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14th February 2025
A new Green Paper published by the European Society of Intensive Care Medicine highlights the importance of addressing environmental sustainability in intensive care. Katherine Price speaks to Professor Jan De Waele, who led the work, to find out the context, conclusions and key takeaways of the Green Paper and how frontline intensivists can help to drive the sustainability agenda forwards while maintaining high quality patient care.
Intensive care units (ICUs) are among the most resource-intensive hospital departments, with high levels of energy consumption, waste, reliance on single-use devices, medicines and resource-intensive therapies.
One study found the greenhouse gas emissions per ICU bed per day were more than double that of an acute care bed. This creates a vicious cycle in which ICU emissions are contributing to climate change, which itself is producing more patients, increasingly complex conditions and even new diseases.
Against this backdrop, the European Society of Intensive Care Medicine (ESICM) sought to produce a white paper demonstrating how it is possible to maintain and even enhance patient care at a high standard while limiting the environmental impact of ICU activities.
Objectives included evaluating the impact of climate change on ICUs, the environmental impact of ICU activities, identifying key opportunities to reduce this impact, and developing a framework for initiatives including actionable strategies. The resulting Green Paper entitled ‘Environmental sustainability in intensive care: the path forward‘ was published in October 2024.
The ESICM Executive Committee appointed a task force of experts and committee representatives to develop the Green Paper. They worked to identify key areas and actions informed by personal experience, relevant literature and member feedback.
Lead author and task force chair, Professor Jan De Waele, is an intensivist in the surgical ICU at Ghent University Hospital in Belgium. President of the ESICM since October 2024, he was drawn to intensive care medicine by the dynamics of acute disease and multifaceted, fast-changing environment.
‘Intensive care medicine is becoming a speciality in its own right,’ he says. ‘It has become much more complex over the last 20-30 years compared to when I started my training.’
Interested in environmental sustainability, he noticed that while many intensive care professionals were taking steps to be more sustainable in their private lives, this wasn’t necessarily being applied to their practice in the hospital.
‘This Green Paper is not only a practical guide, it’s also a call to action. The fact that we prioritised this hopefully helps people understand that this is an important thing for them, and that it’s not just something that you can switch off when you enter the hospital,’ he explains.
‘It’s an overview of the little information we have right now and trying to give some direction and guidance for our members.’
While he says the intensive care community mirrors society at large in that there is a growing awareness of the importance of environmental sustainability, equally, there are those who turn a blind eye to the problem or resist change, presenting a challenge to the task force and the aims of the Green Paper.
‘There is, of course, always some resistance. Climate change is still something that is contested around the world and, based on recent trends in international politics, one may expect that we still have some work to do,’ Professor De Waele says.
As well as highlighting four main areas for strategies and solutions – clinical care; research and innovation; awareness and education; and ESICM leadership – the Green Paper categorises actions into three tiers.
Tier 1 actions require minimal resources and can quickly contribute to environmental sustainability, such as energy-saving measures, training and promoting reusables. Tier 2 actions require more investment and coordination but can result in significant benefits, for example digitising communications and recordkeeping, or investing in more energy-efficient equipment. Tier 3 includes highly impactful actions that may require considerable investment, long-term planning, like sourcing renewable energy and retrofitting buildings, and cultural change within an organisation.
Intensivists and other intensive care professionals are encouraged to contribute to a multidisciplinary ‘green team’ and evaluate systems and processes to identify low-value clinical practices that could be changed or removed to reduce costs and environmental burden but also improve patient care. Professor De Waele explains that this includes ‘unnecessary lab tests, examinations, having patients in the hospital for too long’, among others.
The paper also lists recommendations for the ESICM itself, such as developing sustainability educational pathways, embedding the topic into courses and organising an annual sustainability conference.
Professor De Waele hopes the main takeaway for intensivists is ‘that what we do in the ICU does significantly impact the environment’ and that to mitigate this goes beyond switching the lights off.
‘Part of the resistance to environmental sustainability is often rooted in the fact that people think, “people are taking things away from me”. But it’s more than that, it’s added value,’ he explains, noting that there’s much more to do. For example, integrating sustainability into research, such as including the environmental impact of a new drug or intervention in the outcome measures.
