomized controlled trial in two ICUs in Spain (June 2020-June 2021). We included patients ready for planned extubation with a body mass index >30 and three or fewer risk factors for reintubation. Patients with hypercapnia at the end of the spontaneous breathing trial were excluded. Patients were randomized to undergo NIV with active humidification or HFNC for 48 hours after extubation. The primary outcome was the reintubation rate within 7 days after extubation. As a secondary analysis, we performed a post hoc Bayesian analysis using three different priors. Measurements and Main Results: Of 144 patients (median age, 61 [25th-75th percentile range, 61-67] yr; 65 [45%] men), 72 received NIV and 72 received an HFNC. Reintubation was required in 17 (23.6%) patients receiving NIV and in 24 (33.3%) patients receiving HFNC (difference between groups, 9.7; 95% confidence interval, -4.9, 24.4). All of the secondary analysis showed nonsignificant differences. In the exploratory Bayesian analysis, the probability of a reduction in reintubation with NIV was 99% (data-driven prior), 90% (minimally informative prior), or 89% (skeptical prior). Conclusions: Among adult critically ill patients with obesity at intermediate risk for extubation failure, the rate of reintubation was not significantly lower with NIV than with HFNC. Nevertheless, there is a risk for underpowered results. Clinical trial registered with www.clinicaltrials.gov (NCT04125342).

During the SARS-CoV-2 pandemic, a significant number of critical patients required ventilatory assistance in health institutions. In this context, Ventilator-Associated Pneumonia (VAP) was the most prevalent nosocomial infection among critically ill patients. We aimed to analyze the occurrence of VAP in critically ill patients with SARS-CoV-2 and the risk factors associated with the outcome.

This is a multicenter, retrospective cohort study which included patients ≥18 years old, diagnosed with COVID-19, admitted to intensive care units (ICU) and who received invasive mechanical ventilation (MV) for >2 consecutive days. The associations between the variables were initially tested, and those that showed potential associations (p<0.05) were included in the multivariate logistic regression model.

One third of patients had an episode of VAP, with an incidence density of 34.97 cases per 1000 MV days. In addition, 42.37% (50) of the microorganisms causing VAP were multidrug-resistant, predominantly gram-negative bacteria (61.32%). More than 50% of participants developed healthcare-associated infections and 243 (73.64%) died. The factors associated with greater chances of VAP were: prone position (OR= 3.77), BMI 25-29.9 kg/m2 (OR= 4.76), pressure injury (OR= 4.41), length of stay in the ICU (OR= 1.06), positive tracheal aspirate before VAP (OR= 5.41) and dyspnea (OR= 3.80).

Patients with COVID-19 are at high risk of VAP, which leads to an increased risk of death (OR = 2.18). Multiple factors increase the chances of VAP in this population, namely: work overload in health institutions, prone position, prolonged ICU time, infusion of multiple drugs, invasive devices, and in particular, immobility in bed.

The purpose of this study was to evaluate the treatment strategies that dictate the host susceptibility to secondary bacterial infections during coronavirus disease 2019 (COVID-19).

This nested, case-control study was conducted in three general hospitals in China between 1st December 2022 and 1st March 2023. A total of 456 confirmed COVID-19 patients matched 1:2 (152 cases and 304 controls) based on age, sex, disease severity and age-adjusted Charlson Comorbidity Index (aCCI) using propensity-score matching (PSM) were included. Association of secondary bacterial infections with treatment strategies including the supportive measures, antiviral, and antibacterial therapies were the main outcome measures.

Conditional logistic regression analyses demonstrated that among categorical variables, use of antibiotics, antivirals, intravenous injection of human immunoglobulin, glucocorticoids or anticoagulants were not associated with the risk of secondary bacterial infections in the COVID-19 patients. The use of supplemental oxygen by either low (odds ratio (OR): 0.18, P<0.001) or high flow (OR: 0.06, P<0.001), but not through ventilators were associated with significant protection against secondary bacterial infection. In contrast, feeding through gastric tube (OR: 10.97, P<0.001) or parenteral nutrition (OR: 3.97, P=0.002) was associated with significant increase in the risk of secondary bacterial infections. Similar data were obtained when data were analysed using continuous variables. Further, the early (<5 days post symptom onset, OR: 0.09, P<0.001), but not the late use of antivirals was associated with protection against secondary bacterial infections.

Oxygen supplementation in non-ventilator settings and early use of antivirals were associated with decreased incidences of secondary bacterial infections, while parenteral nutrition or tube feedings were associated with increased incidences of secondary bacterial infections.

Background & objectives Evidence suggests that individuals who have been hospitalised due to COVID-19 are more susceptible to future mortality and readmission, thereby imposing a substantial strain on their quality of life. The available data on intensive care unit (ICU) survivors, particularly in terms of long-term outcomes, is notably insufficient. This study focused on the long-term outcomes for ICU survivors of COVID-19, specifically readmission and mortality, as well as possible risk factors that could lead to their need for readmission. Methods We conducted a prospective observational study of 505 individuals admitted to the ICU of a tertiary care hospital between March 2020 and March 2021. Follow up concluded in January 2024. We evaluated the need for hospital and ICU readmissions, examining potential risk factors, including patient comorbidities, clinical situation at the time of the previous hospital and ICU admission, and evolution and treatment in the ICU. As a secondary objective, we determined the prevalence of long-term mortality. Results Among 341 ICU survivors, 75 (22%) required hospital readmission, with a median time to readmission of 415 days (IQR: 166-797). The most frequent cause of readmission was respiratory conditions (29.3%). The median hospital stay during readmission was six days. Independent risk factors for hospital readmission included age, elevated creatinine levels at ICU admission, and length of stay in the ICU. Of the 75 readmitted to the hospital, 19 required ICU readmission. Ten individuals died following hospital discharge. Interpretation & conclusions Patients requiring ICU admission due to COVID-19 have a significant risk of hospital readmission, particularly those with advanced age, elevated creatinine levels at ICU admission, and longer ICU stays.