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Serafini SC, van Meenen DMP, Pisani L, Neto AS, Ball L, de Abreu MG, Algera AG, Azevedo L, Bellani G, Dondorp AM, Fan E, Laffey JG, Pham T, Tschernko EM, Schultz MJ, van der Woude MCE. Different ventilation intensities among various categories of patients ventilated for reasons other than ARDS--A pooled analysis of 4 observational studies. J Crit Care 2024; 81:154531. [PMID: 38341938 DOI: 10.1016/j.jcrc.2024.154531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/23/2024] [Accepted: 01/30/2024] [Indexed: 02/13/2024]
Abstract
PURPOSE We investigated driving pressure (ΔP) and mechanical power (MP) and associations with clinical outcomes in critically ill patients ventilated for reasons other than ARDS. MATERIALS AND METHODS Individual patient data analysis of a pooled database that included patients from four observational studies of ventilation. ΔP and MP were compared among invasively ventilated non-ARDS patients with sepsis, with pneumonia, and not having sepsis or pneumonia. The primary endpoint was ΔP; secondary endpoints included MP, ICU mortality and length of stay, and duration of ventilation. RESULTS This analysis included 372 (11%) sepsis patients, 944 (28%) pneumonia patients, and 2040 (61%) patients ventilated for any other reason. On day 1, median ΔP was higher in sepsis (14 [11-18] cmH2O) and pneumonia patients (14 [11-18]cmH2O), as compared to patients not having sepsis or pneumonia (13 [10-16] cmH2O) (P < 0.001). Median MP was also higher in sepsis and pneumonia patients. ΔP, as opposed to MP, was associated with ICU mortality in sepsis and pneumonia patients. CONCLUSIONS The intensity of ventilation differed between patients with sepsis or pneumonia and patients receiving ventilation for any other reason; ΔP was associated with higher mortality in sepsis and pneumonia patients. REGISTRATION This post hoc analysis was not registered; the individual studies that were merged into the used database were registered at clinicaltrials.gov: NCT01268410 (ERICC), NCT02010073 (LUNG SAFE), NCT01868321 (PRoVENT), and NCT03188770 (PRoVENT-iMiC).
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Affiliation(s)
- Simon Corrado Serafini
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genova, Italy; Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, the Netherlands.
| | - David M P van Meenen
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, the Netherlands; Department of Anesthesiology, Amsterdam UMC, location 'AMC', Amsterdam, the Netherlands
| | - Luigi Pisani
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, the Netherlands; Section of Operational Research, Doctors with Africa, Padova, Italy; Department of Anesthesiology and Intensive Care Medicine, Miulli Regional Hospital, Acquaviva delle Fonti, Italy; Mahidol-Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Department of Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, Australia; Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genova, Italy; Anesthesia and Intensive Care, Ospedale Policlinico San Martino, IRCCS per l'Oncologia e le Neuroscienze, Genova, Italy
| | - Marcelo Gama de Abreu
- Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Anna Geke Algera
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, the Netherlands
| | - Luciano Azevedo
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil; Department of Emergency Medicine, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Giacomo Bellani
- Centro Interdipartimentale di Scienze Mediche (CISMed), Università di Trento, Italy; UOC anesthesia and Intensive Care 1, Ospedale Santa Chiara, APSS, Trento, Italy
| | - Arjen M Dondorp
- Mahidol-Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, National University of Ireland, and Galway University Hospitals Ireland, Galway, Ireland
| | - Tai Pham
- Equipe d'Epidémiologie Respiratoire integrative, Université Paris-Saclay, Paris, France; Department of Intensive Care, Hôpital de Bicêtre, Paris, France
| | - Edda M Tschernko
- Clinical Department of Cardiothoracic Vascular Surgery Anesthesia and Intensive Care Medicine, Medical University Wien, Vienna, Austria
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, the Netherlands; Mahidol-Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Nuffield Department of Medicine, University of Oxford, Oxford, UK; Clinical Department of Cardiothoracic Vascular Surgery Anesthesia and Intensive Care Medicine, Medical University Wien, Vienna, Austria
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Nijbroek SGLH, Hol L, Serpa Neto A, van Meenen DMP, Hemmes SNT, Hollmann MW, Schultz MJ. Safety and Feasibility of Intraoperative High PEEP Titrated to the Lowest Driving Pressure (ΔP)-Interim Analysis of DESIGNATION. J Clin Med 2023; 13:209. [PMID: 38202214 PMCID: PMC10780246 DOI: 10.3390/jcm13010209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/18/2023] [Accepted: 12/24/2023] [Indexed: 01/12/2024] Open
Abstract
Uncertainty remains about the best level of intraoperative positive end-expiratory pressure (PEEP). An ongoing RCT ('DESIGNATION') compares an 'individualized high PEEP' strategy ('iPEEP')-titrated to the lowest driving pressure (ΔP) with recruitment maneuvers (RM), with a 'standard low PEEP' strategy ('low PEEP')-using 5 cm H2O without RMs with respect to the incidence of postoperative pulmonary complications. This report is an interim analysis of safety and feasibility. From September 2018 to July 2022, we enrolled 743 patients. Data of 698 patients were available for this analysis. Hypotension occurred more often in 'iPEEP' vs. 'low PEEP' (54.7 vs. 44.1%; RR, 1.24 (95% CI 1.07 to 1.44); p < 0.01). Investigators were compliant with the study protocol 285/344 patients (82.8%) in 'iPEEP', and 345/354 patients (97.5%) in 'low PEEP' (p < 0.01). Most frequent protocol violation was missing the final RM at the end of anesthesia before extubation; PEEP titration was performed in 99.4 vs. 0%; PEEP was set correctly in 89.8 vs. 98.9%. Compared to 'low PEEP', the 'iPEEP' group was ventilated with higher PEEP (10.0 (8.0-12.0) vs. 5.0 (5.0-5.0) cm H2O; p < 0.01). Thus, in patients undergoing general anesthesia for open abdominal surgery, an individualized high PEEP ventilation strategy is associated with hypotension. The protocol is feasible and results in clear contrast in PEEP. DESIGNATION is expected to finish in late 2023.
