ABSTRACT Objective: To examine the physical function and respiratory muscle strength of patients - who recovered from critical COVID-19 – after intensive care unit discharge to the ward on Days one (D1) and seven (D7), and to investigate variables associated with functional impairment. Methods: This was a prospective cohort study of adult patients with COVID-19 who needed invasive mechanical ventilation, non-invasive ventilation or high-flow nasal cannula and were discharged from the intensive care unit to the ward. Participants were submitted to Medical Research Council sum-score, handgrip strength, maximal inspiratory pressure, maximal expiratory pressure, and short physical performance battery tests. Participants were grouped into two groups according to their need for invasive ventilation: the Invasive Mechanical Ventilation Group (IMV Group) and the Non-Invasive Mechanical Ventilation Group (Non-IMV Group). Results: Patients in the IMV Group (n = 31) were younger and had higher Sequential Organ Failure Assessment scores than those in the Non-IMV Group (n = 33). The short physical performance battery scores (range 0 - 12) on D1 and D7 were 6.1 ± 4.3 and 7.3 ± 3.8, respectively for the Non-Invasive Mechanical Ventilation Group, and 1.3 ± 2.5 and 2.6 ± 3.7, respectively for the IMV Group. The prevalence of intensive care unit-acquired weakness on D7 was 13% for the Non-IMV Group and 72% for the IMV Group. The maximal inspiratory pressure, maximal expiratory pressure, and handgrip strength increased on D7 in both groups, but the maximal expiratory pressure and handgrip strength were still weak. Only maximal inspiratory pressure was recovered (i.e., > 80% of the predicted value) in the Non-IMV Group. Female sex, and the need and duration of invasive mechanical were independently and negatively associated with the short physical performance battery score and handgrip strength. Conclusion: Patients who recovered from critical COVID-19 and who received invasive mechanical ventilation presented greater disability than those who were not invasively ventilated. However, they both showed marginal functional improvement during early recovery, regardless of the need for invasive mechanical ventilation. This might highlight the severity of disability caused by SARS-CoV-2. Objective COVID19 COVID 19 COVID-1 D (D1 D7, , (D7) impairment Methods noninvasive non highflow high flow sumscore, sumscore sum score, sum-score tests NonInvasive Non NonIMV . Results n 31 33. 33 33) range 12 61 6 1 6. 43 4 3 4. 73 7 7. 38 8 3.8 13 1. 25 2 5 2. 26 37 3.7 unitacquired acquired 72 weak i.e., ie i e (i.e. 80 value sex Conclusion ventilated However recovery SARSCoV2. SARSCoV2 SARSCoV SARS CoV SARS-CoV-2 COVID1 COVID- (D (D7 3. i.e. (i.e SARS-CoV- i.e SARS-CoV

