RESUMEN
BACKGROUND: Prone positioning (PP) has demonstrated its potential for improving outcomes in patients with ARDS who require invasive mechanical ventilation. However, the ability of prolonged proning to reduce mortality in patients with COVID-19-specifically, sessions lasting > 24 h-remains uncertain. METHODS: In this retrospective cohort study, we examined 158 subjects with COVID-19 pneumonia who required mechanical ventilation due to moderate-to-severe ARDS. Seventy-six subjects were placed in standard PP and 82 in extended PP, defined as prone sessions lasting at least 32 h. Our primary aim was to evaluate the effect of EPP on 90-d survival in subjects with COVID-19 with acute severe respiratory failure. To ensure the reliability of our findings and to minimize bias, we applied 3 adjustment approaches: cardinality matching (CM), matching weighting (MW), and inverse probability of treatment weighting with stabilized and trimmed weights (SW). We used Kaplan-Meier curves and Cox proportional hazard models to analyze the effects of EPP on 90-d mortality and sensitivity analysis by calculating E-values. RESULTS: The overall crude 90-d mortality rate was 31.7%. The unadjusted 90-d mortality rates were 19.5% in the EPP group and 44.7% in the SPP group (hazard ratio [HR] 0.35 [95% CI 0.19- 0.63], P < .001). After adjustment for confounding factors using CM, MW, and SW, baseline covariates were balanced between the 2 groups. Subjects in the EPP group exhibited lower 90-d mortality rates after adjustment using CM (HR 0.42 [95% CI 0.23-0.79], P = .007), MW (HR 0.45 [95% CI 0.21-0.95], P = .036), or SW (HR 0.29 [95% CI 0.15-0.56], P < .001). CONCLUSIONS: Extended PP was associated with improved 90-d survival in subjects with COVID-19 undergoing mechanical ventilation for severe ARDS. These findings suggest the potential benefit of EPP in the management of COVID-19-related respiratory failure. Further research and prospective studies are warranted to confirm and elucidate the underlying mechanisms of this association.
RESUMEN
PURPOSE: Frailty is a common condition among critically ill patients. Usually evaluated in a mixed population of medical, cardiac and surgical patients, we aimed to assess the impact of frailty on short- and long-term mortality exclusively in critically ill older medical patients. MATERIALS AND METHODS: We included 285 patients aged≥70â¯years admitted to ICU (2009-2017). Comorbidities, severity scores, treatment intensity and complications were recorded. Pre-hospital frailty, measured by Clinical Frailty Scale (CFS), was defined as a scoreâ¯≥â¯5 according to this scale. RESULTS: Prevalence of frailty (CFSâ¯≥â¯5) of 18.6%. Frail patients were more likely to be female (64.2% vs. 35.6%, pâ¯<â¯.001) or suffer from heart failure (17% vs. 6%,pâ¯=â¯.021). Apache II score was higher in frail than in non-frail patients (27.4⯱â¯7.1 vs. 24.8⯱â¯8.6,pâ¯=â¯.041). Age, comorbidities, treatment intensity, complications, and ICU and hospital length of stay were similar between frail and non-frail patients. Life-sustaining treatment limitation was more frequent in frail patients (47.2% vs. 20.7%,pâ¯<â¯.001). Except for ICU mortality, frailty was an independent predictor of short- and long-term mortality after adjustment for sociodemographic, comorbidities, severity scores, treatment intensity and complications. CONCLUSIONS: Frailty (CFSâ¯≥â¯5) was independently associated with short- and long-term mortality in older patients admitted to ICU exclusively due to a medical reason.
Asunto(s)
Enfermedad Crítica/mortalidad , Fragilidad/mortalidad , Unidades de Cuidados Intensivos , Anciano , Anciano de 80 o más Años , Comorbilidad , Femenino , Evaluación Geriátrica , Insuficiencia Cardíaca/epidemiología , Insuficiencia Cardíaca/mortalidad , Hospitalización , Humanos , Estimación de Kaplan-Meier , Tiempo de Internación , Masculino , Persona de Mediana Edad , Prevalencia , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Índice de Severidad de la EnfermedadRESUMEN
RESUMEN La necrolisis epidérmica tóxica es una reacción cutánea adversa de tipo inmunológico secundaria en la mayor parte de los casos a la administración de un fármaco. La necrolisis epidérmica tóxica, el síndrome de Steven Johnson y el eritema exudativo multiforme forman parte del mismo espectro de enfermedad. La mortalidad de la necrolisis epidérmica tóxica es alrededor del 30%. La fisiopatología de la necrolisis epidérmica tóxica es semejante en muchos aspectos a la de las quemaduras dérmicas superficiales. La afectación mucosa del epitelio ocular y genital se asocia con secuelas graves si no se trata de forma temprana. Se acepta en general que los pacientes con necrolisis epidérmica tóxica son tratados mejor en unidades de grandes quemados, donde existe experiencia en el manejo de enfermos con pérdida cutánea extensa. El tratamiento es de soporte, eliminación y cobertura con derivados biosintéticos de la piel de las zonas afectadas, tratamiento de la afectación mucosa, y tratamiento inmunosupresor específico. De los tratamientos ensayados sólo se usa actualmente en la mayor parte de los centros la inmunoglobulina G y la ciclosporina A, aun cuando no existe evidencia sólida para recomendar ningún tratamiento específico. Entre los aspectos particulares del tratamiento de esta enfermedad se encuentra la prevención de secuelas relacionadas con la formación de sinequias, los cuidados oculares para prevenir secuelas graves que pueden conducir a la ceguera, y el tratamiento específico inmunosupresor. Un mejor conocimiento de los principios del manejo de la necrolisis epidérmica tóxica llevará a un mejor manejo de la enfermedad, a una mayor supervivencia y una menor prevalencia de las secuelas.
