Background Thrombosis and inflammation may contribute to the risk of death and complications among patients with coronavirus disease 2019 (Covid-19). We hypothesized that therapeutic-dose anticoagulation may improve outcomes in noncritically ill patients who are hospitalized with Covid-19. Methods In this open-label, adaptive, multiplatform, controlled trial, we randomly assigned patients who were hospitalized with Covid-19 and who were not critically ill (which was defined as an absence of critical care–level organ support at enrollment) to receive pragmatically defined regimens of either therapeutic-dose anticoagulation with heparin or usual-care pharmacologic thromboprophylaxis. The primary outcome was organ support–free days, evaluated on an ordinal scale that combined in-hospital death (assigned a value of −1) and the number of days free of cardiovascular or respiratory organ support up to day 21 among patients who survived to hospital discharge. This outcome was evaluated with the use of a Bayesian statistical model for all patients and according to the baseline d -dimer level. Results The trial was stopped when prespecified criteria for the superiority of therapeutic-dose anticoagulation were met. Among 2219 patients in the final analysis, the probability that therapeutic-dose anticoagulation increased organ support–free days as compared with usual-care thromboprophylaxis was 98.6% (adjusted odds ratio, 1.27; 95% credible interval, 1.03 to 1.58). The adjusted absolute between-group difference in survival until hospital discharge without organ support favoring therapeutic-dose anticoagulation was 4.0 percentage points (95% credible interval, 0.5 to 7.2). The final probability of the superiority of therapeutic-dose anticoagulation over usual-care thromboprophylaxis was 97.3% in the high d -dimer cohort, 92.9% in the low d -dimer cohort, and 97.3% in the unknown d -dimer cohort. Major bleeding occurred in 1.9% of the patients receiving therapeutic-dose anticoagulation and in 0.9% of those receiving thromboprophylaxis. Conclusions In noncritically ill patients with Covid-19, an initial strategy of therapeutic-dose anticoagulation with heparin increased the probability of survival to hospital discharge with reduced use of cardiovascular or respiratory organ support as compared with usual-care thromboprophylaxis. (ATTACC, ACTIV-4a, and REMAP-CAP ClinicalTrials.gov numbers, NCT04372589 , NCT04505774 , NCT04359277 , and NCT02735707 .)

Although advances in intensive care have enabled more patients to survive an acute critical illness, they also have created a large and growing population of chronically critically ill patients with prolonged dependence on mechanical ventilation and other intensive care therapies. Chronic critical illness is a devastating condition: mortality exceeds that for most malignancies, and functional dependence persists for most survivors. Costs of treating the chronically critically ill in the United States already exceed $20 billion and are increasing. In this article, we describe the constellation of clinical features that characterize chronic critical illness. We discuss the outcomes of this condition including ventilator liberation, mortality, and physical and cognitive function, noting that comparisons among cohorts are complicated by variation in defining criteria and care settings. We also address burdens for families of the chronically critically ill and the difficulties they face in decision-making about continuation of intensive therapies. Epidemiology and resource utilization issues are reviewed to highlight the impact of chronic critical illness on our health care system. Finally, we summarize the best available evidence for managing chronic critical illness, including ventilator weaning, nutritional support, rehabilitation, and palliative care, and emphasize the importance of efforts to prevent the transition from acute to chronic critical illness. As steps forward for the field, we suggest a specific definition of chronic critical illness, advocate for the creation of a research network encompassing a broad range of venues for care, and highlight areas for future study of the comparative effectiveness of different treatment venues and approaches.

Background: After critical illness, new or worsening impairments in physical, cognitive, and/or mental health function are common among patients who have survived. Who should be screened for long-term impairments, what tools to use, and when, remain unclear. Objectives: Provide pragmatic recommendations to clinicians caring for adult survivors of critical illness related to screening for post-discharge impairments. Participants: 31 international experts in risk-stratification and assessment of survivors of critical illness, including practitioners involved in the Society of Critical Care Medicine's (SCCM) Thrive Post-ICU Collaboratives, survivors of critical illness, and clinical researchers. Design: SCCM consensus conference on post-intensive care syndrome (PICS) prediction and assessment, held in Dallas, in May, 2019.Meeting Outcomes: We concluded that existing tools are insufficient to reliably predict PICS. We identified factors before (e.g., frailty, pre-existing functional impairments), during (e.g., duration of delirium, sepsis, acute respiratory distress syndrome), and after (e.g., early symptoms of anxiety, depression, or post-traumatic stress disorder (PTSD)) critical illness that can be used to identify patients at high-risk for cognitive, mental health, and physical impairments after critical illness in whom screening is recommended. We recommend serial assessments, beginning within 2-4 weeks of hospital discharge, using the following screening tools: Montreal Cognitive Assessment

Objective: To measure the impact of staged implementation of full versus partial ABCDE bundle on mechanical ventilation (MV) duration, intensive care unit (ICU) and hospital lengths of stay (LOS), and cost.

