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ObjectiveBy extracting early chest CT radiomic features of COVID-19 patients, we explored their correlation with laboratory indicators and oxygenation index (PaO2/FiO2), thereby developed an Artificial Intelligence (AI) model based on radiomic features to predict the deterioration of oxygenation function in COVID-19 patients.MethodsThis retrospective study included 384 patients with COVID-19, whose baseline information, laboratory indicators, oxygenation-related parameters, and non-enhanced chest CT images were collected. Utilizing the PaO2/FiO2 stratification proposed by the Berlin criteria, patients were divided into 4 groups, and differences in laboratory indicators among these groups were compared. Radiomic features were extracted, and their correlations with laboratory indicators and the PaO2/FiO2 were analyzed, respectively. Finally, an AI model was developed using the PaO2/FiO2 threshold of less than 200 mmHg as the label, and the model’s performance was assessed using the area under the receiver operating characteristic curve (AUC), sensitivity and specificity. Group datas comparison was analyzed using SPSS software, and radiomic features were extracted using Python-based Pyradiomics.ResultsThere were no statistically significant differences in baseline characteristics among the groups. Radiomic features showed differences in all 4 groups, while the differences in laboratory indicators were inconsistent, with some PaO2/FiO2 groups showed differences and others not. Regardless of whether laboratory indicators demonstrated differences across different PaO2/FiO2 groups, they could all be captured by radiomic features. Consequently, we chose radiomic features as variables to establish an AI model based on chest CT radiomic features. On the training set, the model achieved an AUC of 0.8137 (95% CI [0.7631–0.8612]), accuracy of 0.7249, sensitivity of 0.6626 and specificity of 0.8208. On the validation set, the model achieved an AUC of 0.8273 (95% CI [0.7475–0.9005]), accuracy of 0.7739, sensitivity of 0.7429 and specificity of 0.8222.ConclusionThis study found that the early chest CT radiomic features of COVID-19 patients are strongly associated not only with early laboratory indicators but also with the lowest PaO2/FiO2. Consequently, we developed an AI model based on CT radiomic features to predict deterioration in oxygenation function, which can provide a reliable basis for further clinical management and treatment.

Objective: The importance of prone positioning has increased with the density of coronavirus disease-2019-related acute respiratory distress syndrome (C-ARDS) during the pandemic process. It is aimed to investigate the effect of prolonged duration of prone positioning in C-ARDS patients on the blood gas parameters at the time after supine positioning (post-prone effect), the feasibility, the safety, and the mortality for 28 days. Materials and Methods: This study was a single-center prospective observational study with 1000 beds, 432 of which were intensive care units. Severe and moderate ARDS; the blood gas parameters (PaO2/FiO2, PaO2, SpO2 etc.) of the patients who were applied the standard prone (16 hours) and the extended prone (36 hours) position were compared. Results: It was observed that PaO2/FiO2 PaO2 and SpO2 values measured at the 8th hour (t4) (post-prone) after the prone was placed in the supine position in the prolonged prone group were higher than before the prone (t1) (p

Qiang Lai,1– 3 Yiqin Xia,1– 3 Wentao Yang,1– 3 Yiwu Zhou1– 3 1Emergency Department, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China; 2Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China; 3Disaster Medical Center, Sichuan University, Chengdu, Sichuan, People’s Republic of ChinaCorrespondence: Yiwu Zhou, Emergency Department, West China Hospital of Sichuan University, Chengdu, Sichuan, People’s Republic of China, Email 456zyw@163.comObjective: To develop a concise scoring system for efficient and rapid assessment of sepsis prognosis applicable to emergency departments.Methods: This was a single-center retrospective cohort study of patients with sepsis. In this study, a new scoring system (oxygenation index, lactate, and Glasgow coma scale: GOL) was developed through a derivation group, and then the GOL was validated using a validation group. Multivariate logistic regression analysis was performed to investigate the relationship between GOL and 28-day adverse outcomes. The GOL was compared with the previous scoring system using receiver operating characteristic curves (ROC) and decision analysis curves. The endpoints of this study were mortality, mechanical ventilation (MV), and admission to the intensive care unit (AICU).Results: 608 patients were included in the derivation group and 213 patients in the validation group, with 131 and 42 deaths, respectively. In the validation group, lactate (Lac), oxygenation index (PaO2/FiO2), and Glasgow coma scale score (GCS), the three best performers in predicting 28-day mortality from receiver operating characteristic curves, were used to construct the GOL. The higher the GOL score, the higher the incidence of death, MV and AICU within 28 days. Multifactorial logistic regression analysis showed that when the GOL was greater than 1, it was an independent risk factor for 28-day mortality, MV, and AICU. In predicting 28-day mortality, GOL was superior to the quick Sequential Organ Failure Assessment (qSOFA), Mortality in Emergency Department Sepsis Score (MEDS), Systemic Inflammatory Response Syndrome Score (SIRS), and Modified Early Warning Score (MEWS), and was comparable to the Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA).Conclusion: The GOL is a simple, rapid, and accurate method for early identification of patients at increased risk of in-hospital death from sepsis.Keywords: sepsis, GCS, lactic acid, oxygenation index, PaO2/FiO2, prognosis

Background: Oxygenation index [OI = (MAP × FiO2 × 100)/PaO2] assesses the severity of hypoxic respiratory failure. Oxygen saturation index [OSI = (MAP × FiO2 × 100)/SpO2] is a noninvasive method to assesses the severity of hypoxic respiratory failure. Conventionally used PaO2/FiO2 (P/F) ratio to measure the severity of ARDS requires arterial blood gas (ABG) sampling. It tenders limited prognostic information mandating the need for better markers. Oxygenation index (needs arterial sampling) and OSI (a noninvasive method) are substitutes to provide mortality information in ARDS patients. We evaluated the correlation between P/F, OI, and OSI in invasively ventilated COVID-19 ARDS patients (C-ARDS) and looked at its relationship with mortality. Patients and methods: A retrospective study of invasively ventilated C-ARDS >18 years of age managed in COVID ICU. Ventilator settings (FiO2, mean airway pressure), pulse oximetry (SpO2), and ABG values (PaO2) were simultaneously noted at the time of sample collection. Patient outcomes (alive and deceased) were documented. Differences in parameters between survivors and nonsurvivors were assessed using independent sample t-test. Receiver operating characteristic (ROC) analysis with Youden's index was used to identify cutoff values to determine survival. Results: A total of 1557 measurements for 203 patients were collected over the maximum duration of 21 days after ventilation. About 147 (72.4%) were males and 56 (27.6%) were females. On day one of ventilation, 161 (79.3%) had P/F ratio <200, 28 (13.8%) had P/F ratio between 200 and 300, and 14 (6.9%) had P/F ratio >300. There was a linear relationship between P/F ratio and OSI (r = -0.671), P/F and OI (r = -0.753), and OSI and OI (r = 0.893) (p < 0.001). After natural log transform, the correlation between these factors became stronger [P/F ratio and OSI (r = -0.797), PF and OI (r = -0.949), and OSI and OI (r = 0.902) (p < 0.001)]. About 74 (36.5%) patients survived. Survivors had significantly higher P/F ratio as compared with nonsurvivors (p < 0.05). Oxygen saturation index and OI were significantly lower in survivors as compared with nonsurvivors. Based on day-1 reading, a higher OSI (AUC = 0.719, 95% CI = 0.648-0.790) and OI (AUC = 0.752. 95% CI = 0.684-0.819) significantly can predict mortality. On the other hand, a higher P/F ratio can predict survival (AUC = 0.734, 95% CI = 0.664-0.805). P/F ratio of 160 on day 1 can predict survival. Oxygen saturation index values above 10.4% and OI above 13.5% were the cutoff derived for day 1 values to predict mortality. Conclusion: Noninvasive OSI can be used to assess the severity of hypoxic respiratory failure in C-ARDS without arterial access in resource-limited settings. Oxygen saturation index can noninvasively provide prognostic information in invasively ventilated C-ARDS patients. [ABSTRACT FROM AUTHOR]

