Short‐term complications and post‐acute sequelae in hospitalized paediatric patients with COVID ‐19 and obesity: A multicenter cohort study
Gonzalo ValenzuelaGonzalo Muinelo AlarcónClara SchulzeRocío RodríguezTamara García‐SalumCatalina Pardo‐RoaJorge LévicanEileen SerranoMaría José AvendañoMonserrat GutiérrezLoreto GodoyPamela CéspedesSandra BermúdezJaviera AravenaIrini NicolaidesEliana C. MartinezConstanza Gómez‐CanobbioMacarena JofréAndrea SalinasDaniela DepaoliCarolina S. Diaz- LozaAndrés MuñozNatalia OrmazábalDiana ManzurJosé BarrigaLeonardo I. AlmonacidEstefany Poblete‐CárdenasErick SalinasAndrés Muñoz‐MarcosSalesa BarjaRafael Medina
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Summary Background Obesity increases the severity of coronavirus disease 2019 illness in adults. The role of obesity in short‐term complications and post‐acute sequelae in children is not well defined. Objective To evaluate the relationship between obesity and short‐term complications and post‐acute sequelae of SARS‐CoV‐2 infection in hospitalized paediatric patients. Methods An observational study was conducted in three tertiary hospitals, including paediatric hospitalized patients with a confirmatory SARS‐CoV‐2 RT‐PCR from March 2020 to December 2021. Obesity was defined according to WHO 2006 (0–2 years) and CDC 2000 (2–20 years) growth references. Short‐term outcomes were intensive care unit admission, ventilatory support, superinfections, acute kidney injury, and mortality. Neurological, respiratory, and cardiological symptoms and/or delayed or long‐term complications beyond 4 weeks from the onset of symptoms were considered as post‐acute sequalae. Adjusted linear, logistic regression and generalized estimating equations models were performed. Results A total of 216 individuals were included, and 67 (31.02%) of them had obesity. Obesity was associated with intensive care unit admission (aOR = 5.63, CI95% 2.90–10.94), oxygen requirement (aOR = 2.77, CI95% 1.36–5.63), non‐invasive ventilatory support (aOR = 6.81, CI95% 2.11–22.04), overall superinfections (aOR = 3.02 CI95% 1.45–6.31), and suspected bacterial pneumonia (aOR = 3.00 CI95% 1.44–6.23). For post‐acute sequalae, obesity was associated with dyspnea (aOR = 9.91 CI95% 1.92–51.10) and muscle weakness (aOR = 20.04 CI95% 2.50–160.65). Conclusions In paediatric hospitalized patients with COVID‐19, severe short‐term outcomes and post‐acute sequelae are associated with obesity. Recognizing obesity as a key comorbidity is essential to develop targeted strategies for prevention of COVID‐19 complications in children.Cite
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Pneumonia associated with mechanical ventilation in the intensive care unit (ICU) setting is one of the most common infections managed by intensivists. The current classification of nosocomial pneumonia includes hospital-acquired pneumonia, ventilator-associated pneumonia (VAP), and nursing home-
Ventilator-associated Pneumonia
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ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Zante B, Happ S, Haltmeier T, Schefold J. Aerosplenism in the intensive care unit. Anaesthesiology Intensive Therapy. 2017;49(3). APA Zante, B., Happ, S., Haltmeier, T., & Schefold, J. (2017). Aerosplenism in the intensive care unit. Anaesthesiology Intensive Therapy, 49(3). Chicago Zante, Bjoern, Sebastian Happ, Tobias Haltmeier, and Joerg C. Schefold. 2017. "Aerosplenism in the intensive care unit". Anaesthesiology Intensive Therapy 49 (3). Harvard Zante, B., Happ, S., Haltmeier, T., and Schefold, J. (2017). Aerosplenism in the intensive care unit. Anaesthesiology Intensive Therapy, 49(3). MLA Zante, Bjoern et al. "Aerosplenism in the intensive care unit." Anaesthesiology Intensive Therapy, vol. 49, no. 3, 2017. Vancouver Zante B, Happ S, Haltmeier T, Schefold J. Aerosplenism in the intensive care unit. Anaesthesiology Intensive Therapy. 2017;49(3).
