Predictive Factors for Physiotherapy Session Length at an Adult Intensive Care Unit: A Longitudinal Panel Study

OBJECTIVE

To identify predictive factors for the length of physiotherapy sessions for adult intensive care unit (ICU) patients.

DESIGN

Longitudinal panel study.

SETTING

ICU of a secondary-care public teaching hospital, the University Hospital at the University of Sao Paulo, Brazil.

PARTICIPANTS

Medical and surgical patients who received physiotherapy (N=181) assessed in 339 physiotherapy sessions.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The study investigator followed physiotherapists during their work shift and timed the physiotherapy session's length with a stopwatch. The association between session length and patient, physiotherapist, and service-related factors was evaluated by a mixed model.

RESULTS

Assessed in this study were 339 physiotherapy sessions during 79 periods of observation that involved 181 patients and 19 physiotherapists. Median session length was 29 (interquartile range: 22.6-38.9) minutes; median number of patients assisted per physiotherapist per 6-hour shift was 5 (4-5). Physiotherapist's median age was 35 (26-39) years old, and median ICU experience was 13.0 (0.4-16.0) years. Patients were mostly older adults who were post surgery and had been at the ICU for 5 (2-9) days. Factors associated with physiotherapy session length (min) were the following: performing both motor- and respiratory-related physiotherapy procedures during the session (β=6.5; 95% confidence interval [CI], 3.8-9.2), altered chest x-ray (β=2.8; 95% CI, 0.3-5.3), ICU mobility scale (IMS) (β=1.2; 95% CI, 0.4-2.0), contraindication to any level of out-of-bed mobilization (β=-6.9; 95% CI, -10.5 to -3.3), afternoon shift (β=-4.0; 95% CI, -6.7 to -1.4), and Barthel index (β=-0.2; 95% CI, -0.3 to -0.1).

CONCLUSIONS

The factors associated with longer session lengths were performing both motor- and respiratory-related physiotherapy procedures during the session, altered chest x-ray, and the IMS. Contraindication to any level of out-of-bed mobilization and sessions performed during the afternoon shift (vs the morning shift) were associated with shorter session lengths.

Impact of exposure time in awake prone positioning on clinical outcomes of patients with COVID-19-related acute respiratory failure treated with high-flow nasal oxygen: a multicenter cohort study

Background

In patients with COVID-19-related acute respiratory failure (ARF), awake prone positioning (AW-PP) reduces the need for intubation in patients treated with high-flow nasal oxygen (HFNO). However, the effects of different exposure times on clinical outcomes remain unclear. We evaluated the effect of AW-PP on the risk of endotracheal intubation and in-hospital mortality in patients with COVID-19-related ARF treated with HFNO and analyzed the effects of different exposure times to AW-PP.

Methods

This multicenter prospective cohort study in six ICUs of 6 centers in Argentine consecutively included patients > 18 years of age with confirmed COVID-19-related ARF requiring HFNO from June 2020 to January 2021. In the primary analysis, the main exposure was awake prone positioning for at least 6 h/day, compared to non-prone positioning (NON-PP). In the sensitivity analysis, exposure was based on the number of hours receiving AW-PP. Inverse probability weighting–propensity score (IPW-PS) was used to adjust the conditional probability of treatment assignment. The primary outcome was endotracheal intubation (ETI); and the secondary outcome was hospital mortality.

Results

During the study period, 580 patients were screened and 335 were included; 187 (56%) tolerated AW-PP for [median (p25–75)] 12 (9–16) h/day and 148 (44%) served as controls. The IPW–propensity analysis showed standardized differences < 0.1 in all the variables assessed. After adjusting for other confounders, the OR (95% CI) for ETI in the AW-PP group was 0.36 (0.2–0.7), with a progressive reduction in OR as the exposure to AW-PP increased. The adjusted OR (95% CI) for hospital mortality in the AW-PP group ≥ 6 h/day was 0.47 (0.19–1.31). The exposure to prone positioning ≥ 8 h/d resulted in a further reduction in OR [0.37 (0.17–0.8)].