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Affiliation(s)
- Sunny G. L. H. Nijbroek
- Department of Anesthesiology, Amsterdam UMC Location AMC, 1105 AZ Amsterdam, The Netherlands; (S.G.L.H.N.); (L.H.); (D.M.P.v.M.); (M.W.H.)
- Department of Anesthesiology, Radboudumc, 6525 GA Nijmegen, The Netherlands
| | - Liselotte Hol
- Department of Anesthesiology, Amsterdam UMC Location AMC, 1105 AZ Amsterdam, The Netherlands; (S.G.L.H.N.); (L.H.); (D.M.P.v.M.); (M.W.H.)
| | - Ary Serpa Neto
- Department of Intensive Care, Amsterdam UMC Location AMC, 1105 AZ Amsterdam, The Netherlands;
- Department of Critical Care Medicine, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, VIC 3004, Australia
| | - David M. P. van Meenen
- Department of Anesthesiology, Amsterdam UMC Location AMC, 1105 AZ Amsterdam, The Netherlands; (S.G.L.H.N.); (L.H.); (D.M.P.v.M.); (M.W.H.)
| | - Sabrine N. T. Hemmes
- Department of Anesthesiology, The Netherlands Cancer Institute—Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, The Netherlands;
| | - Markus W. Hollmann
- Department of Anesthesiology, Amsterdam UMC Location AMC, 1105 AZ Amsterdam, The Netherlands; (S.G.L.H.N.); (L.H.); (D.M.P.v.M.); (M.W.H.)
| | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam UMC Location AMC, 1105 AZ Amsterdam, The Netherlands;
- Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok 10400, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford OX3 7BN, UK
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Tripipitsiriwat A, Suppapueng O, van Meenen DMP, Paulus F, Hollmann MW, Sivakorn C, Schultz MJ. Epidemiology, Ventilation Management and Outcomes of COPD Patients Receiving Invasive Ventilation for COVID-19-Insights from PRoVENT-COVID. J Clin Med 2023; 12:5783. [PMID: 37762725 PMCID: PMC10532133 DOI: 10.3390/jcm12185783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/22/2023] [Accepted: 08/24/2023] [Indexed: 09/29/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a risk factor for death in patients admitted to intensive care units (ICUs) for respiratory support. Previous reports suggested higher mortality in COPD patients with COVID-19. It is yet unknown whether patients with COPD were treated differently compared to non-COPD patients. We compared the ventilation management and outcomes of invasive ventilation for COVID-19 in COPD patients versus non-COPD patients. This was a post hoc analysis of a nation-wide, observational study in the Netherlands. COPD patients were compared to non-COPD patients with respect to key ventilation parameters. The secondary endpoints included adjunctive treatments for refractory hypoxemia, and 28-day mortality. Of a total of 1090 patients, 88 (8.1%) were classified as having COPD. The ventilation parameters were not different between COPD patients and non-COPD patients, except for FiO2, which was higher in COPD patients. Prone positioning was applied more often in COPD patients. COPD patients had higher 28-day mortality than non-COPD patients. COPD had an independent association with 28-day mortality. In this cohort of patients who received invasive ventilation for COVID-19, only FiO2 settings and the use of prone positioning were different between COPD patients and non-COPD patients. COPD patients had higher mortality than non-COPD patients.
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Affiliation(s)
- Athiwat Tripipitsiriwat
- Division of Respiratory Disease and Tuberculosis, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10400, Thailand;
| | - Orawan Suppapueng
- Division of Clinical Epidemiology, Department of Research, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10400, Thailand;
| | - David M. P. van Meenen
- Department of Intensive Care, Amsterdam UMC, Location AMC, 1105 AZ Amsterdam, The Netherlands; (F.P.); (M.J.S.)
- Department of Anesthesiology, Amsterdam UMC, Location AMC, 1105 AZ Amsterdam, The Netherlands;
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam UMC, Location AMC, 1105 AZ Amsterdam, The Netherlands; (F.P.); (M.J.S.)
- Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, 1101 CD Amsterdam, The Netherlands
| | - Markus W. Hollmann
- Department of Anesthesiology, Amsterdam UMC, Location AMC, 1105 AZ Amsterdam, The Netherlands;
| | - Chaisith Sivakorn
- Intensive Care Unit, University College London Hospital, London NW1 2BU, UK;
| | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam UMC, Location AMC, 1105 AZ Amsterdam, The Netherlands; (F.P.); (M.J.S.)
- Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok 10400, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford OX3 7BN, UK
- Department of Anesthesia, General Intensive Care and Pain Management, Division of Cardiothoracic and Vascular Anesthesia & Critical Care Medicine, Medical University of Vienna, 1090 Vienna, Austria
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Nijbroek SGLH, Roozeman JP, Ettayeby S, Rosenberg NM, van Meenen DMP, Cherpanath TGV, Lagrand WK, Tepaske R, Klautz RJM, Serpa Neto A, Schultz MJ. Closed-Loop ventilation using sidestream versus mainstream capnography for automated adjustments of minute ventilation-A randomized clinical trial in cardiac surgery patients. PLoS One 2023; 18:e0289412. [PMID: 37611007 PMCID: PMC10446221 DOI: 10.1371/journal.pone.0289412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 07/18/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND INTELLiVENT-Adaptive Support Ventilation (ASV) is a closed-loop ventilation mode that uses capnography to adjust tidal volume (VT) and respiratory rate according to a user-set end-tidal CO2 (etCO2) target range. We compared sidestream versus mainstream capnography with this ventilation mode with respect to the quality of breathing in patients after cardiac surgery. METHODS Single-center, single-blinded, non-inferiority, randomized clinical trial in adult patients scheduled for elective cardiac surgery that were expected to receive at least two hours of postoperative ventilation in the ICU. Patients were randomized 1:1 to closed-loop ventilation with sidestream or mainstream capnography. Each breath was classified into a zone based on the measured VT, maximum airway pressure, etCO2 and pulse oximetry. The primary outcome was the proportion of breaths spent in a predefined 'optimal' zone of ventilation during the first three hours of postoperative ventilation, with a non-inferiority margin for the difference in the proportions set at -20%. Secondary endpoints included the proportion of breaths in predefined 'acceptable' and 'critical' zones of ventilation, and the proportion of breaths with hypoxemia. RESULTS Of 80 randomized subjects, 78 were included in the intention-to-treat analysis. We could not confirm the non-inferiority of closed-loop ventilation using sidestream with respect to the proportion of breaths in the 'optimal' zone (mean ratio 0.87 [0.77 to ∞]; P = 0.116 for non-inferiority). The proportion of breaths with hypoxemia was higher in the sidestream capnography group versus the mainstream capnography group. CONCLUSIONS We could not confirm that INTELLiVENT-ASV using sidestream capnography is non-inferior to INTELLiVENT-ASV using mainstream capnography with respect to the quality of breathing in subjects receiving postoperative ventilation after cardiac surgery. TRIAL REGISTRATION NCT04599491 (clinicaltrials.gov).