Individualized positive end-expiratory pressure (PEEP) combined with recruitment maneuvers improves intraoperative oxygenation in individuals undergoing robot-assisted prostatectomy. However, whether electrical impedance tomography (EIT)-guided individualized PEEP without recruitment maneuvers can also improve intraoperative oxygenation is unknown. To test this, fifty-six male patients undergoing elective robot-assisted laparoscopic prostatectomy were randomly assigned to either individualized PEEP (Group PEEPIND, n = 28) or a control with a fixed PEEP of 5 cm H2O (Group PEEP5, n = 28). Individualized PEEP was guided by EIT after placing the patients in the Trendelenburg position and performing intraperitoneal insufflation. Patients in Group PEEPIND maintained individualized PEEP without intermittent recruitment maneuvers, and those in Group PEEP5 maintained a PEEP of 5 cm H2O intraoperatively. Both groups were extubated in a semi-sitting position once the extubation criteria were met. The primary outcome was arterial oxygen partial pressure (PaO2)/inspiratory oxygen fraction (FiO2) prior to extubation. Other outcomes included intraoperative driving pressure, plateau pressure and dynamic, respiratory system compliance, and the incidence of postoperative hypoxemia in the post-operative care unit (PACU). Our results showed that the intraoperative median for PEEPIND was 16 cm H2O (ranging from 12 to 18 cm H2O). EIT-guided PEEPIND was associated with higher PaO2/FiO2 before extubation compared to PEEP5 (71.6 ± 10.7 vs. 56.8 ± 14.1 kPa, p = 0.003). Improved oxygenation extended into the PACU with a lower incidence of postoperative hypoxemia (3.8% vs. 26.9%, p = 0.021). Additionally, PEEPIND was associated with lower driving pressures (12.0 ± 3.0 vs. 15.0 ± 4.4 cm H2O, p = 0.044) and better compliance (44.5 ± 12.8 vs. 33.6 ± 9.1 mL/cm H2O, p = 0.017). Our data indicated that individualized PEEP guided by EIT without intraoperative recruitment maneuvers also improved perioperative oxygenation in patients undergoing robot-assisted laparoscopic radical prostatectomy, which could benefit patients with the risk of intraoperative hemodynamic instability caused by recruitment maneuvers. Trial registration: China Clinical Trial Registration Center Identifier: ChiCTR2100053839. This study was registered on 1 December 2021. The first patient was recruited on 15 December 2021. [ABSTRACT FROM AUTHOR]

Abstract Background To clarify the relationship between the PaO2/FiO2 and 28-day mortality in patients with sepsis. Methods This was a retrospective cohort study regarding MIMIC-IV database. Nineteen thousand two hundred thirty-three patients with sepsis were included in the final analysis. PaO2/FiO2 was exposure variable, 28-day mortality was outcome variable. PaO2/FiO2 was log-transformed as LnPaO2/FiO2. Binary logistic regression was used to explore the independent effects of LnPaO2/FiO2 on 28-day mortality using non-adjusted and multivariate-adjusted models. A generalized additive model (GAM) and smoothed curve fitting was used to investigate the non-linear relationship between LnPaO2/FiO2 and 28-day mortality. A two-piecewise linear model was used to calculate the OR and 95% CI on either side of the inflection point. Results The relationship between LnPaO2/FiO2 and risk of 28-day death in sepsis patients was U-shape. The inflection point of LnPaO2/FiO2 was 5.30 (95%CI: 5.21—5.39), which indicated the inflection point of PaO2/FiO2 was 200.33 mmHg (95%CI: 183.09 mmHg—219.20 mmHg). On the left of inflection point, LnPaO2/FiO2 was negatively correlated with 28-day mortality (OR: 0.37, 95%CI: 0.32—0.43, p

Background: To clarify the relationship between the PaO2/FiO2 and 28-day mortality in patients with sepsis. Methods: This was a retrospective cohort study regarding MIMIC-IV database. Nineteen thousand two hundred thirty-three patients with sepsis were included in the final analysis. PaO2/FiO2 was exposure variable, 28-day mortality was outcome variable. PaO2/FiO2 was log-transformed as LnPaO2/FiO2. Binary logistic regression was used to explore the independent effects of LnPaO2/FiO2 on 28-day mortality using non-adjusted and multivariate-adjusted models. A generalized additive model (GAM) and smoothed curve fitting was used to investigate the non-linear relationship between LnPaO2/FiO2 and 28-day mortality. A two-piecewise linear model was used to calculate the OR and 95% CI on either side of the inflection point. Results: The relationship between LnPaO2/FiO2 and risk of 28-day death in sepsis patients was U-shape. The inflection point of LnPaO2/FiO2 was 5.30 (95%CI: 5.21—5.39), which indicated the inflection point of PaO2/FiO2 was 200.33 mmHg (95%CI: 183.09 mmHg—219.20 mmHg). On the left of inflection point, LnPaO2/FiO2 was negatively correlated with 28-day mortality (OR: 0.37, 95%CI: 0.32—0.43, p < 0.0001). On the right of inflection point, LnPaO2/FiO2 was positively correlated with 28-day mortality in patients with sepsis (OR: 1.53, 95%CI: 1.31—1.80, p < 0.0001). Conclusions: In patients with sepsis, either a high or low PaO2/FiO2 was associated with an increased risk of 28-day mortality. In the range of 183.09 mmHg to 219.20 mmHg, PaO2/FiO2 was associated with a lower risk of 28-day death in patients with sepsis. [ABSTRACT FROM AUTHOR]

Randomized controlled trials comparing tocilizumab and baricitinib in patients with coronavirus disease 2019 (COVID-19) are needed. This was an open-label, randomized controlled trial aiming to address this unmet need. To determine whether baricitinib was non-inferior to tocilizumab, we assessed whether the upper boundary of the two-sided 95% CI of the hazard ratio (HR) did not exceed 1.50. The primary outcome was mechanical ventilation or death by day 28. Secondary outcomes included time to hospital discharge by day 28 and change in WHO progression scale at day 10. We assigned 251 patients with COVID-19 and a PaO 2 / FiO 2 ratio of <200 to receive either tocilizumab (n = 126) or baricitinib (n = 125) plus standard of care. Baricitinib was non-inferior to tocilizumab for the primary composite outcome of mechanical ventilation or death by day 28 (mechanical ventilation or death for patients who received baricitinib, 39.2% [ n = 49/125]; mechanical ventilation or death for patients who received tocilizumab, 44.4% [ n = 56/126]; HR, 0.83; 95% CI, 0.56–1.21; p 0.001 for non-inferiority). Baricitinib was non-inferior to tocilizumab for the time to hospital discharge within 28 days (patients who received baricitinib- discharged alive: 58.4% [ n = 73/125] vs. patients who received tocilizumab- discharged alive: 52.4% [ n = 66/126]; HR, 0.85; 95% CI, 0.61–1.18; p < 0.001 for non-inferiority). There was no significant difference between the baricitinib and tocilizumab arms in the change in WHO scale at day 10 (0.0 [95% CI, 0.0–0.0] vs. 0.0 [95% CI, 0.0–1.0]; p 0.83). In the setting of this trial, baricitinib was non-inferior to tocilizumab with regards to the composite outcome of mechanical ventilation or death by day 28 and the time to discharge by day 28 in patients with severe COVID-19. [ABSTRACT FROM AUTHOR]

