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PURPOSE:Mechanical power (MP) may unify variables known to be related with development of ventilator-induced lung injury. The aim of this study is to examine the association between MP and mortality in critically ill patients receiving invasive ventilation for at least 48 hours. METHODS:This is an analysis of data stored in the databases of the MIMIC-III, and eICU. Critically ill patients receiving invasive ventilation for at least 48 hours were included. The exposure of interest was MP. The primary outcome was in-hospital mortality. RESULTS:In total, 8,207 patients were analyzed. Median MP during the second 24 hours was 21.4 (16.2 to 28.1) J/min in MIMIC-III and 16.0 (11.7 to 22.1) J/min in eICU. MP was independently associated with in-hospital mortality (odds ratio per 5 J/min increase [OR] 1.06 [95% confidence interval [CI] 1.01 to 1.11]; p = 0.021 in MIMIC-III, and 1.10 [1.02 to 1.18]; p = 0.010 in eICU). MP was also associated with ICU-mortality, 30-day mortality, and with ventilator-free days, ICU and hospital length of stay. Even at low tidal volume, high MP was associated with in-hospital mortality (OR 1.70 [1.32 to 2.18]; p < 0.001) and other secondary outcomes. Finally, there is a consistent increase in the risk of death with MP higher than 17.0 J/min. CONCLUSION:High MP of ventilation is independently associated with higher inhospital mortality and several other outcomes in ICU patients receiving invasive ventilation for at least 48 hours.

Background Coagulation abnormalities in COVID-19 patients have not been addressed in depth. Objective To perform a longitudinal evaluation of coagulation profile of patients admitted to the ICU with COVID-19. Methods Conventional coagulation tests, rotational thromboelastometry (ROTEM), platelet function, fibrinolysis, antithrombin, protein C and S were measured at days 0, 1, 3, 7 and 14. Based on median total maximum SOFA score, patients were divided in two groups: SOFA ≤ 10 and SOFA > 10. Results Thirty patients were studied. Some conventional coagulation tests, as aPTT, PT and INR remained unchanged during the study period, while alterations on others coagulation laboratory tests were detected. Fibrinogen levels were increased in both groups. ROTEM maximum clot firmness increased in both groups from Day 0 to Day 14. Moreover, ROTEM–FIBTEM maximum clot firmness was high in both groups, with a slight decrease from day 0 to day 14 in group SOFA ≤ 10 and a slight increase during the same period in group SOFA > 10. Fibrinolysis was low and decreased over time in all groups, with the most pronounced decrease observed in INTEM maximum lysis in group SOFA > 10. Also, D-dimer plasma levels were higher than normal reference range in both groups and free protein S plasma levels were low in both groups at baseline and increased over time, Finally, patients in group SOFA > 10 had lower plasminogen levels and Protein C ​​than patients with SOFA <10, which may represent less fibrinolysis activity during a state of hypercoagulability. Conclusion COVID-19 patients have a pronounced hypercoagulability state, characterized by impaired endogenous anticoagulation and decreased fibrinolysis. The magnitude of coagulation abnormalities seems to correlate with the severity of organ dysfunction. The hypercoagulability state of COVID-19 patients was not only detected by ROTEM but it much more complex, where changes were observed on the fibrinolytic and endogenous anticoagulation system.

There is no broad evidence that any form of monitoring improves outcomes in the ICU and most commonly used devices have not been evaluated by RCT. This review puts into perspective the recent negative studies on the use of the pulmonary artery catheter in the acutely ill.

The optimal ventilation strategy during cardiopulmonary resuscitation (CPR) is unknown. Chest compression (CC) generates circulation, while during decompression, thoracic recoil generates negative pressure and venous return. Continuous flow insufflation of oxygen (CFI) allows noninterrupted CC and generates positive airway pressure (Paw). The main objective of this study was to assess the effects of positive Paw compared with the current recommended ventilation strategy on intrathoracic pressure (P(IT)) variations, ventilation, and lung volume. In a mechanical model, allowing compression of the thorax below an equilibrium volume mimicking functional residual capacity (FRC), CC alone or with manual bag ventilation were compared with two levels of Paw with CFI. Lung volume change below FRC at the end of decompression and P(IT), as well as estimated alveolar ventilation, were measured during the bench study. Recordings were obtained in five cardiac arrest patients to confirm the bench findings. Lung volume was continuously below FRC, and as a consequence P(IT) remained negative during decompression in all situations, including with positive Paw. Compared with manual bag or CC alone, CFI with positive Paw limited the fall in lung volume and resulted in larger positive and negative P(IT) variations. Positive Paw with CFI significantly augmented ventilation induced by CC. Recordings in patients confirmed a major loss of lung volume below FRC during CPR, even with positive Paw. Compared with manual bag ventilation, positive Paw associated with CFI limits the loss in lung volume, enhances CC-induced positive P(IT), maintains negative P(IT) during decompression, and generates more alveolar ventilation.