The Green Paper also stresses the ‘critical’ need to develop flexible sustainability strategies that can be adapted to local needs, resources and conditions. Initiatives that have been seen across Europe include the UK Intensive Care Society’s Gloves Off in Critical Care campaign or efforts in the Netherlands to reduce the amount of paracetamol delivered intravenously in ICUs.
‘There is no uniform solution for every unit and country. You need to look at the low-hanging fruit, and the best to see that are those working at the bedside – the nurses and clinicians,’ explains Professor De Waele.
Green teams, he says, need to be multidisciplinary to ensure initiatives are rooted in clinical practice, are context specific and work for all members of the team – and the best place for teams to start is by focusing on actions that reduce environmental impact but also save time, money and maintain quality of care.
Priorities for the ESICM for 2025 include updating the Surviving Sepsis Campaign guidelines, which are expected to be published within the next 12 months, as well as addressing the Green Paper’s recommendations – towards which the environmental sustainability task force will evolve into a formal multidisciplinary environmental sustainability committee.
The ESICM plans to provide research grants and set up infrastructure to support knowledge exchange on sustainable ICU practice, such as hosting an annual online sustainability conference. There is also work to be done on making ESICM operations more sustainable and engaging with patient and community groups to ensure people understand why changes are being made and that they will not compromise patient care.
‘Now we need to bring this to the bedside, to our members,’ says Professor De Waele. ‘We’ve laid out a number of ideas and solutions, but now it’s up to us – and all of us, not only the ESICM – to solve it and take it seriously and take action.’
21st November 2024
A new survey by the European Society of Paediatric Research (ESPR) has examined how widely lung ultrasound is used in neonatal intensive care units (NICUs) across Europe to better understand what it is used for and how this may be improved.
The survey results, published on behalf of the ESPR Pulmonary Research Consortium, found that although lung ultrasound is available in NICUs throughout the continent, uptake is highly variable.
To improve implementation, the authors suggest the development of learning opportunities for healthcare professionals, as well as the establishment of international guidelines.
The researchers analysed lung ultrasound use in NICUs using an international online survey undertaken in 2023, collecting data from 560 NICUs in 24 countries.
The percentage of NICUs using this technique varied widely between countries, ranging from 20% to 98%. Of the NICUs surveyed, 76% of the units used it for patient care, while 6% used it only for research purposes.
Where lung ultrasound was used in a clinical context, it was most frequently used to diagnose respiratory diseases (68%), to evaluate an infant experiencing acute clinical deterioration (53%) and to guide surfactant treatment (39%).
Respiratory conditions diagnosed by in this way most commonly included pleural effusion, pneumothorax, newborn transient tachypnea and respiratory distress syndrome.
In all NICUs, lung ultrasound was mainly used by neonatologists. The researchers found that experience using it varied widely across Europe, with only 13% of the units having more than five years of experience using the machines. One-third of the units had less than two years’ experience.
The most common reasons for not using lung ultrasound were a lack of technical experience and uncertainty around image interpretation.
Survey respondents and authors suggested that specific courses and an international guideline on neonatal lung ultrasound could promote the uptake of this technique.
Reference
Alonso-Ojembarrena, A et al. Use of neonatal lung ultrasound in European neonatal units: a survey by the European Society of Paediatric Research. Archives of Disease in Childhood. Fetal and Neonatal Edition 2024; Apr 11: DOI: 10.1136/archdischild-2024-327068.
8th December 2023
Reducing oxygen levels in critically ill children on mechanical ventilators in intensive care could save 50 lives each year, according to a new study by Great Ormond Street Hospital (GOSH) and University College London.
The Oxy-PICU study, published in The Lancet, is the largest randomised controlled trial ever conducted in paediatric intensive care units (PICUs).
The researchers recruited 2,040 children from 15 NHS PICUs across England and Scotland. Each of the children required a mechanical ventilator and extra oxygen on admission to the PICU.
The children, who ranged from newborn up to 16 years, were randomly allocated to one of two groups: they received oxygen to the standard target level of oxygen (saturation “SpO2” >94%), or a reduced oxygen target (SpO2 88-92%).
The researchers found that the children who received the lower level of oxygen were 6% more likely to have a better outcome, either in terms of survival or the number of days spent on machines supporting their organs.