Background: During the SARS-CoV-2 pandemic, several biomarkers were shown to be helpful in determining the prognosis of COVID-19 patients. The aim of our study was to evaluate the prognostic value of N-terminal pro-Brain Natriuretic Peptide (NT-pro-BNP) in a cohort of patients with COVID-19. Methods: One-hundred and seven patients admitted to the Covid Hospital of Messina University between June 2022 and January 2023 were enrolled in our study. The demographic, clinical, biochemical, instrumental, and therapeutic parameters were recorded. The primary outcome was in-hospital mortality. A comparison between patients who recovered and were discharged and those who died during the hospitalization was performed. The independent parameters associated with in-hospital death were assessed by multivariable analysis and a stepwise regression logistic model. Results: A total of 27 events with an in-hospital mortality rate of 25.2% occurred during our study. Those who died during hospitalization were older, with lower GCS and PaO2/FiO2 ratio, elevated D-dimer values, INR, creatinine values and shorter PT (prothrombin time). They had an increased frequency of diagnosis of heart failure (p < 0.0001) and higher NT-pro-BNP values. A multivariate logistic regression analysis showed that higher NT-pro-BNP values and lower PT and PaO2/FiO2 at admission were independent predictors of mortality during hospitalization. Conclusions: This study shows that NT-pro-BNP levels, PT, and PaO2/FiO2 ratio are independently associated with in-hospital mortality in subjects with COVID-19 pneumonia. Further longitudinal studies are warranted to confirm the results of this study. [ABSTRACT FROM AUTHOR]

Individualized positive end-expiratory pressure (PEEP) combined with recruitment maneuvers improves intraoperative oxygenation in individuals undergoing robot-assisted prostatectomy. However, whether electrical impedance tomography (EIT)-guided individualized PEEP without recruitment maneuvers can also improve intraoperative oxygenation is unknown. To test this, fifty-six male patients undergoing elective robot-assisted laparoscopic prostatectomy were randomly assigned to either individualized PEEP (Group PEEPIND, n = 28) or a control with a fixed PEEP of 5 cm H2O (Group PEEP5, n = 28). Individualized PEEP was guided by EIT after placing the patients in the Trendelenburg position and performing intraperitoneal insufflation. Patients in Group PEEPIND maintained individualized PEEP without intermittent recruitment maneuvers, and those in Group PEEP5 maintained a PEEP of 5 cm H2O intraoperatively. Both groups were extubated in a semi-sitting position once the extubation criteria were met. The primary outcome was arterial oxygen partial pressure (PaO2)/inspiratory oxygen fraction (FiO2) prior to extubation. Other outcomes included intraoperative driving pressure, plateau pressure and dynamic, respiratory system compliance, and the incidence of postoperative hypoxemia in the post-operative care unit (PACU). Our results showed that the intraoperative median for PEEPIND was 16 cm H2O (ranging from 12 to 18 cm H2O). EIT-guided PEEPIND was associated with higher PaO2/FiO2 before extubation compared to PEEP5 (71.6 ± 10.7 vs. 56.8 ± 14.1 kPa, p = 0.003). Improved oxygenation extended into the PACU with a lower incidence of postoperative hypoxemia (3.8% vs. 26.9%, p = 0.021). Additionally, PEEPIND was associated with lower driving pressures (12.0 ± 3.0 vs. 15.0 ± 4.4 cm H2O, p = 0.044) and better compliance (44.5 ± 12.8 vs. 33.6 ± 9.1 mL/cm H2O, p = 0.017). Our data indicated that individualized PEEP guided by EIT without intraoperative recruitment maneuvers also improved perioperative oxygenation in patients undergoing robot-assisted laparoscopic radical prostatectomy, which could benefit patients with the risk of intraoperative hemodynamic instability caused by recruitment maneuvers. Trial registration: China Clinical Trial Registration Center Identifier: ChiCTR2100053839. This study was registered on 1 December 2021. The first patient was recruited on 15 December 2021.

Abstract Background Data on the safety and efficacy profile of tocilizumab in patients with severe COVID-19 needs to be enriched. Methods In this open label, prospective study, we evaluated clinical outcomes in consecutive patients with COVID-19 and PaO2/FiO2

To compare the changes in thoracic fluid content, PaO 2 /F I O 2 ratio, plateau pressure, compliance, and postoperative ventilation duration in off-pump coronary artery bypass grafting (OPCAB) and on-pump coronary artery bypass grafting (ONCAB). Prospective observational study. Tertiary-care cardiac center. Over an 18-month period, from December 2019 to May 2021, 111 patients who underwent CAB grafting were enrolled. Group I constituted OPCAB patients and Group II the ONCAB patients. After induction, the authors measured thoracic fluid content (TFC), pulmonary compliance, airway pressures, and the PaO 2 /F I O 2 ratio before skin incision (T 1) and after skin closure (T 2). The input, output, as well as the duration of postoperative ventilation, also were recorded. At T 2 , the ONCAB group had a significantly higher change in TFC than the OPCAB group (5.4 ± 1.86 kOhm−1 v 4.32 ± 1.84 kOhm−1, p = 0.012). The fluid balance was significantly higher in the OPCAB group compared with the ONCAB group (2,159.21 ± 108.73 mL v 1,792.50 ± 151.88 mL, p = 0.0001). The decrease in PaO 2 /F I O 2 ratio was significantly lower in the OPCAB group compared with the ONCAB group (–71.34 ± 23.42 v –123.65 ± 36.81, p = 0.000). The increase in plateau pressure, decrease in compliance, and postoperative ventilation period were significantly higher in the patients who underwent ONCAB than the patients who underwent OPCAB (p < 0.05). The change in TFC was greater in the ONCAB group, despite the fact that the fluid balance was higher in the OPCAB group. A higher TFC in ONCAB led to lower PaO 2 /F I O 2 ratio, lower compliance, higher plateau pressures, and longer postoperative ventilation. [ABSTRACT FROM AUTHOR]

ObjectiveThe aim of this study was to test the hypothesis whether serum level of calpains could become a meaningful biomarker for diagnosis of acute lung injury (ALI) in clinical after cardiac surgery using cardiopulmonary bypass (CPB) technology.Methods and resultsSeventy consecutive adults underwent cardiac surgery with CPB were included in this prospective study. Based on the American-European Consensus Criteria (AECC), these patients were divided into ALI (n = 20, 28.57%) and non-ALI (n = 50, 71.43%) groups. Serum level of calpains in terms of calpains’ activity which was expressed as relative fluorescence unit (RFU) per microliter and measured at beginning of CPB (baseline), 1 h during CPB, end of CPB as well as 1, 12, and 24 h after CPB. Difference of serum level of calpains between two groups first appeared at the end of CPB and remained different at subsequent test points. Univariate and multivariate logistic regression analysis indicated that serum level of calpains 1 h after CPB was an independent predictor for postoperative ALI (OR 1.011, 95% CI 1.001, 1.021, p = 0.033) and correlated with a lower PaO2/FiO2 ratio in the first 2 days (The first day: r = -0.389, p < 0.001 and the second day: r = -0.320, p = 0.007) as well as longer mechanical ventilation time (r = 0.440, p < 0.001), intensive care unit (ICU) length of stay (LOS) (r = 0.419, p < 0.001) and hospital LOS (r = 0.297, p = 0.013).ConclusionElevated serum level of calpains correlate with impaired lung function and poor clinical outcomes, indicating serum level of calpains could act as a potential biomarker for postoperative ALI following CPB in adults.Clinical trial registration[https://clinicaltrials.gov/show/NCT05610475], identifier [NCT05610475].