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Inappropriate initial antibiotics for pneumonia infection are usually linked to extended intensive care unit stay and are associated with an increased risk of mortality. This study evaluates the impact of inappropriate initial antibiotics on the length of intensive care unit stay, risk of mortality and the co-predictors that influences these outcomes. This retrospective study was conducted in an intensive care unit of a teaching hospital. The types of pneumonia investigated were hospital-acquired pneumonia and ventilator-associated pneumonia. Three different time points were defined as the initiation of appropriate antibiotics at 24 h, between 24 to 48 h and at more than 48 h after obtaining a culture. Patients had either hospital-acquired pneumonia (59.1%) or ventilator-associated pneumonia (40.9%). The length of intensive care unit stay ranged from 1 to 52 days (mean; 9.78±10.02 days). Patients who received appropriate antibiotic agent at 24 h had a significantly shorter length of intensive care unit stay (5.62 d, P<0.001). The co-predictors that contributed to an extended intensive care unit stay were the time of availability of susceptibility results and concomitant diseases, namely cancer and sepsis. The only predictor of intensive care unit death was cancer. The results support the need for early appropriate initial antibiotic therapy in hospital-acquired pneumonia and ventilator-associated pneumonia infections.
Ventilator-associated Pneumonia
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The most recent edition of the Acute Physiology and Chronic Health Evaluation provides a prediction of intensive care unit length of stay in addition to the probability of hospital mortality. Intensive care length of stay is an important determinant of intensive care costs and may be an important indicator of quality of care. Data were collected from 22 Scottish intensive care units over a 2‐year period to allow comparison of actual intensive care unit length of stay with that predicted by the Acute Physiology and Chronic Health Evaluation III system. Correlation between actual and predicted stay for individual patients was poor. However, performance of the model for patients, grouped either by predicted length of stay or by intensive care unit, indicated that the model stratified patient groups appropriately while demonstrating a consistent bias. Length of stay in Scottish intensive care units was found to be consistently lower than that predicted by a model which is based on intensive care practice in the USA. Variations in severity of illness in intensive care unit populations cannot readily explain differences in intensive care unit length of stay. The availability of a model capable of predicting length of intensive care stay, based on data reflecting practice in the UK, would compliment current methods of assessing effectiveness of intensive care.
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To assess variations in case-mix-adjusted hospital and intensive care unit length of stay and to examine the relationship between intensive care unit and hospital stay.Retrospective cohort study.Sixty-nine intensive and cardiac care units in 23 U.S. hospitals during 2002 to 2008.Intensive care unit admissions (202,300) who met inclusion criteria.None.We obtained hospital and intensive care unit characteristics and patient demographic, clinical, diagnostic, and physiologic variables, mortality, and lengths of stay. We developed and validated a model to assess case-mix-adjusted hospital stay and modified and updated a previously validated model to assess adjusted intensive care unit stay. We used these models to compare observed and expected hospital and intensive care unit stay for each patient by calculating the observed minus expected length of stay. Mean observed intensive care unit stay was 4.33 days and mean predicted intensive care unit stay was 4.09 days (5.9-hr difference); mean observed hospital stay was 9.93 days and mean predicted hospital stay was 9.52 days (9.7-hr difference). Observed minus expected intensive care unit and hospital length of stay were significantly shorter (p < .01) at one intensive care unit and significantly longer (p < .01) at nine intensive care units. There was a correlation between hospital and intensive care unit observed minus expected length of stay across individuals (R2 = .40), which was much stronger across units (R2 = .76).Case-mix-adjusted benchmarks for hospital and intensive care unit stays reveal substantial differences in unit efficiency. Hospital and intensive care unit stays are strongly correlated at the patient and unit level, suggesting that there are causal factors common to both.
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The purpose of the study was to reveal the predictors of more than 24-hour intensive care unit stay for patients activated early (up to 5 hours) after surgery under extracorporeal circulation and to explore the possibilities of predicting the prolongation of postoperative intensive care in the clinical situation under examination. The protocols of anesthetic maintenance, early activation, and postoperative intensive care were analyzed in 83 patients (50 males and 33 females) aged 31 to 82 years, who had been operated on under extracorporeal circulation for various cardiosurgical diseases. The multiple regression analysis showed that the significant predictors of more prolonged intensive care after early activation were the level of arterial lactatemia (p = 0.0021), the dosages of adrenaline and/or noradrenaline (p = 0.0048), age (p = 0.0051), and female sex (p = 0.0142). It was shown that the multiple regression analysis could approximately predict the duration of intensive care after early activation. The predicted and actual durations of intensive care in patients with an intensive care unit stay length of more than 24 hours coincided in 52% of cases. In patients with an intensive care unit stay length of less than 24 hours, the estimated and actual durations of intensive care were in agreement in 92% of cases. It is concluded that it is expedient to take into account the results of the performed analysis in choosing the optimum postoperative management policy in cardiosurgical patients who are to undergo early activation.