In the UK, around 20,000 children are admitted to intensive care each year and roughly 75% will receive additional oxygen through a ventilator.
If the study were to be scaled up, the researchers anticipate that this approach could save 50 lives, free up 6,000 ICU bed days and save £20m annually in the UK alone.
Professor Mark Peters, consultant paediatric intensivist at GOSH, professor of paediatric intensive care at UCL Great Ormond St Institute of Child Health, and lead author on the study, said: ‘Giving the minimum safe dose of anything in intensive care appears to generate the best outcomes, so we wanted to test this approach with oxygen.
‘We found a small benefit of lower oxygen targets that is unlikely to have been due to chance. But because so many children are treated with oxygen, this has the potential to improve outcomes and reduce healthcare costs in the UK and around the world.
‘This could have particular implications in countries where oxygen is a scarce resource, or in situations as we have seen in recent years, where health needs change, and oxygen demand quickly peaks.’
Lauran O’Neill, senior critical care research nurse at GOSH, said: ‘This is a major milestone study, which was nurse-led, with research taking place at the bedside as part of normal clinical care. It’s a great example of a research-hospital vision as every child admitted to ICU was screened for inclusion into the study.
‘Although GOSH teams were managing the study and a major recruiter, undertaking the research process was part of the standard of care for many emergency teams across the country – so training and education was the focus. We had to work well together across all collaborating hospitals to deliver this huge success for our patients.’
The Oxy-PICU study also includes researchers from the Intensive Care National Audit & Research Centre and the Paediatric Critical Care Society Study Group.
It is funded by the National Institute for Health and Care Research (NIHR)’s Health Technology Assessment programme and supported by the NIHR’s Biomedical Research Centres at GOSH and UCLH.
22nd June 2023
An electronic prescribing (EP) system within an intensive care unit (ICU) requires a lower level of clinical pharmacist input compared to a paper-based system, according to a recent prospective, longitudinal UK study.
Although EP systems are designed to reduce medication errors, the quality of evidence on their effectiveness is variable. Nevertheless, within an ICU setting, the use of commercial computerised provider order entry systems led to an 85% reduction in medication prescribing error rates and a 12% reduction in ICU mortality rates. However, few studies have focused on whether EP systems optimise medication therapy, reduce costs, improve the quality of prescribing and patient outcomes.
In the current study, published in the International Journal of Medical Informatics, researchers compared the clinical significance of pharmacist contributions in two ICU departments to understand the impact of an EP system on the quality of patient care.
The team chose one department that used an EP system and compared the extent of pharmacist input with a second department using a paper-based prescribing (PBP) system. The primary outcome was the distribution of clinical significance levels of pharmacist contributions. This was assessed using a tool that assigned a clinical significance rating to pharmacists’ contributions based on the mitigation of risk or negative outcome for the patient and ranged from I (low level) to V (high level).
A total of 303 patients were included, with EP used in 171 patients. Overall, 1,658 contributions were analysed.
The median number of patient reviews in both groups was similar, as was the proportion of reviews with no change (49.3% vs 48.5%, PBP vs EP). In addition, there were 14.9% highly clinically significant pharmacist contributions (levels III and above) with EP compared to 44.6% with PBP.
The EP group had a lower odds for a higher clinical significance contribution compared to the PBP group (Odds ratio, OR = 0.05, 95% CI 0.02-0.12). However, over time, there was a lower odds of a higher level contribution from the PBP group (OR = 0.57, 95% CI 0.42 – 0.78, p < 0.001).
Based on these findings, the researchers concluded that the clinical significance of pharmacist contributions remained both low and stable in over time in the EP group. Moreover, while initially higher, pharmacists in an ICU using a PBP system actually reduced over time.
Taken together, the study suggests that the use of an EP system required significantly less pharmacist input to maintain patient safety, possibly because the EP system enables access to data to improve decision-making at the point of prescribing.
9th March 2023
The potential for long-term cognitive impairment (CP) among mechanically ventilated patients within an intensive care unit can be significantly reduced through early mobilisation according to the findings of a randomised trial by researchers at the University of Chicago, Chicago, USA.