Abstract The ratio between arterial blood partial pressure of oxygen and fraction of inspired oxygen (PaO2/FiO2) was largely used for grading and managing the respiratory failure in non-mechanically ventilated COVID-19. In these patients, the assessment of the true FiO2 in the inspired mixture may be difficult with consequent inaccuracies in PaO2/FiO2 assessment. In 30 severe COVID-19 patients, we observed that PaO2/FiO2 values measured immediately before and after the transition from high-flow nasal cannula (HFNC) to one commercially available Venturi mask O2 therapy were similar (bias mean value 0, standard deviation 23 mmHg). In COVID-19 patients recovering from respiratory failure, PaO2/FiO2 is not different whether measured with a commercially available Venturi mask or HFNC.

Objectives: Prone positioning is widely used in mechanically ventilated patients with COVID-19; however, the specific clinical scenario in which the individual is most poised to benefit is not fully established. In patients with COVID-19 respiratory failure requiring mechanical ventilation, how effective is prone positioning in improving oxygenation and can that response be predicted? Design: This is a retrospective observational study from two tertiary care centers including consecutive patients mechanically ventilated for COVID-19 from 3/1/2020 - 7/1/2021. The primary outcome is improvement in oxygenation as measured by PaO2/FiO2. We describe oxygenation before, during and after prone episodes with a focus on identifying patient, respiratory or ventilator variables that predict prone positioning success. Setting: 2 Tertiary Care Academic Hospitals. Patients: 125 patients mechanically ventilated for COVID-19 respiratory failure. Interventions: Prone positioning Main Results: One hundred twenty-five patients underwent prone positioning a total of 309 times for a median duration of 23 hours IQR (14 - 49). On average, PaO2/FiO2 improved 19%: from 115 mmHg (80 - 148) immediately before proning to 137 mm Hg (95 - 197) immediately after returning to the supine position. Prone episodes were more successful if the pre-prone PaO2/FiO2 was lower and if the patient was on inhaled epoprostenol (iEpo). For individuals with severe acute respiratory distress syndrome (ARDS) (PaO2/FiO2 < 100 prior to prone positioning) and on iEpo, the median improvement in PaO2/FiO2 was 27% in both instances. Conclusions: Prone positioning in mechanically ventilated patients with COVID-19 is generally associated with sustained improvements in oxygenation, which is made more likely by the concomitant use of iEpo and is more impactful in those who are more severely hypoxemic prior to prone positioning. [ABSTRACT FROM AUTHOR]

Background: During the SARS-CoV-2 pandemic, several biomarkers were shown to be helpful in determining the prognosis of COVID-19 patients. The aim of our study was to evaluate the prognostic value of N-terminal pro-Brain Natriuretic Peptide (NT-pro-BNP) in a cohort of patients with COVID-19. Methods: One-hundred and seven patients admitted to the Covid Hospital of Messina University between June 2022 and January 2023 were enrolled in our study. The demographic, clinical, biochemical, instrumental, and therapeutic parameters were recorded. The primary outcome was in-hospital mortality. A comparison between patients who recovered and were discharged and those who died during the hospitalization was performed. The independent parameters associated with in-hospital death were assessed by multivariable analysis and a stepwise regression logistic model. Results: A total of 27 events with an in-hospital mortality rate of 25.2% occurred during our study. Those who died during hospitalization were older, with lower GCS and PaO2/FiO2 ratio, elevated D-dimer values, INR, creatinine values and shorter PT (prothrombin time). They had an increased frequency of diagnosis of heart failure (p < 0.0001) and higher NT-pro-BNP values. A multivariate logistic regression analysis showed that higher NT-pro-BNP values and lower PT and PaO2/FiO2 at admission were independent predictors of mortality during hospitalization. Conclusions: This study shows that NT-pro-BNP levels, PT, and PaO2/FiO2 ratio are independently associated with in-hospital mortality in subjects with COVID-19 pneumonia. Further longitudinal studies are warranted to confirm the results of this study.

Severe COVID-19 has high mortality because cytokin storm will causes Neutrophil Extracellular Trap (NET) and thrombocyte activation. NET could damage alveolar tissue. Biomarker of NET is Citrullinated Histon H3 (Cit-H3). Thrombocyte activation can be depicted by thrombocyte index which are: trombocyte count, MPV, PDW, PCT and P-LCR. This research will analyze correlation cit-H3 and thrombocyte index with PaO2/FiO2 ratio and as mortality predictor in COVID-19 patient. This research is cross sectional in RSUD Dr. Soetomo from June 2020 - June 2021. Subject was adult patient confirmed PCR COVID-19. Blood sampling obtained first and third day of hospitalization. Measurement of Cit-H3 with competitive ELISA. Thrombocyte index on admission and PaO2/FiO2 ratio on admission and third day obtained from medical record. ROC analyses were done for cutoff point of thrombocyte index and CitH3 as mortality predictor. 37 subjects consisted of 19 death patient and 18 survive. Spearman correlation between PDW and PaO2/FiO2 on admission is significant with rs= -0.292 (p<0.05). Correlation CitH3 with PaO2/FiO2 is not significant. P-LCR is significantly higher in death group with cutoff >27% (AUC 0.697; sensitivity 78.9%; specificity 55.6%). Cit-H3 serum significantly higher in death group on admission day and third day. Cit-H3 increases significantly on third day in death group. Cutoff Ci-tH3 as predictor mortality on admission day:10.65 ng/mL (AUC 0.703; sensitivity 84.2%; specificity 55.6%); third day: 12.45 ng/mL (AUC 0.716; sensitivity 89.5%; spesificity 50%). Significant negative correlation between PDW and PaO2/FiO2. P-LCR, Cit-H3 could be used as mortality predictor in COVID-19. [ABSTRACT FROM AUTHOR]

Background: Data on the safety and efficacy profile of tocilizumab in patients with severe COVID-19 needs to be enriched.Methods: In this open label, prospective study, we evaluated clinical outcomes in consecutive patients with COVID-19 and PaO2/FiO2 < 200 receiving tocilizumab plus usual care versus usual care alone. Tocilizumab was administered at the time point that PaO2/FiO2 < 200 was observed. The primary outcome was 28-day mortality. Secondary outcomes included time to discharge, change in PaO2/FiO2 at day 5 and change in WHO progression scale at day 10.Findings: Overall, 114 patients were included in the analysis (tocilizumab plus usual care: 56, usual care: 58). Allocation to usual care was associated with significant increase in 28-day mortality compared to tocilizumab plus usual care [Cox proportional-hazards model: HR: 3.34, (95% CI: 1.21-9.30), (p = 0.02)]. There was not a statistically significant difference with regards to hospital discharge over the 28 day period for patients receiving tocilizumab compared to usual care [11.0 days (95% CI: 9.0 to 16.0) vs 14.0 days (95% CI: 10.0-24.0), HR: 1.32 (95% CI: 0.84-2.08), p = 0.21]. ΔPaO2/FiO2 at day 5 was significantly higher in the tocilizumab group compared to the usual care group [42.0 (95% CI: 23.0-84.7) vs 15.8 (95% CI: - 19.4-50.3), p = 0.03]. ΔWHO scale at day 10 was significantly lower in the tocilizumab group compared to the usual care group (-0.5 ± 2.1 vs 0.6 ± 2.6, p = 0.005).Conclusion: Administration of tocilizumab, at the time point that PaO2/FiO2 < 200 was observed, improved survival and other clinical outcomes in hospitalized patients with severe COVID-19 irrespective of systemic inflammatory markers levels. [ABSTRACT FROM AUTHOR]