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Affiliation(s)
- Sunny G. L. H. Nijbroek
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
- Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Jan-Paul Roozeman
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
- Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Sarah Ettayeby
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Neeltje M. Rosenberg
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
- Department of Internal Medicine, Spaarne Hospital, Haarlem, The Netherlands
| | - David M. P. van Meenen
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
- Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Thomas G. V. Cherpanath
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Wim K. Lagrand
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Robert Tepaske
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Robert J. M. Klautz
- Department of Cardiothoracic Surgery, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Ary Serpa Neto
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
- Australian and New Zealand Intensive Care Research Centre (ANZIC–RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
- Department of Critical Care, Austin Hospital, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paolo, Brazil
| | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
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Buiteman-Kruizinga LA, van Meenen DMP, Bos LDJ, van der Heiden PLJ, Paulus F, Schultz MJ. A closed-loop ventilation mode that targets the lowest work and force of breathing reduces the transpulmonary driving pressure in patients with moderate-to-severe ARDS. Intensive Care Med Exp 2023; 11:42. [PMID: 37442844 DOI: 10.1186/s40635-023-00527-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/01/2023] [Indexed: 07/15/2023] Open
Abstract
INTRODUCTION The driving pressure (ΔP) has an independent association with outcome in patients with acute respiratory distress syndrome (ARDS). INTELLiVENT-Adaptive Support Ventilation (ASV) is a closed-loop mode of ventilation that targets the lowest work and force of breathing. AIM To compare transpulmonary and respiratory system ΔP between closed-loop ventilation and conventional pressure controlled ventilation in patients with moderate-to-severe ARDS. METHODS Single-center randomized cross-over clinical trial in patients in the early phase of ARDS. Patients were randomly assigned to start with a 4-h period of closed-loop ventilation or conventional ventilation, after which the alternate ventilation mode was selected. The primary outcome was the transpulmonary ΔP; secondary outcomes included respiratory system ΔP, and other key parameters of ventilation. RESULTS Thirteen patients were included, and all had fully analyzable data sets. Compared to conventional ventilation, with closed-loop ventilation the median transpulmonary ΔP with was lower (7.0 [5.0-10.0] vs. 10.0 [8.0-11.0] cmH2O, mean difference - 2.5 [95% CI - 2.6 to - 2.1] cmH2O; P = 0.0001). Inspiratory transpulmonary pressure and the respiratory rate were also lower. Tidal volume, however, was higher with closed-loop ventilation, but stayed below generally accepted safety cutoffs in the majority of patients. CONCLUSIONS In this small physiological study, when compared to conventional pressure controlled ventilation INTELLiVENT-ASV reduced the transpulmonary ΔP in patients in the early phase of moderate-to-severe ARDS. This closed-loop ventilation mode also led to a lower inspiratory transpulmonary pressure and a lower respiratory rate, thereby reducing the intensity of ventilation. Trial registration Clinicaltrials.gov, NCT03211494, July 7, 2017. https://clinicaltrials.gov/ct2/show/NCT03211494?term=airdrop&draw=2&rank=1 .
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Affiliation(s)
- Laura A Buiteman-Kruizinga
- Department of Intensive Care, Reinier de Graaf Hospital, Delft, The Netherlands.
- Department of Intensive Care, Amsterdam University Medical Centers, Location 'AMC', Amsterdam, The Netherlands.
| | - David M P van Meenen
- Department of Intensive Care, Amsterdam University Medical Centers, Location 'AMC', Amsterdam, The Netherlands
- Department of Anesthesia, Amsterdam University Medical Centers, Location 'AMC', Amsterdam, The Netherlands
| | - Lieuwe D J Bos
- Department of Intensive Care, Amsterdam University Medical Centers, Location 'AMC', Amsterdam, The Netherlands
- Department of Respiratory Medicine, Amsterdam University Medical Centers, Location 'AMC', Amsterdam, The Netherlands
| | | | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Centers, Location 'AMC', Amsterdam, The Netherlands
- ACHIEVE, Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, Location 'AMC', Amsterdam, The Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
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van der Ven FSLIM, Valk CMA, Blok S, Brouwer MG, Go DM, Lokhorst A, Swart P, van Meenen DMP, Paulus F, Schultz MJ. Broadening the Berlin definition of ARDS to patients receiving high-flow nasal oxygen: an observational study in patients with acute hypoxemic respiratory failure due to COVID-19. Ann Intensive Care 2023; 13:64. [PMID: 37452196 PMCID: PMC10349031 DOI: 10.1186/s13613-023-01161-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND High-flow nasal oxygen (HFNO) is increasingly used in patients with acute hypoxemic respiratory failure. It is uncertain whether a broadened Berlin definition of acute respiratory distress syndrome (ARDS), in which ARDS can be diagnosed in patients who are not receiving ventilation, results in similar groups of patients receiving HFNO as in patients receiving ventilation. METHODS We applied a broadened definition of ARDS in a multicenter, observational study in adult critically ill patients with acute hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19), wherein the requirement for a minimal level of 5 cm H2O PEEP with ventilation is replaced by a minimal level of airflow rate with HFNO, and compared baseline characteristics and outcomes between patients receiving HFNO and patients receiving ventilation. The primary endpoint was ICU mortality. We also compared outcomes in risk for death groups using the PaO2/FiO2 cutoffs as used successfully in the original definition of ARDS. Secondary endpoints were hospital mortality; mortality on days 28 and 90; need for ventilation within 7 days in patients that started with HFNO; the number of days free from HFNO or ventilation; and ICU and hospital length of stay. RESULTS Of 728 included patients, 229 patients started with HFNO and 499 patients with ventilation. All patients fulfilled the broadened Berlin definition of ARDS. Patients receiving HFNO had lower disease severity scores and lower PaO2/FiO2 than patients receiving ventilation. ICU mortality was lower in receiving HFNO (22.7 vs 35.6%; p = 0.001). Using PaO2/FiO2 cutoffs for mild, moderate and severe arterial hypoxemia created groups with an ICU mortality of 16.7%, 22.0%, and 23.5% (p = 0.906) versus 19.1%, 37.9% and 41.4% (p = 0.002), in patients receiving HFNO versus patients receiving ventilation, respectively. CONCLUSIONS Using a broadened definition of ARDS may facilitate an earlier diagnosis of ARDS in patients receiving HFNO; however, ARDS patients receiving HFNO and ARDS patients receiving ventilation have distinct baseline characteristics and mortality rates. TRIAL REGISTRATION The study is registered at ClinicalTrials.gov (identifier NCT04719182).