Patients in both medical and surgical intensive care units are at a high risk of long-term cognitive impairment. In fact, after only two days of documented delirium, at 12 months, 71% of survivors had cognitive impairment and of whom, 36% had severe impairment. While delirium commonly occurs in critical illness, whether this causes longer-term cognitive impairment is less clear. Delirium can be reduced through early mobilisation, i.e., whole-body rehabilitation with interruption of sedation and physical and occupational therapy in the earliest days of critical illness. However, no studies have examined whether early mobilisation also positively impacts on the longer-term development of CP.
In the current study, the US team performed a randomised trial of early mobilisation among functionally independent and mechanically ventilated patients admitted to the ICU versus usual care to determine if this reduced cognitive impairment, 12 months after the critical illness. Adult patients admitted to the ICU intensive-care unit (ICU), were randomised 1:1 to either early physical and occupational therapy (i.e., early mobilisation) or usual care. The primary outcome, cognitive impairment 1 year after hospital discharge, was assessed using the Montreal Cognitive Assessment (MoCA) scale and on which, CP is deemed to be present if the score is < 26.
Cognitive impairment and early mobilisation
A total of 198 patients with mean age of 56.2 years (42.5% female) were equally randomised to early mobilisation or usual care.
When assessed after 12 months, the rate of CP among those assigned to early mobilisation was 24% (mean MoCA score = 26) compared with 43% (mean MoCA score = 23) with usual care and this difference was statistically significant (p = 0.0043). In fact, CP was also significantly lower upon hospital discharge, (54% vs 69%, p = 0.029). The early mobilisation group also had significantly fewer ICU-acquired weaknesses (p = 0.0001) and higher physical component quality-of-life scores (p < 0.0001). However, there were no significant differences in the rates of functional independence or mental component scores between groups after 12 months.
The authors concluded that early mobilisation could be the first known intervention to improve long-term cognitive impairment among ICU patients following mechanical ventilation.
Citation
Patel BK et al. Effect of early mobilisation on long-term cognitive impairment in critical illness in the USA: a randomised controlled trial. Lancet Respir Med 2023
25th May 2022
A multi-inflammatory index (MII) biomarker have been shown to have good predictive power for mortality among COVID-19 patients admitted to an intensive care unit (ICU). This was the main finding of a study by a team of Turkish researchers.
It is common among patients with severe COVID-19 to develop acute respiratory distress syndrome (ARDS) which represents a life-threatening form of respiratory failure and after the initial infection, neutrophils, which form part of the innate immune system, rapidly infiltrate the lungs.
However, lymphocytes also have an important role in both immune homeostasis and inflammatory responses throughout the body and lymphopenia has been shown to be an effective and reliable indicator of the severity and hospitalisation in COVID-19 patients.
Nevertheless, infection with COVID-19 produces several biochemical abnormalities including elevation of C-reactive protein in patients with severe disease, together with hyper-inflammation and a cytokine storm. In fact, alterations in the level of several markers has been shown to be of value in predicting the prognosis of patients infected with the virus.
One particular biomarker, the multi-inflammatory index (MMI), which includes the neutrophil to lymphocyte ratio (NLR) and C-reactive protein (CRP), has been shown to have good prognostic mortality value when originally examined in patients with metastatic colorectal cancer undergoing first-line chemotherapy.
As other research has found that both the neutrophil-lymphocyte ratio and C-reactive protein are significantly higher in patients with COVID-19 and who subsequently die, the Turkish team wondered if the MII – which includes both measures – would have prognostic value for identifying which critically ill patients with COVID-19, were at a higher risk of mortality.
The team retrospectively analysed data on COVID-19 patients admitted to an ICU and compared the prognostic value of MII with a range of inflammatory biomarkers including the urea to albumin ratio, CRP to albumin ratio and the D-dimer to albumin ratio.
Multi-inflammatory index and COVID-19 mortality
A total of 348 patients with a median age of 74 years (59% male) were admitted to ICU due to COVID-19 and included in the analysis.
Overall, 24.7% of patients survived and the remainder died. While co-morbidities such as hypertension, diabetes and COPD were numerically higher among those who died, these differences were not statistically different.