Up to fifteen percent of patients with novel pandemic coronavirus disease (Covid-19) have acute respiratory failure (ARF). Ratio between arterial partial pressure of oxygen (PaO2) and fraction of inspired oxygen (FiO2), P/F, is currently used as a marker of ARF severity in Covid-19. P/F does not reflect the respiratory efforts made by patients to maintain arterial blood oxygenation, such as tachypnea and hyperpnea, leading to hypocapnia. Standard PaO2, the value of PaO2 adjusted for arterial partial pressure of carbon dioxide (PaCO2) of the subject, better reflects the pathophysiology of hypoxemic ARF. We hypothesized that the ratio between standard PaO2 over FiO2 (STP/F) better predicts Covid-19 ARF severity compared to P/F. Aim of this pilot prospectic observational study was to observe differences between STP/F and P/F in predicting outcome failure, defined as need of invasive mechanical ventilation and/or deaths in Covid-19 ARF. Accuracy was calculated using Receiver Operating Characteristics (ROC) analysis and areas under the ROC curve (AUROC) were compared. 349 consecutive subjects admitted to our respiratory wards due to Covid-19 ARF were enrolled. STP/F was accurate to predict mortality and superior to P/F with, respectively, AUROC 0.710 versus 0.688, p = 0.012.Both STP/F and PF were accurate to predict outcome failure (AUROC respectively of 0.747 and 0.742, p = 0.590). This is the first study assessing the role of STP/F in describing severity of ARF in Covid-19. According to results, STP/F is accurate and superior to P/F in predicting in-hospital mortality. [ABSTRACT FROM AUTHOR]

Few data are available regarding follow up of patients with coronavirus disease 2019 (COVID-19) after their discharge. We aim to describe the long-term outcomes of survivors of hospitalization for COVID-19 followed up first at an outpatient facility and subsequently by telephone. Observational prospective study conducted at a tertiary general hospital. Clinical and radiological progression was assessed and data were recorded on a standardized reporting form. Patients were divided into three groups according to Pa o 2 /Fi o 2 at hospitalization: Pa o 2 /Fi o 2 >300, Pa o 2 /Fi o 2 300–200 and Pa o 2 /Fi o 2 <200. A logistic multivariate regression model was performed to identify factors associated with persistence of symptoms. For facility follow up, 302 individuals were enrolled. Median follow up was 45 days after discharge; 78% (228/294) of patients had COVID-19-related symptoms (53% asthenia, 56% respiratory symptoms) and 40% (122/302) had residual pulmonary radiographic lesions. Pa o 2 /Fi o 2 <200 was an independent predictor of persistent dyspnoea (OR 1.87, 95% CI 1.38–2.52, p < 0.0001). Pa o 2 /Fi o 2 >300 was associated with resolution of chest radiographic lesions (OR 0.56, 95% CI 0.42–0.74, p < 0.0001). Fifty per cent of patients required specific medical follow up after the first consultation and were transferred to another physician. A total of 294 patients were contacted for telephone follow up after a median follow-up time of 7 months. Fifty per cent of patients (147/294) still presented symptoms and 49% (145/294) had psychological disorders. Asthenia was identified in 27% (78/294) and dyspnoea in 10% (28/294) of patients independently of Pa o 2 /Fi o 2. Patients with COVID-19 require long-term follow up because of the persistence of symptoms; patients with low Pa o 2 /Fi o 2 during the acute illness require special attention. [Display omitted] [ABSTRACT FROM AUTHOR]

Abstract Background Although low tidal volume is strongly recommended for acute respiratory distress syndrome (ARDS), whether or not the benefit varies according to the severity of ARDS remains unclear. This study aimed to investigate whether or not there is an interaction between low tidal volume and severity of ARDS. Methods This was a secondary analysis from a randomized controlled trial. The patients were subgrouped according to whether the PaO2/FiO2 (P/F) was > 150 or ≤ 150 mmHg on day 0. The interaction between a tidal volume of 6 mL/kg and the P/F was investigated in hierarchical chi-square analysis and logistic regression models. Results Eight hundred and thirty-six patients with ARDS were enrolled (345 in the high P/F subgroup [> 150 mmHg] and 491 in the low P/F subgroup [≤ 150 mmHg]). Compared to the traditional tidal volume group, the mortality of patients with low tidal volume was significantly lower in the high P/F subgroup (41/183 (22.4%) vs. 64/162 (39.5%), p = 0.001) but not in the low P/F subgroup (95/256 (37.1%) vs. 96/235 (40.8%), p = 0.414). In the hierarchical chi-square analysis, the test of homogeneity was significant (risk ratio of mortality 0.56 [0.40–0.79] vs. 0.91 [0.73–1.13], p = 0.018). In the multivariable logistic model, the odds ratio of mortality for the interacted item was significant (2.02, 95% confidence interval [CI] 1.06–3.86, p = 0.033). The odds ratio of mortality for low tidal volume was significant in the high P/F subgroup (0.42, 95% CI 0.24–0.72, p = 0.002) but not in the low P/F subgroup (0.89, 95% CI 0.60–1.31, p = 0.554). Conclusions The benefits of low tidal volume ventilation remain uncertain in patients with severe ARDS. Further studies are needed to validate this significant interaction.

Abstract Context End-tidal carbon dioxide (EtCO2) is used as a noninvasive bedside test to assess the adequacy of ventilation and physiologic dead space in mechanically ventilated patients. The gradient difference between EtCO2 and partial pressure of arterial carbon dioxide (PaCO2) is directly related to an increase in the physiologic dead space. Aim The aim of this study was to evaluate the role of measuring the gradient between EtCO2 and PaCO2 in adults with acute respiratory distress (ARDS). Settings and design This was a prospective consecutive enrollment study. Patients and methods Overall, 51 cases were recruited after the diagnosis of ARDS was made according to the Berlin definition. Patients were mechanically ventilated as per the lung-protective protocol. Daily arterial blood gases were collected and for every sample, the EtCO2 value was collected electronically by capnography using an endotracheal tube for the first 5 days. Results Cases were classified into survivors and nonsurvivors: 26 cases were because of extrapulmonary causes and 25 cases were because of pulmonary causes. The mean value of the APACHE II score for all cases on admission was 21.6. The mean length of ICU stay was 12.7 days. For all study cases, PaO2/FiO2 was the lowest at day 1 and the highest at day 5. We found a significant negative correlation between PaO2/FiO2 and the gradient at days 2, 4, and day 5, and a significant positive correlation between the gradient on admission and the APACHE II score (r=0.4, P≤0.05). Nonsurvivors had a significantly higher gradient and lower EtCO2 and PaO2/FiO2 levels at all time intervals, whereas PaCO2 alone was found to be nonsignificant. Conclusion In ARDS, EtCO2 and gradient are reliable indicators of severity.