Conclusion

In the study population, AW-PP for ≥ 6 h/day reduced the risk of endotracheal intubation, and exposure ≥ 8 h/d reduced the risk of hospital mortality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03881-2.

Predictors of failure with high-flow nasal oxygen therapy in COVID-19 patients with acute respiratory failure: a multicenter observational study

PURPOSE

We aimed to describe the use of high-flow nasal oxygen (HFNO) in patients with COVID-19 acute respiratory failure and factors associated with a shift to invasive mechanical ventilation.

METHODS

This is a multicenter, observational study from a prospectively collected database of consecutive COVID-19 patients admitted to 36 Spanish and Andorran intensive care units (ICUs) who received HFNO on ICU admission during a 22-week period (March 12-August 13, 2020). Outcomes of interest were factors on the day of ICU admission associated with the need for endotracheal intubation. We used multivariable logistic regression and mixed effects models. A predictive model for endotracheal intubation in patients treated with HFNO was derived and internally validated.

RESULTS

From a total of 259 patients initially treated with HFNO, 140 patients (54%) required invasive mechanical ventilation. Baseline non-respiratory Sequential Organ Failure Assessment (SOFA) score [odds ratio (OR) 1.78; 95% confidence interval (CI) 1.41-2.35], and the ROX index calculated as the ratio of partial pressure of arterial oxygen to inspired oxygen fraction divided by respiratory rate (OR 0.53; 95% CI: 0.37-0.72), and pH (OR 0.47; 95% CI: 0.24-0.86) were associated with intubation. Hospital site explained 1% of the variability in the likelihood of intubation after initial treatment with HFNO. A predictive model including non-respiratory SOFA score and the ROX index showed excellent performance (AUC 0.88, 95% CI 0.80-0.96).

CONCLUSIONS

Among adult critically ill patients with COVID-19 initially treated with HFNO, the SOFA score and the ROX index may help to identify patients with higher likelihood of intubation.

Diagnosis of pulmonary embolism in patients with acute exacerbations of chronic obstructive pulmonary disease: A cross-sectional study

INTRODUCTION

Pulmonary embolism (PE) remains a frequent complication in patients with chronic obstructive pulmonary disease (COPD). It is unclear that the extent to which the traditional risk stratifying scores for PE are accurate in this population.

METHODS

Cross-sectional study of adult patients with COPD and suspected PE included in an Institutional Registry of Thromboembolic Disease at a tertiary teaching hospital in the city of Buenos Aires, Argentina. We estimated the area under the receiver operating characteristic curves (AU-ROC), sensitivity and specificity of the Wells and Geneva scores using a positive computed tomography angiography as the gold standard for PE. We also estimated the sensitivity and specificity for the presence of isolated worsening of dyspnea at presentation, without other cardinal symptoms of acute exacerbation of COPD.

RESULTS

A total of 168 patients were included, of which 22% had confirmed PE. The AUC was 0.66 (95% CI 0.56-0.76) and 0.56 (95% CI 0.45-0.67) for the Wells and Geneva, respectively. Considering the most widely used cutoff points, the sensitivity and specificity were 24% and 90% for the Wells and 59% and 43% for the Geneva score, respectively. Isolated worsening of dyspnea on presentation had a sensitivity of 92% and specificity of 37%.

CONCLUSIONS

Both Wells and Geneva scores exhibit poor diagnostic accuracy for the diagnosis of PE in patients with COPD. The presence of isolated worsening of dyspnea on presentation could be an easy to identify criteria for the initial triage in this population. Further validation of our findings remains warranted.

[Extremely elevated erythrosedimentation in an adult population in the City of Buenos Aires]

BACKGROUND

An extremely elevated erythrosedimentation rate (ESR), defined as equal or higher than 100 mm/h, has been linked to serious underlying conditions, such as infections, connective tissue and oncologic disease.

AIM

To analyze a group of patients in order to determine the underlying diagnosis and the characteristics associated with extremely elevated ESR in our environment.