Using multiple logistic regression, among all the inflammatory measures used, only MII was found to be an independent predictor of mortality (odds ratio, OR = 0.99, 95% CI 0.99 – 0.99, p = 0.03). Other significant predictors included age (OR = 1.07), the NLR (OR = 1.07).
Commenting on their results, the authors suggested that the likely reason why the NLR ratio was elevated in COVID-19 patients was because of an increased neutrophil count and a corresponding lymphopenia.
They concluded that MII represents a simple and practical biomarker which could help identify COVID-19 patients with a poor prognosis and called for further studies to validate these retrospective findings.
Citation
Gozdas HT et al. Multi-inflammatory Index as a Novel Mortality Predictor in Critically Ill COVID-19 Patients J Intensive Care Med 2022
12th May 2022
Cancer patients with COVID-19 have been found to be at a greater risk of hospitalisation and 30-day all-cause mortality compared to those without the disease according to the results of a study by a US team from Texas.
The presence of cancer has become a recognised factor that is associated with a higher risk for severe outcomes in those infected with COVID-19 and which is largely due to the presence of a compromised immune system.
During the early course of the pandemic, studies observed that a higher proportion of cancer patients infected with COVID-19 were both hospitalised and subsequently died, compared to those without the disease. In contrast, however, other studies have suggested that cancer and non-cancer patients have comparable COVID-19 outcomes after adjusting for age, sex, and comorbidity.
Furthermore, the impact of factors such as cancer treatments, different cancer types on COVID-19 related outcomes has been less well studied.
For the present study, the US researchers examined the association between cancer-specific characteristics and COVID-19 outcomes. They turned to the Optum de-identified COVID-19 electronic health record, which is derived from over 700 hospitals and 7000 clinics across the USA. Using these data, the researchers examined the outcome of those with a laboratory confirmed COVID-19 and a recorded cancer diagnosis.
The primary objective was to determine the effect of cancer on COVID-19 outcomes including 30-day all-cause mortality, hospitalisation, intensive care unit (ICU) admission and ventilator use. These outcomes were also analysed by the nature and type of cancer in comparison to patients without cancer.
The authors the explored if there were any other specific factors in those with cancer which impacted on COVID-19 outcomes.
Cancer patient with COVID-19 and related outcomes
A total of 271,639 patients with confirmed COVID-19 of whom 18,460, with a mean age of 66 years (45.3% male) had a cancer diagnosis were analysed. Among those with cancer, 8034 patients had a history of cancer for longer than 12 months and 10,426 had a more recent diagnosis, i.e., within 1 year before COVID-19.
30-day all-cause mortality was more than three times higher among those with cancer (6.8% vs 1.9%) compared to non-cancer patients. After adjustment for age, sex, ethnicity and risk factors, the presence of cancer was associated with a 7% higher risk of death (relative risk, RR = 1.07, 95% CI 1.01 – 1.14, p = 0.028) compared to those without the disease.
Similarly, there was a 4% higher risk of hospitalisation (RR = 1.04, 95% CI 1.01 – 1.07, p = 0.006). When comparing the duration of cancer, those with a recent diagnosis had both a significant (p < 0.001) increased risk of mortality (RR = 1.17) and hospitalisation (RR = 1.10) although this risk was non-significant for those who had cancer for much longer.
There was also an increased mortality risk for those with recent metastatic (RR = 2.09), solid tumour (RR = 1.12) and haematological (RR = 1.48) cancers compared with those without the disease. Individual cancers with a significantly elevated risk were leukaemia (RR = 1.58), liver (RR = 2.46), lung (RR = 1.85) and pancreatic (RR = 1.94).
When exploring the factors related to COVID-19 mortality in those with recent cancer, both chemotherapy (RR = 1.37) and radiotherapy (RR = 1.83) within 3-months before COVID-19, were significantly associated with a higher risk of death as was increasing age (i.e., > 75 years) (RR = 6.69).
In addition, the only significant co-morbidities were cardiovascular disease (RR = 1.72), diabetes (RR = 1.39) and renal disease (RR = 1.51).
Citation
Kim Y et al. Characterizing cancer and COVID-19 outcomes using electronic health records PLoS One 2022
11th February 2022
Multi-organ ultrasound might be of value in ruling out a pulmonary embolism (PE) in critically ill patients with COVID-19 and potentially reduce the need for computed-tomography pulmonary angiography (CTPA). This was the conclusion of a study by researchers from the department of Acute Internal Medicine, Amsterdam UMC, the Netherlands.