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Affiliation(s)
- Fleur-Stefanie L I M van der Ven
- Department of Intensive Care, Amsterdam UMC, Location AMC,, Amsterdam, The Netherlands.
- Department of Intensive Care, Rode Kruis Ziekenhuis, Beverwijk, The Netherlands.
| | - Christel M A Valk
- Department of Intensive Care, Amsterdam UMC, Location AMC,, Amsterdam, The Netherlands
| | - Siebe Blok
- Department of Intensive Care, Amsterdam UMC, Location AMC,, Amsterdam, The Netherlands
| | - Michelle G Brouwer
- Department of Intensive Care, Amsterdam UMC, Location AMC,, Amsterdam, The Netherlands
| | - Dai Ming Go
- Department of Intensive Care, Amsterdam UMC, Location AMC,, Amsterdam, The Netherlands
| | - Amanda Lokhorst
- Department of Intensive Care, Amsterdam UMC, Location AMC,, Amsterdam, The Netherlands
| | - Pien Swart
- Department of Intensive Care, Amsterdam UMC, Location AMC,, Amsterdam, The Netherlands
| | - David M P van Meenen
- Department of Intensive Care, Amsterdam UMC, Location AMC,, Amsterdam, The Netherlands
- Department of Anesthesiology, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam UMC, Location AMC,, Amsterdam, The Netherlands
- Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC, Location AMC,, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A), Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Hol L, Schultz MJ, Martin-Loeches I, van Meenen DMP, Serpa Neto A, Paulus F. Differences in Ventilation Management and Outcomes between the Two First Waves of the COVID-19 Pandemic-A Comparison between Two Nationwide Observational Studies in The Netherlands. J Clin Med 2023; 12:4507. [PMID: 37445542 DOI: 10.3390/jcm12134507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 06/12/2023] [Accepted: 07/03/2023] [Indexed: 07/15/2023] Open
Abstract
The aim of this analysis was to compare ventilation management and outcomes in invasively ventilated patients with acute hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19) between the first and second wave in the Netherlands. This is a post hoc analysis of two nationwide observational COVID-19 studies conducted in quick succession. The primary endpoint was ventilation management. Secondary endpoints were tracheostomy use, duration of ventilation, intensive care unit (ICU) and hospital length of stay (LOS), and mortality. We used propensity score matching to control for observed confounding factors. This analysis included 1122 patients from the first and 568 patients from the second wave. Patients in the second wave were sicker, had more comorbidities, and had worse oxygenation parameters. They were ventilated with lower positive end-expiratory pressure and higher fraction inspired oxygen, had a lower oxygen saturation, received neuromuscular blockade more often, and were less often tracheostomized. Duration of ventilation was shorter, but mortality rates were similar. After matching, the fraction of inspired oxygen was lower in the second wave. In patients with acute hypoxemic respiratory failure due to COVID-19, aspects of respiratory care and outcomes rapidly changed over the successive waves.
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Affiliation(s)
- Liselotte Hol
- Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, 1105 AZ Amsterdam, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, 1105 AZ Amsterdam, The Netherlands
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok 10400, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford OX37BN, UK
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St James's Street, Leinster, D08 NYH1 Dublin, Ireland
- Department of Clinical Medicine, Trinity College, D02 PN40 Dublin, Ireland
| | - David M P van Meenen
- Department of Anesthesiology, Amsterdam University Medical Centers, Location AMC, 1105 AZ Amsterdam, The Netherlands
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, 1105 AZ Amsterdam, The Netherlands
| | - Ary Serpa Neto
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, 1105 AZ Amsterdam, The Netherlands
- Department of Critical Care Medicine, Hospital Israelite Albert Einstein, Sao Paolo 05652-900, Brazil
- Department of Critical Care Medicine, Austin Hospital and University of Melbourne, Melbourne 3084, Australia
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Centers, Location AMC, 1105 AZ Amsterdam, The Netherlands
- Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, 1091 GC Amsterdam, The Netherlands
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Daenen K, Huijben JA, Boyd A, Bos LDJ, Stoof SCM, van Willigen H, Gommers DAMPJ, Moeniralam HS, den Uil CA, Juffermans NP, Kant M, Valkenburg AJ, Pillay J, van Meenen DMP, Paulus F, Schultz MJ, Dalm VASH, van Gorp ECM, Schinkel J, Endeman H. Optimal Dosing and Timing of High-Dose Corticosteroid Therapy in Hospitalized Patients With COVID-19: Study Protocol for a Retrospective Observational Multicenter Study (SELECT). JMIR Res Protoc 2023; 12:e48183. [PMID: 37266993 DOI: 10.2196/48183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 04/24/2023] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND In hospitalized patients with COVID-19, the dosing and timing of corticosteroids vary widely. Low-dose dexamethasone therapy reduces mortality in patients requiring respiratory support, but it remains unclear how to treat patients when this therapy fails. In critically ill patients, high-dose corticosteroids are often administered as salvage late in the disease course, whereas earlier administration may be more beneficial in preventing disease progression. Previous research has revealed that increased levels of various biomarkers are associated with mortality, and whole blood transcriptome sequencing has the ability to identify host factors predisposing to critical illness in patients with COVID-19. OBJECTIVE Our goal is to determine the most optimal dosing and timing of corticosteroid therapy and to provide a basis for personalized corticosteroid treatment regimens to reduce morbidity and mortality in hospitalized patients with COVID-19. METHODS This is a retrospective, observational, multicenter study that includes adult patients who were hospitalized due to COVID-19 in the Netherlands. We will use the differences in therapeutic strategies between hospitals (per protocol high-dose corticosteroids or not) over time to determine whether high-dose corticosteroids have an effect on the following outcome measures: mechanical ventilation or high-flow nasal cannula therapy, in-hospital mortality, and 28-day survival. We will also explore biomarker profiles in serum and bronchoalveolar lavage fluid and use whole blood transcriptome analysis to determine factors that influence the relationship between high-dose corticosteroids and outcome. Existing databases that contain routinely collected electronic data during ward and intensive care admissions, as well as existing biobanks, will be used. We will apply longitudinal modeling appropriate for each data structure to answer the research questions at hand. RESULTS As of April 2023, data have been collected for a total of 1500 patients, with data collection anticipated to be completed by December 2023. We expect the first results to be available in early 2024. CONCLUSIONS This study protocol presents a strategy to investigate the effect of high-dose corticosteroids throughout the entire clinical course of hospitalized patients with COVID-19, from hospital admission to the ward or intensive care unit until hospital discharge. Moreover, our exploration of biomarker and gene expression profiles for targeted corticosteroid therapy represents a first step towards personalized COVID-19 corticosteroid treatment. TRIAL REGISTRATION ClinicalTrials.gov NCT05403359; https://clinicaltrials.gov/ct2/show/NCT05403359. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/48183.