METHODS

Cross-sectional study of adult patients, who presented with at least one ESR equal or higher than 100 mm/h at Hospital Italiano, in Buenos Aires (Buenos Aires, Argentina) between January 2002 and August 2014.

RESULTS

During the previously stated period of time, we analyzed the results of 879 patients. All patients were over 18 years of age. The median for the ESR results was 111 mm/h (interquartile range 105-120). The most prevalent etiology of an elevated ESR was infectious (41.64%), followed by malignancies (21.62%) and autoimmune / inflammatory diseases (12.97%). The most frequent individual diagnosis found was pneumonia (11.49%), followed by undetermined causes (5.92%).

CONCLUSION

When comparing inpatient versus outpatient populations, the most frequent cause was infectious in the former group, while malignancies were the most frequent diagnosis in the latter.

[Associated factors with the presence of secondary neoplastic cells in the cerebrospinal fluid of patients with suspected carcinomatous meningitis]

BACKGROUND

Improvement in oncologic therapy has increased survival in oncologic patients. There has been a concomitant increase in the incidence of secondary meningeal involvement. Early diagnosis is mandatory.

OBJECTIVE

To identify factors associated with the presence of secondary neoplastic cells in cerebrospinal fluid of patients with suspected carcinomatous meningitis (CM) Methods: Cross-sectional study involving adult patients with solid cancer diagnosis and suspected CM between 2004 and 2014 at Hospital Italiano de Buenos Aires. All included patients had at least one lumbar puncture with cerebrospinal fluid (CSF) analysis. CM cases were defined by the presence of neoplastic cells in CFS. We evaluated the association of each factor (cancer characteristics, clinical engagement of central nervous system, CSF analysis) with CM using a logistic regression model.

RESULTS

We included 77 patients: mean age was 62 years (SD 13.1), 58.4% (45) were female. The most common oncologic disease was lung cancer 29.9% (23), followed by breast 23.4% (18) cancer. CM was detected in 23.4% (18) patients. In univariate analysis, glychorrachia, the CSF leukocyte count, the meningeal involvement on MRI, headache and delirium were significantly associated with MC. In the multivariate model that included the variables significantly associated in the crude analysis, the only variable that remained significantly associated with MC was the glychorrachia (OR 0.93 95%CI 0.9 - 0.97, p <0.001).

DISCUSSION

These results suggest that as the glychorrachia increases, the probability of having MC decreases. These findings are consistent with previous studies.

Clinical Characteristics and Outcomes in a Population With Disseminated Herpes Zoster: A Retrospective Cohort Study

INTRODUCTION

Shingles is the cutaneous expression of the reactivation of latent varicella zoster virus infection in sensory ganglia. It presents as vesicles in the corresponding dermatome. The condition is called disseminated herpes zoster (DHZ) when more than 2 contiguous dermatomes are affected, more than 20 vesicles are observed outside the initial dermatome, or involvement is systemic. DHZ is rare and most frequently occurs in immunocompromised patients.

OBJECTIVES

To describe the epidemiology, predisposing factors, clinical presentation, laboratory findings, and clinical course of patients with DHZ, and to compare the findings in immunocompromised and immunocompetent patients.

METHODOLOGY

We analyzed a retrospective case series of adults hospitalized between February 2010 and October 2015.

RESULTS

Forty-one patients with virologically confirmed manifestations of DHZ were included. Stress as a trigger factor was detected in 39% and immunodepression in 58.5%. Immunocompromised patients were younger than the immunocompetent patients (mean ages, 60.5 vs 82 years, P<.01). The 8 immunocompetent patients with no detectable trigger factors were older (mean age, 85 years). In 95% of cases, DHZ was initially limited to a single dermatome and then spread to other dermatomes or became disseminated. Thrombocytopenia was detected in 56% of cases. Complication rates were similar in immunocompromised and immunocompetent patients (54% vs 59%, P>.01). Six patients died; there was no difference in mortality between the 2 groups.

CONCLUSION

This study provides evidence on the relationship between DHZ, the presence of underlying immunodepression, and complications. Immunosenescence may play an important role in the onset of this disease in older immunocompetent patients.