Among those who are critically ill with COVID-19, studies suggest an increased risk of thrombo-embolism and subsequent death. In fact, the incidence of PE is reported to be around 2.6 – 8.9% of COVID-19 in hospitalised patients and up to one-third of those requiring intensive care unit (ICU) admission, despite standard prophylactic anticoagulation.
In a 2010 survey, the majority of the radiologists indicated that CTPA is the new reference standard for the diagnosis of pulmonary embolism. However, in cases where CTPA is unavailable, a 2020 meta-analysis has indicated that cardiopulmonary ultrasound may be useful in areas where CTPA is unavailable or unsuitable, as this modality can help detect right ventricular strain (RVS) which has a high degree of specificity for a PE.
In addition, an emergency department study concluded that the use of multi-organ ultrasound is more sensitive than single-organ ultrasonography and increases the accuracy of clinical pre-test probability estimation in patients with suspected PE.
However, whether multi-organ ultrasound would be of value in ruling out a PE among critically ill patients with COVID-19 is unclear and was the objective of the current study by the Dutch team. They set out to compare the diagnostic value of lung, deep vein and cardiac ultrasound both separately and in combination for the detection of PE.
Included patients were adults (> 18 years) admitted to an intensive care unit and for whom a multi-organ ultrasound scan was performed within 24 hours of a CTPA.
Multi-organ ultrasound scan results and pulmonary embolism
A total of 140 CTPA scans were performed in 70 consecutive patients with a mean age of 67.5 years (80% male) and patients underwent 126 lung, 123 deep vein and 125 cardiac ultrasound scans.
The diagnostic accuracy of sub-pleural consolidations was 42.9% (95% CI 34.1 – 52), and 75.6% (95% CI 67.1 – 82.9%) for deep vein ultrasound and 74.4% (95% CI 65.8 – 81.8%) for RVS on cardiopulmonary ultrasound.
When the signs of multi-organ ultrasound scans were combined, the sensitivity was high at 87.5% (95% CI 67.6 – 97.3) although the specificity was low at 25%.
The authors concluded that while the use of individual single site ultrasounds were of limited value on their own, multi-organ ultrasound had a higher sensitivity and could therefore be of value at ruling out a PE.
They described how these data suggested the use of multi-organ ultrasound has the potential to reduce the amount of CTPA’s undertaken adding that since devices were hand-held and hence more accessible, scanning could be undertaken by intensive care personnel.
Citation
Lieveld A et al. Multi-organ point-of-care ultrasound for detection of pulmonary embolism in critically ill COVID-19 patients – A diagnostic accuracy study J Crit Care 2022
27th January 2022
Intensive care unit (ICU) patients continue to frequently experience physical, mental and cognitive symptoms one year after their acute infection with COVID-19. This was the main finding from a study by researchers from the Radboud University Medical Center, Nijmegen, the Netherlands.
ICU patients who survive serious illnesses such as acute respiratory distress syndrome are known to have persistent functional disability one year after discharge from an intensive care unit. Moreover, during the current pandemic, patients recovering from severe COVID-19 have been found to present with early mild to moderate functional impairment, mildly reduced quality of life and a worsening of pain and depression/anxiety symptoms at 6 months. In addition, other work indicates frequent cognitive sequelae after infection with COVID-19.
However, longer-term outcome data among ICU patients admitted to these units due to COVID-19, is lacking. As a result, for the present study, the Dutch researchers set out to establish the extent of any long-term physical, mental and cognitive symptoms among this patient cohort.
They recruited patients discharged from ICU due to COVID-19 but excluded individuals whose stay in ICU was less than 12 hours as well as those with a life expectancy of less than 48 hours. For the three main outcomes, the team assessed physical symptoms based on the Clinical Fragility Score (CFS) for which the cut-off score, indicative of frailty is 5.
Mental symptoms such as anxiety and depression were measured using the Hospital Anxiety and Depression scale (HADS), which has a cut-off value of 8 and finally, cognitive symptoms were assessed using the abbreviated Cognitive Failure Questionnaire-14, for which the cut-off score was 43.