RESUMO Objetivo: Examinar a função física e a força muscular respiratória de pacientes que se recuperaram da COVID-19 grave após a alta da unidade de terapia intensiva para a enfermaria nos Dias 1 e 7 e investigar as variáveis associadas ao comprometimento funcional. Métodos: Trata-se de estudo de coorte prospectivo de pacientes adultos com COVID-19 que necessitaram de ventilação mecânica invasiva, ventilação mecânica não invasiva ou cânula nasal de alto fluxo e tiveram alta da unidade de terapia intensiva para a enfermaria. Os participantes foram submetidos aos testes Medical Research Council sum-score, força de preensão manual, pressão inspiratória máxima, pressão expiratória máxima e short physical performance battery. Os participantes foram agrupados em dois grupos conforme a necessidade de ventilação mecânica invasiva: o Grupo Ventilação Mecânica Invasiva (Grupo VMI) e o Grupo Não Ventilação Mecânica Invasiva (Grupo Não VMI). Resultados: Os pacientes do Grupo VMI (n = 31) eram mais jovens e tinham pontuações do Sequential Organ Failure Assessment mais altas do que os do Grupo VMI (n = 33). As pontuações do short physical performance battery (intervalo de zero a 12) nos Dias 1 e 7 foram 6,1 ± 4,3 e 7,3 ± 3,8, respectivamente para o Grupo Não VMI, e 1,3 ± 2,5 e 2,6 ± 3,7, respectivamente para o Grupo VMI. A prevalência de fraqueza adquirida na unidade de terapia intensiva no Dia 7 foi de 13% para o Grupo Não VMI e de 72% para o Grupo VMI. A pressão inspiratória máxima, a pressão expiratória máxima e a força de preensão manual aumentaram no Dia 7 em ambos os grupos, porém a pressão expiratória máxima e a força de preensão manual ainda eram fracas. Apenas a pressão inspiratória máxima foi recuperada (ou seja, > 80% do valor previsto) no Grupo Não VMI. As variáveis sexo feminino, e necessidade e duração da ventilação mecânica invasiva foram associadas de forma independente e negativa à pontuação do short physical performance battery e à força de preensão manual. Conclusão: Os pacientes que se recuperaram da COVID-19 grave e receberam ventilação mecânica invasiva apresentaram maior incapacidade do que aqueles que não foram ventilados invasivamente. No entanto, os dois grupos de pacientes apresentaram melhora funcional marginal durante a fase inicial de recuperação, independentemente da necessidade de ventilação mecânica invasiva. Esse resultado pode evidenciar a gravidade da incapacidade causada pelo SARS-CoV-2. Objetivo COVID19 COVID 19 COVID-1 Métodos Tratase Trata sumscore, sumscore sum score, score sum-score . Resultados n 31 33. 33 33) intervalo 12 61 6 6, 43 4 3 4, 73 7, 38 8 3,8 13 1, 25 2 5 2, 26 37 3,7 72 fracas seja 80 previsto feminino Conclusão invasivamente entanto recuperação SARSCoV2. SARSCoV2 SARSCoV SARS CoV 2. SARS-CoV-2 COVID1 COVID- 3, SARS-CoV- SARS-CoV

Abstract Importance: Despite ambulation capacity being associated with a decreased level of physical activity and survival may be influenced by the functional capacity, studies have not addressed the association between ambulation capacity and death in patients hospitalized by COVID-19. Objective: To verify the functional, clinical, and sociodemographic risk factors associated with in-hospital death in individuals with severe COVID-19. Methods: It is a cohort retrospective study performed at a large tertiary hospital. Patients 18 years of age or more, of both sexes, hospitalized due to severe COVID-19 were included. Cases with dubious medical records and/or missing essential data were excluded. Patients were classified according to their ambulation capacity before the COVID-19 infection. Information regarding sociodemographic characteristics, in-hospital death, total hospital stays, Intensive Care Unit (ICU) stays, and the necessity of Mechanical Ventilation (MV) were collected from medical records and registered in a RedCap database. Multiple logistic regression analysis was used to identify possible factors associated with the in-hospital death rate. Results: Data from 1110 participants were included in the statistical analysis. The median age of the patients was 57 (46‒66) years, 58.42% (n = 590) were male, and 61.73% (n = 602) were brown or black. The case fatality rate during hospitalization was 36.0% (n = 363). In-hospital death was associated with ambulation capacity; dependent ambulators (OR = 2.3; CI 95% = 1.2-4.4) and non-functional ambulation (OR = 1.9; CI 95% = 1.1-3.3), age [older adults (OR = 3.0; CI 95% = 1.9‒4.), ICU stays (OR = 1.4; CI 95% = 1.2‒1.4), immunosuppression (OR = 5.5 CI 95% = 2.3‒13.5) and mechanical ventilation (OR = 27.5; CI 95% = 12.0-62.9). Conclusion and relevance: Decreased ambulation capacity, age, length of ICU stay, immunosuppression, and mechanical ventilation was associated with a high risk of in-hospital death due to COVID-19.

OBJECTIVES: Medical and surgical intensive care unit patients represent two different populations and require different treatment approaches. The aim of this study was to investigate the parameters associated with mortality in medical and surgical intensive care units. METHODS: This was a prospective cohort study of adult patients admitted to a medical and surgical intensive care unit teaching hospital over an 11-month period. Factors associated with mortality were explored using logistic regression analysis. RESULTS: In total, 827 admissions were observed, and 525 patients >18 years old and with a length of stay >24 h were analyzed. Of these patients, 227 were in the medical and 298 were in the surgical intensive care unit. The surgical patients were older (p<0.01) and had shorter lengths of stay (p<0.01). The mortality in the intensive care unit (35.1 vs. 26.2, p = 0.02) and hospital (48.8 vs. 35.5, p<0.01) was higher for medical patients. For patients in the surgical intensive care unit, death was independently associated with the need for mechanical ventilation, prognostic score (SAPS II), community-acquired infection, nosocomial infection, and intensive care unit-acquired infection. For patients in the medical intensive care unit, death was independently associated with the need for mechanical ventilation and prognostic score. CONCLUSIONS: Although the presence of infection is associated with a high mortality in both the medical and surgical intensive care units, the results of this prospective study suggest that infection has a greater impact in patients admitted to the surgical intensive care unit. Measures and trials to prevent and treat sepsis may be most effective in the surgical intensive care unit population.