ABSTRACT Toxic epidermal necrolysis is an adverse immunological skin reaction secondary in most cases to the administration of a drug. Toxic epidermal necrolysis, Stevens-Johnson syndrome, and multiform exudative erythema are part of the same disease spectrum. The mortality rate from toxic epidermal necrolysis is approximately 30%. The pathophysiology of toxic epidermal necrolysis is similar in many respects to that of superficial skin burns. Mucosal involvement of the ocular and genital epithelium is associated with serious sequelae if the condition is not treated early. It is generally accepted that patients with toxic epidermal necrolysis are better treated in burn units, which are experienced in the management of patients with extensive skin loss. Treatment includes support, elimination, and coverage with biosynthetic derivatives of the skin in affected areas, treatment of mucosal involvement, and specific immunosuppressive treatment. Of the treatments tested, only immunoglobulin G and cyclosporin A are currently used in most centers, even though there is no solid evidence to recommend any specific treatment. The particular aspects of the treatment of this disease include the prevention of sequelae related to the formation of synechiae, eye care to prevent serious sequelae that can lead to blindness, and specific immunosuppressive treatment. Better knowledge of the management principles of toxic epidermal necrolysis will lead to better disease management, higher survival rates, and lower prevalence of sequelae.
Asunto(s)
Humanos , Síndrome de Stevens-Johnson/fisiopatología , Enfermedad Crítica , Inmunosupresores/uso terapéutico , Inmunoglobulina G/uso terapéutico , Tasa de Supervivencia , Síndrome de Stevens-Johnson/complicaciones , Síndrome de Stevens-Johnson/terapia , Ciclosporina/uso terapéutico , Progresión de la EnfermedadRESUMEN
Toxic epidermal necrolysis is an adverse immunological skin reaction secondary in most cases to the administration of a drug. Toxic epidermal necrolysis, Stevens-Johnson syndrome, and multiform exudative erythema are part of the same disease spectrum. The mortality rate from toxic epidermal necrolysis is approximately 30%. The pathophysiology of toxic epidermal necrolysis is similar in many respects to that of superficial skin burns. Mucosal involvement of the ocular and genital epithelium is associated with serious sequelae if the condition is not treated early. It is generally accepted that patients with toxic epidermal necrolysis are better treated in burn units, which are experienced in the management of patients with extensive skin loss. Treatment includes support, elimination, and coverage with biosynthetic derivatives of the skin in affected areas, treatment of mucosal involvement, and specific immunosuppressive treatment. Of the treatments tested, only immunoglobulin G and cyclosporin A are currently used in most centers, even though there is no solid evidence to recommend any specific treatment. The particular aspects of the treatment of this disease include the prevention of sequelae related to the formation of synechiae, eye care to prevent serious sequelae that can lead to blindness, and specific immunosuppressive treatment. Better knowledge of the management principles of toxic epidermal necrolysis will lead to better disease management, higher survival rates, and lower prevalence of sequelae.
La necrolisis epidérmica tóxica es una reacción cutánea adversa de tipo inmunológico secundaria en la mayor parte de los casos a la administración de un fármaco. La necrolisis epidérmica tóxica, el síndrome de Steven Johnson y el eritema exudativo multiforme forman parte del mismo espectro de enfermedad. La mortalidad de la necrolisis epidérmica tóxica es alrededor del 30%. La fisiopatología de la necrolisis epidérmica tóxica es semejante en muchos aspectos a la de las quemaduras dérmicas superficiales. La afectación mucosa del epitelio ocular y genital se asocia con secuelas graves si no se trata de forma temprana. Se acepta en general que los pacientes con necrolisis epidérmica tóxica son tratados mejor en unidades de grandes quemados, donde existe experiencia en el manejo de enfermos con pérdida cutánea extensa. El tratamiento es de soporte, eliminación y cobertura con derivados biosintéticos de la piel de las zonas afectadas, tratamiento de la afectación mucosa, y tratamiento inmunosupresor específico. De los tratamientos ensayados sólo se usa actualmente en la mayor parte de los centros la inmunoglobulina G y la ciclosporina A, aun cuando no existe evidencia sólida para recomendar ningún tratamiento específico. Entre los aspectos particulares del tratamiento de esta enfermedad se encuentra la prevención de secuelas relacionadas con la formación de sinequias, los cuidados oculares para prevenir secuelas graves que pueden conducir a la ceguera, y el tratamiento específico inmunosupresor. Un mejor conocimiento de los principios del manejo de la necrolisis epidérmica tóxica llevará a un mejor manejo de la enfermedad, a una mayor supervivencia y una menor prevalencia de las secuelas.