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Affiliation(s)
- Katrijn Daenen
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, Netherlands
- Department of Viroscience, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Jilske A Huijben
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Anders Boyd
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, Netherlands
- HIV Monitoring Foundation, Amsterdam, Netherlands
- Infectious Diseases, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, Netherlands
| | - Lieuwe D J Bos
- Department of Intensive Care, Amsterdam University Medical Centers, location Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centers, location Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Sara C M Stoof
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Hugo van Willigen
- Department of Medical Microbiology & Infection Prevention, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, Netherlands
| | | | - Hazra S Moeniralam
- Department of Internal Medicine and Intensive Care, St Antonius Hospital, Nieuwegein, Netherlands
| | | | - Nicole P Juffermans
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis Hospital, Amsterdam, Netherlands
- Laboratory of Translational Intensive Care, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Merijn Kant
- Department of Pulmonology, Amphia Hospital, Breda, Netherlands
- Department of Intensive Care, Amphia Hospital, Breda, Netherlands
| | - Abraham J Valkenburg
- Department of Anesthesiology and Intensive Care, Isala Clinics, Zwolle, Netherlands
| | - Janesh Pillay
- Department of Intensive Care, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- Department of Pathology and Medical Biology, Groningen Research Institute for Asthma and Chronic Obstructive Pulmonary Disease, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - David M P van Meenen
- Department of Intensive Care, Amsterdam University Medical Centers, location Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
- Department of Anesthesiology, Amsterdam University Medical Centers, location Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Centers, location Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
- Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, location Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centers, location Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Virgil A S H Dalm
- Department of Immunology, Erasmus University Medical Center, Rotterdam, Netherlands
- Division of Allergy & Clinical Immunology, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Eric C M van Gorp
- Department of Viroscience, Erasmus University Medical Center, Rotterdam, Netherlands
- Department of Internal Medicine, Erasmus University Medical Center, Erasmus, Netherlands
| | - Janke Schinkel
- Department of Medical Microbiology & Infection Prevention, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, Netherlands
| | - Henrik Endeman
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, Netherlands
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9
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Lilien TA, van Meenen DMP, Schultz MJ, Bos LDJ, Bem RA. Hyperoxia-Induced Lung Injury in Acute Respiratory Distress Syndrome: What is its Relative Impact? Am J Physiol Lung Cell Mol Physiol 2023. [PMID: 37129255 DOI: 10.1152/ajplung.00443.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023] Open
Abstract
Over the past decade, the interest in oxygen toxicity has led to various observational studies and randomized clinical trials in critically ill patients, assessing association with outcomes and the potential benefit of restrictive oxygenation targets. Yet to date, no consensus has been reached regarding the clinical impact of hyperoxia and hyperoxemia. In this perspective article, we explore the experimental and clinical evidence on hyperoxia-induced lung injury (HILI) and assess its relative impact in current critical care practice, specifically in patients who require oxygen therapy due to acute respiratory distress syndrome (ARDS). Here, we suggest that in current clinical practice in the setting of ARDS HILI may actually be of less importance than other ventilator-related factors.
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Affiliation(s)
- Thijs A Lilien
- Department of Intensive Care, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - David M P van Meenen
- Department of Intensive Care, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Department of Anesthesiology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Lieuwe D J Bos
- Department of Intensive Care, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Reinout A Bem
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
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10
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Botta M, Caritg O, van Meenen DMP, Pacheco A, Tsonas AM, Mooij WE, Burgener A, Manrique Hehl T, Shrestha GS, Horn J, Tuinman PR, Paulus F, Roca O, Schultz MJ. Oxygen Consumption with High-Flow Nasal Oxygen versus Mechanical Ventilation- An International Multicenter Observational Study in COVID-19 Patients (PROXY-COVID). Am J Trop Med Hyg 2023; 108:1035-1041. [PMID: 36972693 PMCID: PMC10160903 DOI: 10.4269/ajtmh.22-0793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 01/27/2023] [Indexed: 03/29/2023] Open
Abstract
The COVID-19 pandemic led to local oxygen shortages worldwide. To gain a better understanding of oxygen consumption with different respiratory supportive therapies, we conducted an international multicenter observational study to determine the precise amount of oxygen consumption with high-flow nasal oxygen (HFNO) and with mechanical ventilation. A retrospective observational study was conducted in three intensive care units (ICUs) in the Netherlands and Spain. Patients were classified as HFNO patients or ventilated patients, according to the mode of oxygen supplementation with which a patient started. The primary endpoint was actual oxygen consumption; secondary endpoints were hourly and total oxygen consumption during the first two full calendar days. Of 275 patients, 147 started with HFNO and 128 with mechanical ventilation. Actual oxygen use was 4.9-fold higher in patients who started with HFNO than in patients who started with ventilation (median 14.2 [8.4-18.4] versus 2.9 [1.8-4.1] L/minute; mean difference = 11.3 [95% CI 11.0-11.6] L/minute; P < 0.01). Hourly and total oxygen consumption were 4.8-fold (P < 0.01) and 4.8-fold (P < 0.01) higher. Actual oxygen consumption, hourly oxygen consumption, and total oxygen consumption are substantially higher in patients that start with HFNO compared with patients that start with mechanical ventilation. This information may help hospitals and ICUs predicting oxygen needs during high-demand periods and could guide decisions regarding the source of distribution of medical oxygen.