JUSTIFICATIVA E OBJETIVOS: Os pacientes criticamente enfermos representam uma população com múltiplos fatores de risco para aspiração. Associa-se a essa complicação a redução do estado de consciência, ventilação mecânica e comorbidades como o acidente vascular encefálico (AVE), freqüentemente presente nos pacientes internados em unidade de terapia intensiva (UTI). A identificação das alterações da deglutição pode auxiliar na detecção de pacientes com alto risco de aspiração, prevenindo complicações pulmonares como a pneumonia aspirativa. O objetivo deste relato foi mostrar um caso de broncopneumonia aspirativa recorrente grave, após acidente vascular encefálico agudo e intubação traqueal, alertando para a necessidade do diagnóstico e do tratamento adequados nestes pacientes. RELATO DO CASO: Paciente do sexo masculino, 57 anos internado no hospital por AVE, evoluiu após 10 dias de internação com quadr o de pneumonia aspirativa, necessitando de intubação traqueal e transferência para a UTI. Permaneceu intubado por quatro dias, e logo após a extubação evoluiu com progressivo infiltrado pulmonar relacionado a novos episódios de aspiração. A avaliação fonoaudiológica na UTI classificou o paciente como portador de disfagia orofaríngea grave, com risco para penetração e aspiração laringotraqueal. Recebeu alta da UTI após 13 dias, porém na enfermaria evoluiu com novo quadro aspirativo após oito dias, necessitando de re-internação na UTI e prolongada internação hospitalar. CONCLUSÕES: Os pacientes internados em UTI devem ter seu risco para alterações de deglutição e de aspiração identificado para que medidas preventivas possam ser instituídas, evitando-se a morbidade e a mortalidade associada à aspiração.

BACKGROUND AND OBJECTIVES: Critically ill patients represent a population with multiple risk factors for aspiration. Features such as decreased level of consciousness, mechanical ventilation, and comorbities as stroke, correlate with this increased threat in intensive care unit (ICU) patients. Recognition of deglutition dysfunction may identify patients at high risk of aspiration, and thereby help to avoid pulmonary complications such as recurrent pneumonia. The goal of our report is show a severe case of recurrent aspirative pneumonia after acute stroke and intubation, alerting to appropriate diagnosis and treatment of this condition. CASE REPORT: A male patient, 57 year old, was admitted to the hospital because of acute stroke. Ten days later, the patient began to have fever and severe shortness of breath. He was admitted to the ICU necessitating of intratracheal intubation. Four days after intubation he was extubated, however, he had a new aspirative pneumonia in ICU, newly treated. An evaluation of swallowing demonstrated a severe deglutition dysfunction with a high risk of aspiration. The patient was transferred, but aspirative pneumonia was diagnosed eight days after his ICU discharge and he was readmitted, stayed for a long time in ICU and presenting severe morbidity. CONCLUSIONS: ICU patients who are at risk for swallowing dysfunction and aspiration should be identified to prevent their associated morbidity and mortality.