ICU patients mental, physical and cognitive scores
A total of 246 patients with a mean age of 61.2 years (71.5% male) completed the one-year follow-up questionnaires.
At 12 months 74.3% of ICU patients reported physical symptoms compared to 26.2% for mental and 16.2% for cognitive symptoms respectively. In addition, 30.6% of patients reported symptoms from at least two of these domains with 10.5% having symptoms from all three domains.
For the CFS, the median value after one year was 2, with 6.1% of patients exceeding the cut-off score for frailty. Similarly, 18.3% exceeded the cut-off score for HADS, indicating anxiety and depression and 16.2% exceeded the cognitive failure score cut-off.
Among the range of new physical symptoms developed, 38.9% reported a weakened condition, 26.3% reported joint stiffness, followed by joint pain (25.5%) and muscle weakness (24.8%). Symptoms of anxiety and depression were reported by 17.9% and 18.3% respectively.
The authors concluded that among ICU patients, one year after treatment, physical, mental and cognitive symptoms continued to be reported.
Citation
Heesakkers H et al. Clinical Outcomes Among Patients With 1-Year Survival Following Intensive Care Unit Treatment for COVID-19 JAMA 2020
13th January 2022
Atorvastatin use among intensive care patients does not result in a significant reduction of adverse outcomes among patients with COVID-19.
Atorvastatin given to patients infected with COVID-19 and admitted to an intensive care unit (ICU) is not associated with a significant reduction in adverse outcomes according to research by a team from the Rajaie Cardiovascular Medical and Research Centre, Tehran, Iran.
Hydroxymethylglutaryl coenzyme A reductase inhibitors (or statins), are known to exert a direct antithrombotic effect in models of arterial and venous thrombosis via a mechanism unrelated to the cholesterol-lowering activity, as well as having anti-inflammatory properties .
Furthermore, a 2021 systematic review also identified additional identified additional pleiotropic effects including antiviral and immunomodulatory that might help treat COVID-19.
Given this potential beneficial role for statins, the Iranian team sought to examine the impact of atorvastatin on thromboembolic events or death, in patients with the COVID-19, admitted to ICU. Their study was part of the INSPIRATION trial which had two arms: one that explored the effect of prophylactic anticoagulation and the other focusing on the use of atorvastatin.
The team recruited adult patients (> 18 years of age) with a PCR confirmed COVID-19 infection, admitted to ICU and in whom there was no baseline therapeutic need for a statin. Enrolled patients were then randomised 1:1 to atorvastatin 20 mg daily or matching placebo and followed for 30 days after randomisation.
For patients requiring mechanical ventilation, the drug was delivered via a nasogastric or orogastric tube. The primary outcome of interest was a composite of venous or arterial thrombosis, treatment with extracorporeal membrane oxygenation or all-cause mortality within 30 days of randomisation.
A total of 587 patients with a median age of 57 years (44% female) were randomised to atorvastatin or placebo and treatment was used for a median of 21 days and slightly less, at 19 days for placebo. The median length of stay within ICU was 5 days in both groups.
After 30 days, the primary outcome had occurred in 95 (33%) of patients assigned to atorvastatin and 108 (36%) of those given placebo (odds ratio, OR = 0.84, 95% CI 0.58 – 1.21, p = 0.35).
The results for the primary outcome were largely driven by mortality, with 31% and 35% of deaths in the atorvastatin and placebo groups respectively although no patients required extracorporeal membrane oxygenation.
The use of imaging tests such as computed tomography pulmonary angiograms and doppler, revealed a similar level of venous thromboembolism diagnoses in the two groups (20% vs 20%, p = 0.64).
There was also no difference in the incidence of arterial thrombosis. In subgroup analysis, there were no sex-related differences, among patients older/younger than 65 years, smokers or in those with/without obesity or diabetes.
In trying to account for their findings, the authors speculated that atorvastatin may have had a small protective effect which was undetectable or that statins were only of benefit in the early stages of COVID-19 infection prior to the inflammatory response which led to irreversible damage.
Citation
INSPIRATION-S investigators. Atorvastatin versus placebo in patients with covid-19 in intensive care: randomized controlled trial. BMJ 2022.
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