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Affiliation(s)
- Michela Botta
- Department of Intensive Care, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Oriol Caritg
- Department of Intensive Care, Vall d'Hebron University Hospital, Barcelona, Spain
| | - David M P van Meenen
- Department of Intensive Care, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Andrés Pacheco
- Department of Intensive Care, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Anissa M Tsonas
- Department of Intensive Care, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Willemijn E Mooij
- Department of Intensive Care, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Alessia Burgener
- Department of Intensive Care, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Tosca Manrique Hehl
- Department of Intensive Care, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Gentle S Shrestha
- Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Janneke Horn
- Department of Intensive Care, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
- Amsterdam Neurosciences, Amsterdam UMC Research Institute, Amsterdam, The Netherlands
| | - Pieter R Tuinman
- Department of Intensive Care, Amsterdam University Medical Centers, location VUMC, Amsterdam, The Netherlands
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
- Urban Vitality, Centre of Expertise, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Oriol Roca
- Department of Intensive Care, Parc Taulí de Sabadell University Hospital, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
- Ciber Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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11
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Goossen RL, Verboom M, Blacha M, Smesseim I, Beenen LFM, van Meenen DMP, Paulus F, Schultz MJ. Incidence of Air Leaks in Critically Ill Patients with Acute Hypoxemic Respiratory Failure Due to COVID-19. Diagnostics (Basel) 2023; 13:1156. [PMID: 36980464 PMCID: PMC10046975 DOI: 10.3390/diagnostics13061156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 03/10/2023] [Accepted: 03/11/2023] [Indexed: 03/30/2023] Open
Abstract
Subcutaneous emphysema, pneumothorax and pneumomediastinum are well-known complications of invasive ventilation in patients with acute hypoxemic respiratory failure. We determined the incidences of air leaks that were visible on available chest images in a cohort of critically ill patients with acute hypoxemic respiratory failure due to coronavirus disease of 2019 (COVID-19) in a single-center cohort in the Netherlands. A total of 712 chest images from 154 patients were re-evaluated by a multidisciplinary team of independent assessors; there was a median of three (2-5) chest radiographs and a median of one (1-2) chest CT scans per patient. The incidences of subcutaneous emphysema, pneumothoraxes and pneumomediastinum present in 13 patients (8.4%) were 4.5%, 4.5%, and 3.9%. The median first day of the presence of an air leak was 18 (2-21) days after arrival in the ICU and 18 (9-22)days after the start of invasive ventilation. We conclude that the incidence of air leaks was high in this cohort of COVID-19 patients, but it was fairly comparable with what was previously reported in patients with acute hypoxemic respiratory failure in the pre-COVID-19 era.
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Affiliation(s)
- Robin L. Goossen
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
| | - Mariëlle Verboom
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
| | - Mariëlle Blacha
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
| | - Illaa Smesseim
- Department of Thoracic Oncology, Antoni van Leeuwenhoek Ziekenhuis, 1066 CX Amsterdam, The Netherlands
| | - Ludo F. M. Beenen
- Department of Radiology, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
| | - David M. P. van Meenen
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
- Department of Anesthesiology, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
- ACHIEVE, Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, 1091 GC Amsterdam, The Netherlands
| | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
- Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok 10400, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford OX3 7BN, UK
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12
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Stilma W, Valk CMA, van Meenen DMP, Morales L, Remmelzwaal D, Myatra SN, Artigas A, Neto AS, Paulus F, Schultz MJ. Practice of Awake Prone Positioning in Critically Ill COVID-19 Patients-Insights from the PRoAcT-COVID Study. J Clin Med 2022; 11:jcm11236988. [PMID: 36498564 PMCID: PMC9739110 DOI: 10.3390/jcm11236988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 11/17/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022] Open
Abstract
We describe the incidence, practice and associations with outcomes of awake prone positioning in patients with acute hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19) in a national multicenter observational cohort study performed in 16 intensive care units in the Netherlands (PRoAcT−COVID-study). Patients were categorized in two groups, based on received treatment of awake prone positioning. The primary endpoint was practice of prone positioning. Secondary endpoint was ‘treatment failure’, a composite of intubation for invasive ventilation and death before day 28. We used propensity matching to control for observed confounding factors. In 546 patients, awake prone positioning was used in 88 (16.1%) patients. Prone positioning started within median 1 (0 to 2) days after ICU admission, sessions summed up to median 12.0 (8.4−14.5) hours for median 1.0 day. In the unmatched analysis (HR, 1.80 (1.41−2.31); p < 0.001), but not in the matched analysis (HR, 1.17 (0.87−1.59); p = 0.30), treatment failure occurred more often in patients that received prone positioning. The findings of this study are that awake prone positioning was used in one in six COVID-19 patients. Prone positioning started early, and sessions lasted long but were often discontinued because of need for intubation.