Extracorporeal circulation
Extracorporeal
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Nosocomial pneumonia is the second most frequent cause of nosocomial infection. Most studies have been carried out in intensive care units with patients requiring mechanical ventilation or at high risk for developing nosocomial pneumonia. However, about half of the cases of nosocomial pneumonia occur outside intensive care unit and differ from ventilator-associated pneumonia in several aspects. Patients admitted in conventional hospital wards are not exposed to such aggressive maneuvers as those receiving mechanical ventilation. Moreover, changes in the oropharyngeal flora are probably delayed and the community flora persists longer in them. In addition, these patients are more susceptible to the pathogens present in the air and water environment. These facts suggest that the etiology and therapeutic approach in these 2 groups are not totally comparable.
Etiology
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Ventilator-associated Pneumonia
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Context: Iatrogenic injuries are very common in critically ill adults. However, the financial implications of these events are incompletely understood. Objective: To determine the costs of adverse events in patients in the medical intensive care unit and in the cardiac intensive care unit. Design, Setting, and Patients: We performed a matched case-control analysis on data collected during a prospective 1-yr observation study (July 2002 to June 2003) of medical intensive care unit and cardiac intensive care unit patients at an academic, tertiary care urban hospital. A total of 108 cases were matched with 375 controls in our study. Main Outcome Measures: Costs of care and lengths of stay were determined from hospital billing systems for patients in the medical and cardiac intensive care units. We then determined the incremental costs and lengths of stay for patients with adverse events compared with patients without events while in the intensive care unit. Costs were truncated for patients with a second adverse event on a subsequent day during the intensive care unit stay. Results: For 56 medical intensive care unit patients, the cost of an adverse event was $3,961 (p = .010) and the increase in length of stay was 0.77 days (p = .048). This extrapolated to annual costs of $853,000 for adverse events in the medical intensive care unit. Similarly, for 52 cardiac intensive care unit patients, the cost of an adverse event was $3,857 (p = .023), corresponding to $630,000 in annual costs. On average, patients with events in the cardiac intensive care unit had an increase of 1.08 days in length of stay (p = .003). Conclusions: Patients who require intensive care are especially at risk for adverse events, and the associated costs with such events are substantial. The costs of adverse events may justify further investment in prevention strategies.
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Background and Purpose of the study: Hyperglycemia and insulin resistance are common findings among critically ill patients. Intensive insulin therapy reduces morbidity and mortality in patients of surgical and medical intensive care units (ICUs), but its role in patients of general intensive care units still remains unknown. The present study was designed to determine the effect of intensive insulin therapy on ICU mortality. Methods: Adult patients admitted to general intensive care units in Valiy-e- Asr Hospital, who required intensive care for at least five days were considered for a prospective, randomized and control study. On admission, patients were randomly chosen either to normalize their blood glucose levels or to prepare them for conventional therapy. Results: Intensive insulin therapy reduced blood glucose levels of 129 patients but did not have any significant effect on reduction of mortality rate of hospitalized patients (30.6% in the conventional-treatment group vs. 38.8% in the intensive-treatment group, p > 0.05). However, the morbidity rate was significantly plummeted as a consequence of acceleration in the process of weaning of the patient from mechanical ventilation, and subsequently discharging from the ICU. The benefit of intensive insulin therapy was attributed to its effect on mortality among patients who remained in the intensive care unit for more than five days (78.9% conventionaltreatment group vs. 46.2% intensive-treatment group, p = 0.04). Conclusion: Intensive insulin therapy significantly reduced morbidity but not mortality among the patients in general intensive care units. The very possible risk of subsequent diseaseassociated and fatal complications was reduced in patients who were treated for five days or longer time. Further studies are required to confirm these preliminary results.
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