Abstract Introduction Surfactant is usually deficiency in adult acute respiratory distress syndrome(ARDS) patients and surfactant administration may be a useful therapy. The aim of this study was to perform a meta-analysis of the effect of surfactant administration on outcomes of adult patients with acute respiratory distress syndrome. Methods PubMed, EMBASE, Medline, Cochrane database, Elsevier, Web of Science and http://clinicaltrials.gov were searched and investigated until December 2017. Randomized controlled trials(RCTs) comparing surfactant administration with general therapy in adult patients with ARDS were enrolled. The primary outcome was mortality (7–10-day, 28–30-day and 90–180-day). Secondary outcome included oxygenation (PaO2/FiO2 ratio). Demographic variables, surfactant administration, and outcomes were retrieved. Sensitivity analyses were used to evaluate the impact of study quality issues on the overall effect. Funnel plot inspection, Egger’s and Begger’s test were applied to investigate the publication bias. Internal validity was assessed with the risk of bias tool. Random errors were evaluated with trial sequential analysis(TSA). Quality levels were assessed by Grading of Recommendations Assessment, Development, and Evaluation methodology(GRADE). Results Eleven RCTs with 3038 patients were identified. Surfactant administration could not improve mortality of adult patients [Risk ratio (RR) (95%CI)) = 1.02(0.93–1.12), p = 0.65]. Subgroup analysis revealed no difference of 7–10-day mortality [RR(95%CI)) = 0.89(0.54–1.49), p = 0.66], 28–30-day mortality[RR(95%CI) = 1.00(0.89–1.12), p = 0.98] and 90–180-day mortality [RR(95%CI) = 1.11(0.94–1.32), p = 0.22] between surfactant group and control group. The change of the PaO2/FiO2 ratio in adult ARDS patients had no difference [MD(95%CI) = 0.06(− 0.12–0.24), p = 0.5] after surfactant administration. Finally, TSA and GRADE indicated lack of firm evidence for a beneficial effect. Conclusions Surfactant administration has not been shown to improve mortality and improve oxygenation for adult ARDS patients. Large rigorous randomized trials are needed to explore the effect of surfactant to adult ARDS patients.

Rationale: Clinicians commonly use short-term physiologic markers to assess the benefit of ventilator adjustments. Improved arterial oxygen tension/pressure (PaO2)/fraction of inspired oxygen (FiO2) after ventilator adjustment in acute respiratory distress syndrome is associated with lower mortality. However, as driving pressure (ΔP) reflects lung stress and strain, changes in ΔP may more accurately reflect benefits or harms of ventilator adjustments compared with changes in oxygenation.Objectives: We aimed to compare the association between mortality and the changes in PaO2/FiO2 and ΔP following protocolized ventilator changes.Methods: We assessed associations between mortality and changes in PaO2/FiO2 (ΔPaO2/FiO2) and ΔP (ΔΔP) after postrandomization positive end-expiratory pressure (PEEP) and tidal volume adjustment in reanalyses of the ALVEOLI (Assessment of Low Tidal Volume and Elevated End-Expiratory Volume to Obviate Lung Injury) and ExPress (Expiratory Pressure) trials. We included subjects with available pre- and postintervention PaO2/FiO2 and ΔP (372 in ALVEOLI and 596 in ExPress). In each separate trial cohort, we performed multivariable Cox regression testing the association between ΔPaO2/FiO2 and ΔΔP with mortality.Results: In ALVEOLI, when analyzed as separate variables, ΔPaO2/FiO2 was associated with mortality only in subjects in whom PEEP increased, whereas ΔΔP was associated with mortality irrespective of direction of PEEP change. When modeled together, improved ΔPaO2/FiO2 was not associated with mortality, whereas ΔΔP remained associated with mortality (adjusted hazard ratio [aHR], 1.50 per 5 cm H2O increase; 95% confidence interval [95% CI], 1.21-1.85). When modeled together in ExPress, ΔΔP (aHR, 1.42; 95% CI, 1.14-1.78) was more strongly associated with mortality than ΔPaO2/FiO2 (aHR, 0.95 per 25 mm Hg increase; 95% CI, 0.90-1.00).Conclusions: Reduced ΔP following protocolized ventilator changes was more strongly and consistently associated with lower mortality than was increased PaO2/FiO2, making ΔΔP more informative about benefit from ventilator adjustments. Our results reinforce the primacy of ΔP, rather than oxygenation, as the key variable associated with outcome. [ABSTRACT FROM AUTHOR]

Background: Outcome prediction in patients with acute respiratory distress syndrome (ARDS) greatly improves when patients are reclassified based on predefined arterial oxygen partial pressure to fractional inspired oxygen ratios (PaO2/FiO2) and positive end–expiratory pressure (PEEP) cutoffs 24 h after the initial ARDS diagnosis. The aim of this study was to test whether outcome prediction improves when patients are reclassified based on predefined PaO2/FiO2 and PEEP cutoffs 24 h after development of mild hypoxemia while not having ARDS. Methods: Post hoc analysis of a large prospective, multicenter, observational study that ran in the ICUs of two academic hospitals in the Netherlands between January 2011 and December 2013. Patients were classified into four groups using predefined cutoffs for PaO2/FiO2 (250 mmHg) and PEEP (5 cm H2O), both at onset of hypoxemia and after 24 h: PaO2/FiO2 ≥ 250 mmHg and PEEP < 6 cm H2O (group I), PaO2/FiO2 ≥ 250 mmHg and PEEP ≥ 6 cm H2O (group II), PaO2/FiO2 < 250 mmHg and PEEP < 6 cm H2O (group III), and PaO2/FiO2 < 250 mmHg and PEEP ≥ 6 cm H2O (group IV), to look for trend association with all-cause in-hospital mortality, the primary outcome. Secondary outcome were ICU- and 90-day mortality, and the number of ventilator-free days or ICU-free days and alive at day 28. Results: The analysis included 689 consecutive patients. All-cause in-hospital mortality was 35%. There was minimal variation in mortality between the four groups at onset of hypoxemia (33, 36, 38, and 34% in groups I to IV, respectively; P = 0.65). Reclassification after 24 h resulted in a strong trend with increasing mortality from group I to group IV (31, 31, 37, and 48% in groups I to IV, respectively; P < 0.01). Similar trends were found for the secondary endpoints. Conclusions: Reclassification using PaO2/FiO2 and PEEP cutoffs after 24 h improved classification for outcome in invasively ventilated ICU patients with hypoxemia not explained by ARDS, compared to classification at onset of hypoxemia. Trial registration: ClinicalTrials.gov identifier: NCT01905033. Registered on July 11, 2013. Retrospectively registered. [ABSTRACT FROM AUTHOR]

Background: Myocardial involvement in the course of coronavirus disease 2019 (COVID-19) pneumonia has been reported, though not fully characterized yet. The aim of the present study is to undertake a joint evaluation of hs-Troponin and natriuretic peptides (NP) in patients hospitalized for COVID-19 pneumonia. Methods: In this multicenter observational study, we analyzed data from n = 111 patients. Cardiac biomarkers subgroups were identified according to values beyond reference range. Results: Increased hs-Troponin and NP were found in 38 and 56% of the cases, respectively. As compared to those with normal cardiac biomarkers, these patients were older, had higher prevalence of cardiovascular diseases (CVD) and had more severe COVID-19 pneumonia by higher CRP and d-dimer and lower PaO2/FIO2. Two-dimensional echocardiography performed in a subset of patients (n = 24) showed significantly reduced left ventricular ejection fraction in patients with elevated NP (p = 0.02), whereas right ventricular systolic function (tricuspid annular plane systolic excursion) was significantly reduced both in patients with high hs-Troponin and NP (p = 0.022 and p = 0.03, respectively). Both hs-Troponin and NP were higher in patients with in-hospital mortality (p = 0.001 and p = 0.002, respectively). On multivariable analysis, independent associations were found of hs-Troponin with age, PaO2/FIO2 and d-dimer (B = 0.419, p = 0.001; B = − 0.212, p = 0.013; and B = 0.179, p = 0.037, respectively) and of NP with age and previous CVD (B = 0.480, p < 0.001; and B = 0.253, p = 0.001, respectively). Conclusions: Myocardial involvement at admission is common in COVID-19 pneumonia. Independent associations of hs-Troponin with markers of disease severity and of NP with underlying CVD might point toward existing different mechanisms leading to their elevation in this setting. [ABSTRACT FROM AUTHOR]