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Affiliation(s)
- Willemke Stilma
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
- Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, 1105 BD Amsterdam, The Netherlands
- Correspondence:
| | - Christel M. A. Valk
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
| | - David M. P. van Meenen
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
- Department of Anesthesiology, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
| | - Luis Morales
- Servei de Medicina Intensiva, Hospital Universitari Sant Pau, 08025 Barcelona, Spain
- Translational Research Laboratory, Institut d’Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona Sabadell, 08208 Barcelona, Spain
| | - Daantje Remmelzwaal
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
| | - Sheila N. Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai 400012, India
| | - Antonio Artigas
- Intensive Care Department, CIBER Enfermedades Respiratorias, Parc Tauli University Hospital, 08208 Sabadell, Spain
- Autonomous University of Barcelona, 08193 Sabadell, Spain
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care, Research Center (ANZIC-RC), Monash University, Melbourne 3800, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo 05652-900, Brazil
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
- Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, 1105 BD Amsterdam, The Netherlands
| | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7LG, UK
- Mahidol–Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand
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13
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Schuijt MTU, van Meenen DMP, Martin-Loeches I, Mazzinari G, Schultz MJ, Paulus F, Serpa Neto A. Association of Time-Varying Intensity of Ventilation With Mortality in Patients With COVID-19 ARDS: Secondary Analysis of the PRoVENT-COVID Study. Front Med (Lausanne) 2021; 8:725265. [PMID: 34869421 PMCID: PMC8637438 DOI: 10.3389/fmed.2021.725265] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 09/14/2021] [Indexed: 01/08/2023] Open
Abstract
Background: High intensity of ventilation has an association with mortality in patients with acute respiratory failure. It is uncertain whether similar associations exist in patients with acute respiratory distress syndrome (ARDS) patients due to coronavirus disease 2019 (COVID-19). We investigated the association of exposure to different levels of driving pressure (ΔP) and mechanical power (MP) with mortality in these patients. Methods: PRoVENT-COVID is a national, retrospective observational study, performed at 22 ICUs in the Netherlands, including COVID-19 patients under invasive ventilation for ARDS. Dynamic ΔP and MP were calculated at fixed time points during the first 4 calendar days of ventilation. The primary endpoint was 28-day mortality. To assess the effects of time-varying exposure, Bayesian joint models adjusted for confounders were used. Results: Of 1,122 patients included in the PRoVENT-COVID study, 734 were eligible for this analysis. In the first 28 days, 29.2% of patients died. A significant increase in the hazard of death was found to be associated with each increment in ΔP (HR 1.04, 95% CrI 1.01-1.07) and in MP (HR 1.12, 95% CrI 1.01-1.36). In sensitivity analyses, cumulative exposure to higher levels of ΔP or MP resulted in increased risks for 28-day mortality. Conclusion: Cumulative exposure to higher intensities of ventilation in COVID-19 patients with ARDS have an association with increased risk of 28-day mortality. Limiting exposure to high ΔP or MP has the potential to improve survival in these patients. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT04346342.
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Affiliation(s)
- Michiel T U Schuijt
- Department of Intensive Care, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
| | - David M P van Meenen
- Department of Intensive Care, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
| | - Ignacio Martin-Loeches
- Department of Clinical Medicine, Trinity Centre for Health Sciences, Multidisciplinary Intensive Care Research Organization (MICRO), St James's Hospital, Dublin, Ireland
| | - Guido Mazzinari
- Department of Anaesthesiology, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC, Location AMC, Amsterdam, Netherlands.,Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam UMC, Location AMC, Amsterdam, Netherlands.,ACHIEVE, Centre of Applied Research, Amsterdam University of Applied Sciences, Faculty of Health, Amsterdam, Netherlands
| | - Ary Serpa Neto
- Department of Intensive Care, Amsterdam UMC, Location AMC, Amsterdam, Netherlands.,Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, VIC, Australia.,Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia.,Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital, Melbourne, VIC, Australia.,Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Pãulo, Brazil
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14
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Stilma W, van Meenen DMP, Valk CMA, de Bruin H, Paulus F, Serpa Neto A, Schultz MJ. Incidence and Practice of Early Prone Positioning in Invasively Ventilated COVID-19 Patients-Insights from the PRoVENT-COVID Observational Study. J Clin Med 2021; 10:jcm10204783. [PMID: 34682907 PMCID: PMC8541588 DOI: 10.3390/jcm10204783] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/30/2021] [Accepted: 10/12/2021] [Indexed: 02/02/2023] Open
Abstract
We describe the incidence and practice of prone positioning and determined the association of use of prone positioning with outcomes in invasively ventilated patients with acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19) in a national, multicenter observational study, performed at 22 intensive care units in the Netherlands. Patients were categorized into 4 groups, based on indication for and actual use of prone positioning. The primary outcome was 28-day mortality. Secondary endpoints were 90-day mortality, and ICU and hospital length of stay. In 734 patients, prone positioning was indicated in 60%-the incidence of prone positioning was higher in patients with an indication than in patients without an indication for prone positioning (77 vs. 48%, p = 0.001). Patients were left in the prone position for median 15.0 (10.5-21.0) hours per full calendar day-the duration was longer in patients with an indication than in patients without an indication for prone positioning (16.0 (11.0-23.0) vs. 14.0 (10.0-19.0) hours, p < 0.001). Ventilator settings and ventilation parameters were not different between the four groups, except for FiO2 which was higher in patients having an indication for and actually receiving prone positioning. Our data showed no difference in mortality at day 28 between the 4 groups (HR no indication, no prone vs. no indication, prone vs. indication, no prone vs. indication, prone: 1.05 (0.76-1.45) vs. 0.88 (0.62-1.26) vs. 1.15 (0.80-1.54) vs. 0.96 (0.73-1.26) (p = 0.08)). Factors associated with the use of prone positioning were ARDS severity and FiO2. The findings of this study are that prone positioning is often used in COVID-19 patients, even in patients that have no indication for this intervention. Sessions of prone positioning lasted long. Use of prone positioning may affect outcomes.
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Affiliation(s)
- Willemke Stilma
- Department of Intensive Care, Amsterdam UMC, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands; (D.M.P.v.M.); (C.M.A.V.); (H.d.B.); (F.P.); (M.J.S.)
- Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, 1105 BD Amsterdam, The Netherlands
- Correspondence:
| | - David M. P. van Meenen
- Department of Intensive Care, Amsterdam UMC, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands; (D.M.P.v.M.); (C.M.A.V.); (H.d.B.); (F.P.); (M.J.S.)
| | - Christel M. A. Valk
- Department of Intensive Care, Amsterdam UMC, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands; (D.M.P.v.M.); (C.M.A.V.); (H.d.B.); (F.P.); (M.J.S.)
| | - Hendrik de Bruin
- Department of Intensive Care, Amsterdam UMC, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands; (D.M.P.v.M.); (C.M.A.V.); (H.d.B.); (F.P.); (M.J.S.)