Rationale: Both acute respiratory distress syndrome (ARDS) and intensive care unit (ICU) delirium are associated with significant morbidity and mortality. However, the risk of delirium and its impact on mortality in ARDS patients is unknown.Objectives: To determine if ARDS is associated with a higher risk for delirium compared with respiratory failure without ARDS, and to determine the association between ARDS and in-hospital mortality after adjusting for delirium.Methods: Prospective observational cohort study of adult ICU patients admitted to two urban academic hospitals.Measurements and Main Results: Delirium was assessed daily using the Confusion Assessment Method for the ICU and Richmond Agitation and Sedation Scale. Of the 564 patients in our cohort, 48 had ARDS (9%). Intubated patients with ARDS had the highest prevalence of delirium compared with intubated patients without ARDS and nonintubated patients (73% vs. 52% vs. 21%, respectively; P , 0.001). After adjusting for common risk factors for delirium, ARDS was associated with a higher risk for delirium compared with mechanical ventilation without ARDS (odds ratio [OR],.54]; P = 0.01 vs. OR, 1.98 [1.16-3.40]; P , 0.013); reference was nonintubated patients. Although ARDS was significantly associated with hospital mortality (OR,.50]), the effect was largely reduced after adjusting for delirium and persistent coma (OR, ]).Conclusions: Our findings suggest that ARDS is associated with a greater risk for ICU delirium than mechanical ventilation alone, and that the association between ARDS and in-hospital mortality is weakened after adjusting for delirium and coma. Future studies are needed to determine if prevention and reduction of delirium in ARDS patients can improve outcomes.

Background Health categories of elderly patients prior to critical illness may explain differences in mortality during and after admission to intensive care units (ICUs). Objectives To estimate the effect of pre-ICU health categories on mortality during and after critical illness, focusing specifically on the effect of pre-ICU frailty on short- and long-term mortality. Design Retrospective cohort study using linked Medicare claims data from 2004–2008. Participants A nationally representative sample of elderly Medicare beneficiaries who were admitted to an ICU in 2005. Measurements Patients were classified into four pre-ICU health categories (Robust; Cancer; Chronic Organ Failure; Frailty) using claims data from the year prior to admission, allowing for assignment to multiple categories. We assessed the association between pre-ICU health categories and hospital and 3-year mortality using multivariable logistic regression and Cox proportional Hazards models. Results Among 47,427 elderly ICU patients, 18.8% were Robust; 28.6% had pre-ICU Cancer; 68.1% Chronic Organ Failure and 34.0% Frailty; 41.3% qualified for multiple categories. Overall hospital mortality was 12.6%, with the lowest mortality for Robust patients (9.7%). Patients with pre-ICU Frailty had a higher hospital mortality compared to patients with the same pre-ICU health categories without frailty (adjusted Odds Ratios ranged from 1.27 (95% confidence interval (CI) 1.10–1.47) to 1.52 (95% CI 1.35–1.63)). Robust hospital survivors had the lowest 3-year mortality (24.6%). Pre-ICU Frailty conferred a higher 3-year mortality compared to pre-ICU categories without frailty (adjusted Hazard Ratios ranged from 1.54 (95% CI 1.45–1.64) to 1.84 (95% CI 1.70–1.99). Conclusion Critically ill elderly patients can be categorized by Pre-ICU health categories. These categories, particularly pre-ICU Frailty, may be important for understanding risk of death during and after critical illness.

Author contributions: KH, JMP, LB, CS had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. All other authors contributed substantially to the study design, data analysis and interpretation, and the writing of the manuscript.

A communication skills program can be feasibly integrated into a critical care training program and is associated with improvements in fellows' skills and comfort with leading family meetings.