Objective: To investigate clinical efficacy and safety of convalescent plasma (CP) therapy in coronavirus disease 2019 (COVID-19) patients. Methods: We included 4 severe patients and 3 critical patients. The date of admission to hospital ranged from January 30 to February 19, 2020. We retrospectively collected clinical and outcome data. Relative parameters were compared. Results: After CP therapy, the symptoms and respiratory functions were improved. Median PaO2/FIO2 increased from 254 (142-331) to 326 (163–364), and dependence of oxygen supply decreased. Median time to lesion's first absorption was 5 (2–7) days, undetectable viral RNA was 11 (3.5–15.7) days. Median lymphocyte count (0.77 × 109/L vs 0.85 × 109/L) and albumin level (31g/L vs 36 g/L) were elevated, C-reactive protein (44 mg/L vs 18 mg/L), D-dimer (5.9 mg/L vs 4 mg/L) and lactate dehydrogenase (263 U/L vs 245 U/L) decreased. No obvious adverse reactions were observed. At the follow-up on June 14, 2020, 6 patients had completely recovered and one died from terminal disease. Conclusion: CP therapy for COVID-19 was effective and safe. Three patients who did not combine with antiviral therapy after CP also obtained viral clearance and clinical improvement. However, CP therapy failed to save the life of a terminally ill patient. [ABSTRACT FROM AUTHOR]

We aimed to observe and investigate the clinical significance of vascular endothelium growth factor (VEGF) levels in exhaled breath condensate (EBC) from patients with acute respiratory distress syndrome (ARDS). An improved EcoScreen condenser was used to collect EBC from 31 ARDS patients on mechanical ventilation and from 22 healthy subjects. Serum and EBC VEGF levels were analyzed with ELISA. VEGF levels in the EBC of patients with different grades of lung injuries were analyzed. The correlation between VEGF levels and clinical indicators was analyzed. Serum and EBC VEGF levels were linearly and positively correlated with a correlation coefficient of 0.694 (P< 0.01). The VEGF level in the EBC of ARDS patients was significantly lower than that in the control group (P< 0.01). The VEGF level in the EBC of the mild ARDS group was higher than that in the moderate-severe ARDS group (P< 0.01). The VEGF level in the EBC of the survival group was higher than that in the mortality group. The VEGF level in the EBC of ARDS patients was positively correlated with PaO2/FiO2 and PaO2 and was negatively correlated with lung injury score (LIS) and A-aDO2/PaO2. The changes in VEGF levels in the EBC of ARDS patients can reflect the severity of lung injury. Therefore, VEGF level in EBC can be used as an auxiliary index for judging the severity and prognosis of ARDS patients. [ABSTRACT FROM AUTHOR]

End-stage kidney disease has a high prevalence in patients undergone Coronary Artery Bypass Grafting (CABG) and could cause a wide spectrum of morbidities, due to deep water and electrolyte or acid-base impairments. The aim of this study was to assess the effect of low Creatinine Clearances (ClCr) on arterial oxygenation defect, as common post-CABG morbidity. The study was conducted as a prospective cohort, the pure on pump CABG patients were grouped based on their preoperative ClCr to groups A (ClCr≥60) and B (ClCr

Introduction: Surfactant is usually deficiency in adult acute respiratory distress syndrome(ARDS) patients and surfactant administration may be a useful therapy. The aim of this study was to perform a meta-analysis of the effect of surfactant administration on outcomes of adult patients with acute respiratory distress syndrome.Methods: PubMed, EMBASE, Medline, Cochrane database, Elsevier, Web of Science and http://clinicaltrials.gov were searched and investigated until December 2017. Randomized controlled trials(RCTs) comparing surfactant administration with general therapy in adult patients with ARDS were enrolled. The primary outcome was mortality (7-10-day, 28-30-day and 90-180-day). Secondary outcome included oxygenation (PaO2/FiO2 ratio). Demographic variables, surfactant administration, and outcomes were retrieved. Sensitivity analyses were used to evaluate the impact of study quality issues on the overall effect. Funnel plot inspection, Egger's and Begger's test were applied to investigate the publication bias. Internal validity was assessed with the risk of bias tool. Random errors were evaluated with trial sequential analysis(TSA). Quality levels were assessed by Grading of Recommendations Assessment, Development, and Evaluation methodology(GRADE).Results: Eleven RCTs with 3038 patients were identified. Surfactant administration could not improve mortality of adult patients [Risk ratio (RR) (95%CI)) = 1.02(0.93-1.12), p = 0.65]. Subgroup analysis revealed no difference of 7-10-day mortality [RR(95%CI)) = 0.89(0.54-1.49), p = 0.66], 28-30-day mortality[RR(95%CI) = 1.00(0.89-1.12), p = 0.98] and 90-180-day mortality [RR(95%CI) = 1.11(0.94-1.32), p = 0.22] between surfactant group and control group. The change of the PaO2/FiO2 ratio in adult ARDS patients had no difference [MD(95%CI) = 0.06(- 0.12-0.24), p = 0.5] after surfactant administration. Finally, TSA and GRADE indicated lack of firm evidence for a beneficial effect.Conclusions: Surfactant administration has not been shown to improve mortality and improve oxygenation for adult ARDS patients. Large rigorous randomized trials are needed to explore the effect of surfactant to adult ARDS patients. [ABSTRACT FROM AUTHOR]

End-stage kidney disease has a high prevalence in patients undergone Coronary Artery Bypass Grafting (CABG) and could cause a wide spectrum of morbidities, due to deep water and electrolyte or acidbase impairments. The aim of this study was to assess the effect of low Creatinine Clearances (ClCr) on arterial oxygenation defect, as common post-CABG morbidity. The study was conducted as a prospective cohort, the pure on pump CABG patients were grouped based on their preoperative ClCr to groups A (ClCr=60) and B (ClCr<60). Postoperatively, the PaO2/FiO2 values in 1 hour after ICU admission and 4 hours after extubation, intubation time duration, duration of ICU stay and high concentration oxygen demand were compared. Among 229 patients who remain in the study, 121 were in group A, and 108 in B group. Except for age, weight, height, BMI, and pump time, other demographic and independent variables were similar between two groups. The higher values of PaO2/FiO2 and PaO2, 1 hour after ICU admission and 4 hours after extubation in group B, were not statistically significant, while SpO2 value, 1 hour after ICU admission was higher in group B (98.19±1.37) in compare with group A (97.78±1.57) (P=0.040). Intubation time duration (10.85 in A vs. 12.79 in B; P=0.306), duration of ICU stay (39.04 in A vs. 43.09 in B; P=0.114) and high concentration oxygen demand (2.5% in A vs. 3.8% in B; P=0.089) were similar between groups of study. Lower Preoperative ClCr values do not deteriorate post-CABG arterial oxygenation. [ABSTRACT FROM AUTHOR]

Competing Interests: The authors have disclosed no conflicts of interest.