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam UMC, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands; (D.M.P.v.M.); (C.M.A.V.); (H.d.B.); (F.P.); (M.J.S.)
- Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, 1105 BD Amsterdam, The Netherlands
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne 3004, Australia;
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo 05652-900, Brazil
| | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam UMC, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands; (D.M.P.v.M.); (C.M.A.V.); (H.d.B.); (F.P.); (M.J.S.)
- Mahidol–Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford OX3 7BN, UK
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van Meenen DMP, van der Hoeven SM, Binnekade JM, de Borgie CAJM, Merkus MP, Bosch FH, Endeman H, Haringman JJ, van der Meer NJM, Moeniralam HS, Slabbekoorn M, Muller MCA, Stilma W, van Silfhout B, Neto AS, ter Haar HFM, Van Vliet J, Wijnhoven JW, Horn J, Juffermans NP, Pelosi P, Gama de Abreu M, Schultz MJ, Paulus F. Effect of On-Demand vs Routine Nebulization of Acetylcysteine With Salbutamol on Ventilator-Free Days in Intensive Care Unit Patients Receiving Invasive Ventilation: A Randomized Clinical Trial. JAMA 2018; 319:993-1001. [PMID: 29486489 PMCID: PMC5885882 DOI: 10.1001/jama.2018.0949] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE It remains uncertain whether nebulization of mucolytics with bronchodilators should be applied for clinical indication or preventively in intensive care unit (ICU) patients receiving invasive ventilation. OBJECTIVE To determine if a strategy that uses nebulization for clinical indication (on-demand) is noninferior to one that uses preventive (routine) nebulization. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial enrolling adult patients expected to need invasive ventilation for more than 24 hours at 7 ICUs in the Netherlands. INTERVENTIONS On-demand nebulization of acetylcysteine or salbutamol (based on strict clinical indications, n = 471) or routine nebulization of acetylcysteine with salbutamol (every 6 hours until end of invasive ventilation, n = 473). MAIN OUTCOMES AND MEASURES The primary outcome was the number of ventilator-free days at day 28, with a noninferiority margin for a difference between groups of -0.5 days. Secondary outcomes included length of stay, mortality rates, occurrence of pulmonary complications, and adverse events. RESULTS Nine hundred twenty-two patients (34% women; median age, 66 (interquartile range [IQR], 54-75 years) were enrolled and completed follow-up. At 28 days, patients in the on-demand group had a median 21 (IQR, 0-26) ventilator-free days, and patients in the routine group had a median 20 (IQR, 0-26) ventilator-free days (1-sided 95% CI, -0.00003 to ∞). There was no significant difference in length of stay or mortality, or in the proportion of patients developing pulmonary complications, between the 2 groups. Adverse events (13.8% vs 29.3%; difference, -15.5% [95% CI, -20.7% to -10.3%]; P < .001) were more frequent with routine nebulization and mainly related to tachyarrhythmia (12.5% vs 25.9%; difference, -13.4% [95% CI, -18.4% to -8.4%]; P < .001) and agitation (0.2% vs 4.3%; difference, -4.1% [95% CI, -5.9% to -2.2%]; P < .001). CONCLUSIONS AND RELEVANCE Among ICU patients receiving invasive ventilation who were expected to not be extubated within 24 hours, on-demand compared with routine nebulization of acetylcysteine with salbutamol did not result in an inferior number of ventilator-free days. On-demand nebulization may be a reasonable alternative to routine nebulization. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02159196.
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Affiliation(s)
- David M. P. van Meenen
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, the Netherlands
| | | | - Jan M. Binnekade
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, the Netherlands
| | | | - Maruschka P. Merkus
- Clinical Research Unit, Academic Medical Center, University of Amsterdam, the Netherlands
| | - Frank H. Bosch
- Department of Intensive Care, Rijnstate, Arnhem, the Netherlands
| | - Henrik Endeman
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | | | | | - Hazra S. Moeniralam
- Department of Intensive Care, Antonius Hospital, Nieuwegein, the Netherlands
| | - Mathilde Slabbekoorn
- Department of Intensive Care, Haaglanden Medical Center, The Hague, the Netherlands
| | | | - Willemke Stilma
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - Bart van Silfhout
- Department of Intensive Care, Antonius Hospital, Nieuwegein, the Netherlands
| | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Jan Van Vliet
- Department of Intensive Care, Rijnstate, Arnhem, the Netherlands
| | | | - Janneke Horn
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, the Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, the Netherlands
| | - Nicole P. Juffermans
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, the Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, the Netherlands
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, San Martino Policlinico Hospital, IRCCS for Oncology, University of Genoa, Genoa, Italy
| | - Marcelo Gama de Abreu
- Pulmonary Engineering Group, Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus; Technische Universität Dresden, Dresden, Germany
| | - Marcus J. Schultz
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, the Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, the Netherlands
- Mahidol Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Frederique Paulus
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, the Netherlands
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van Meenen LCC, van Meenen DMP, de Rooij SE, ter Riet G. Response to Dr. Alain Braillon. J Am Geriatr Soc 2015; 63:1282-3. [DOI: 10.1111/jgs.13501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | | | - Sophia E. de Rooij
- Geriatrics Section; Department of Internal Medicine; Academic Medical Center; University of Amsterdam; Amsterdam the Netherlands
| | - Gerben ter Riet
- Department of General Practice; Academic Medical Center; University of Amsterdam; Amsterdam the Netherlands
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van Meenen LCC, van Meenen DMP, de Rooij SE, ter Riet G. Risk Prediction Models for Postoperative Delirium: A Systematic Review and Meta-Analysis. J Am Geriatr Soc 2014; 62:2383-90. [DOI: 10.1111/jgs.13138] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
| | | | - Sophia E. de Rooij
- Geriatrics Section; Department of Internal Medicine; Academic Medical Center; University of Amsterdam; Amsterdam The Netherlands
| | - Gerben ter Riet
- Department of General Practice; Academic Medical Center; University of Amsterdam; Amsterdam the Netherlands
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