Objective: To evaluate the impact of continuous positive airway pressure during cardiac surgery on post-operative pulmonary dysfunction after coronary artery bypass grafting. Methodology: This randomized control trial was conducted in Chaudhry Pervaiz Ellahi Institute of Cardiology, Multan from January 2016 to July 2016. All patients meeting the inclusion criteria who were planned to undergo CABG surgery using cardiopulmonary bypass were selected. Patients were randomly allocated into two groups. Group I: (CPAP group): in this group continuous positive airway pressure was continued after application of aortic cross clamp during surgery. Group II (Study group): in this group ventilation was kept stopped during the whole surgical procedure. P< 0.05 was considered significant. Results: Total of 150 patients were divided in two equal groups of 125 patients each. No significant difference between age and gender of patients in CPAP and control group was observered. Mean bypass time and cross-clamp time was also same in two groups. PaO2/FiO2 Ratio after one hour and four hour of surgery was significantly high in CPAP group as compared to Non-ventilation group with p=0.001 and 0.03 respectively. Alveolar-arterial oxygen gradient after one hour of extubation was 21.47+1.03 kPa in CPAP group versus 27.73+2.19 kPa in non-ventilation group with p=0.001. Similarly alveolar-arterial oxygen gradient after four hours of surgery was also significantly less in CPAP group 19.18+2.04 kPa versus 20.80+2.57 kPa in non-ventilation group with p=0.001. Mechanical ventilation time after surgery was also significantly less in CPAP group 5.12+1.89 hours in CPAP group versus 6.36+2.57 hours in non-ventilation group (p = 0.001). Conclusion: Application of continuous positive airway pressure (CPAP) at 10 cm of H2O during cardiopulmonary bypass had a significant positive impact on post-operative pulmonary oxygenation. [ABSTRACT FROM AUTHOR]

Background/aim: Treatment failure in hospitalized patients with community-acquired pneumonia is a major cause of mortality. The aim of this study was to evaluate the factors affecting treatment success in community-acquired pneumonia. Materials and methods: A total of 537 patients (mean age: 66.1 ± 15.8 years, 365 males) registered to the Turkish Thoracic Society Pneumonia Database were analyzed. Of these, clinical improvement or cure, defined as treatment success, was achieved in 477, whereas 60 patients had treatment failure and/or died. Results: Lower numbers of neutrophils (5989.9 ± 6237.3 vs. 8495.6 ± 7279.5/mm3), higher blood urea levels (66.1 ± 42.1 vs. 51.2 ± 38.2 mg/dL), higher Pneumonia Severity Index (PSI) scores (123.3 ± 42.6 vs. 96.3 ± 32.9), higher CURB-65 scores (2.7 ± 1.2 vs. 2.2 ± 0.9), lower PaO2/FiO2 ratios (216.3 ± 86.8 vs. 269.9 ± 65.6), and the presence of multilobar (33.3% vs. 16.4%) and bilateral (41.7% vs. 18.9%) radiologic infiltrates were related to treatment failure. The PSI score and PaO2/FiO2 ratio were independent parameters affecting treatment results in multivariate linear regression analysis (P < 0.001). Conclusion: The risk of treatment failure is high in patients with severe pneumonia and with respiratory failure. Effective treatment and close monitoring are required for these cases. [ABSTRACT FROM AUTHOR]

Acute respiratory distress syndrome ( ARDS) is one of the severe complications of influenza H1N1/09 infection, resulting in high mortality. Effective treatment strategies for ARDS are needed. This report presents two cases of ARDS due to influenza in Vietnam. Both cases were similar in terms of starting symptoms, the rapid progression to ARDS, and the treatment strategy, direct hemoperfusion with a polymyxin- B-immobilized fiber column ( PMX- DHP) and oseltamivir. However, the clinical course of disease and the outcomes were different. For case 1, treatment was initiated on day 4 following the onset of hypoxemia due to ARDS. Symptoms improved rapidly after treatment and the patient was discharged on day 12. For case 2, treatment was initiated on day 9 after the onset of symptoms. Despite intensive therapy, the patient died on day 18. In conclusion, treatment with PMX- DHP and oseltamivir is effective on ARDS due to influenza but only if initiated early. [ABSTRACT FROM AUTHOR]

Objective: Although all definitions of acute respiratory distress syndrome use some measure of hypoxemia, neither the Berlin definition nor recently proposed pediatric-specific definitions proposed by the Pediatric Acute Lung Injury Consensus Conference utilizing oxygenation index specify which Pao2/Fio2 or oxygenation index best categorizes lung injury. We aimed to identify variables associated with mortality and ventilator-free days at 28 days in a large cohort of children with acute respiratory distress syndrome. Design: Prospective, observational, single-center study. Setting: Tertiary care, university-affiliated PICU. Patients: Two-hundred eighty-three invasively ventilated children with the Berlin-defined acute respiratory distress syndrome. Interventions: None. Measurements and Main Results: Between July 1, 2011, and June 30, 2014, 283 children had acute respiratory distress syndrome with 37 deaths (13%) at the Children's Hospital of Philadelphia. Neither initial Pao2/Fo2 nor oxygenation index at time of meeting acute respiratory distress syndrome criteria discriminated mortality. However, 24 hours after, both Pao2/Fio2 and oxygenation index discriminated mortality (area under receiver operating characteristic curve, 0.68 [0.59-0.77] and 0.66 [0.57-0.75]; p < 0.001). Pao2/Fio2 at 24 hours categorized severity of lung injury, with increasing mortality rates of 5% (Pao2/Fio2, > 300), 8% (Pao2/ Fio2, 201-300), 18% (Pao2/Fio2, 101-200), and 37% (Pao2/Fio2, ≤ 100) across worsening Berlin categories. This trend with 24-hour Pao2/Fio2 was seen for ventilator-free days (22, 19, 14, and 0 ventilator-free days across worsening Berlin categories; p < 0.001) and duration of ventilation in survivors (6, 9, 13, and 24 d across categories; p < 0.001). Similar results were obtained with 24-hour oxygenation index. Conclusions: Pao2/Fio2 and oxygenation index 24 hours after meeting acute respiratory distress syndrome criteria accurately stratified outcomes in children. Initial values were not helpful for prognostication. Definitions of acute respiratory distress syndrome may benefit from addressing timing of oxygenation metrics to stratify disease severity. [ABSTRACT FROM AUTHOR]

Objective: Blood analyses are preferred in the observation of cases requiring intensive care unit (ICU) following a trauma. The purpose of this study was to examine the relationship of albumin, C-reactive protein (CRP), PaO2/FiO2 and glucose levels of trauma patients at time of admission with mortality. Material and Method: The patients who were admitted into ICU following a trauma between the years of 2010 and 2012 were retrospectively evaluated. 200 trauma cases were included in the study. Their demographic data, APACHE II scores, Glasgow Coma Scales (GCS), and arterial blood gas in the lactate and PaO2/FiO2 ratio, CRP, glucose and albumin levels in the first collected arterial blood gas, as well as, the presence of thoracic, cardiac, renal, abdominal and head trauma, length of ICU stay and mortality were recorded. Results: Of the patients included in the study 84% were male, with an average age of 38.3 and an average APACHE II score of 16.6. 64% suffered from head trauma and the average GCS was calculated to be 11.2. The patients were observed in the ICU for an average of 18.7 days and the rate of mortality was 33.5%. GCS, PaO2/FiO2, age and elevated lactate levels increased mortality as independent risk factors. Conclusion: It has been concluded that parameters like age and the first GCS, lactate, glucose, albumin and PaO2/FiO2 at time of acceptance into the ICU were found to be related with mortality. [ABSTRACT FROM AUTHOR]