OBJETIVO: Determinar a prevalência de infecções em pacientes de Terapia Intensiva, os agentes infecciosos mais comuns e seus padrões de resistência. Identificar os fatores relacionados a infecção adquirida na Unidade de Terapia Intensiva e as taxas de mortalidade. DESENHO: Estudo de prevalência de um dia. LOCAL:Um total de 19 Unidades de Terapia Intensiva do Hospital das Clínicas da FMUSP (HC-FMUSP) participaram do estudo. PACIENTES: Todos os pacientes com idade superior a 16 anos internados em leitos de terapia intensiva por mais de 24 horas foram incluídos. As 19 Unidades de Terapia Intensiva forneceram 126 casos. VARIÁVEIS:Taxas de infecção, uso de antibióticos, padrões de resistência microbiológica, fatores relacionados à infecção adquirida na Unidade de Terapia Intensiva, taxas de mortalidade. RESULTADOS: Um total de 126 pacientes foi estudado. Oitenta e sete (69%) receberam antibióticos no dia do estudo, sendo 72 (57%) para tratamento e 15 (12%) para profilaxia. Baseado no tipo, observou-se que a infecção adquirida na comunidade ocorreu em 15 pacientes (20,8%), infecção hospitalar fora da Unidade de Terapia Intensiva em 24 (33,3%), e infecção adquirida na Unidade de Terapia Intensiva em 22 pacientes (30,6%). Para 11 pacientes (15,3%) não se definiu o tipo de infecção. Quanto ao sítio de infecção, as respiratórias foram as infecções mais comuns (58,5%). Os agentes mais freqüentemente isolados foram: Enterobacteriaceae (33,8%), Pseudomonas aeruginosa (26,4%) e Staphylococcus aureus (16,9%; 100% meticilina-resistentes). Análise multivariada identificou 3 fatores associados à infecção adquirida na Unidade de Terapia Intensiva: idade maior ou igual a 60 anos (p=0,007), uso de sonda nasogástrica (p=0,017) e pós-operatório (p=0,017). Ao final de quatro semanas, a taxa de mortalidade foi de 28,8%. Entre os infectados, a mortalidade foi de 34,7%. Não houve diferença entre as taxas de mortalidade para pacientes infectados e não-infectados (p=0,088). CONCLUSÃO: A taxa de infecção é alta entre os pacientes de terapia intensiva, especialmente as infecções respiratórias. As bactérias predominantes foram: Enterobacteriaceae. Pseudomonas aeruginosa e Staphylococcus aureus (agentes resistentes). Fatores como uso de sonda nasogástrica, pós-operatório e idade maior ou igual a 60 anos mostraram associação com infecção. Este estudo documenta a impressão clínica de que a prevalência de infecção adquirida na Unidade de Terapia Intensiva é alta e sugere que medidas preventivas são importantes para reduzir a ocorrência de infecção em pacientes críticos.

OBJECTIVE: To determine the prevalence rates of infections among intensive care unit patients, the predominant infecting organisms, and their resistance patterns. To identify the related factors for intensive care unit-acquired infection and mortality rates. DESIGN: A 1-day point-prevalence study. SETTING:A total of 19 intensive care units at the Hospital das Clínicas - University of São Paulo, School of Medicine (HC-FMUSP), a teaching and tertiary hospital, were eligible to participate in the study. PATIENTS: All patients over 16 years old occupying an intensive care unit bed over a 24-hour period. The 19 intensive care unit s provided 126 patient case reports. MAIN OUTCOME MEASURES: Rates of infection, antimicrobial use, microbiological isolates resistance patterns, potential related factors for intensive care unit-acquired infection, and death rates. RESULTS: A total of 126 patients were studied. Eighty-seven patients (69%) received antimicrobials on the day of study, 72 (57%) for treatment, and 15 (12%) for prophylaxis. Community-acquired infection occurred in 15 patients (20.8%), non- intensive care unit nosocomial infection in 24 (33.3%), and intensive care unit-acquired infection in 22 patients (30.6%). Eleven patients (15.3%) had no defined type. The most frequently reported infections were respiratory (58.5%). The most frequently isolated bacteria were Enterobacteriaceae (33.8%), Pseudomonas aeruginosa (26.4%), and Staphylococcus aureus (16.9%; [100% resistant to methicillin]). Multivariate regression analysis revealed 3 risk factors for intensive care unit-acquired infection: age > 60 years (p = 0.007), use of a nasogastric tube (p = 0.017), and postoperative status (p = 0.017). At the end of 4 weeks, overall mortality was 28.8%. Patients with infection had a mortality rate of 34.7%. There was no difference between mortality rates for infected and noninfected patients (p=0.088). CONCLUSION: The rate of nosocomial infection is high in intensive care unit patients, especially for respiratory infections. The predominant bacteria were Enterobacteriaceae, Pseudomonas aeruginosa, and Staphylococcus aureus (resistant organisms). Factors such as nasogastric intubation, postoperative status, and age ³60 years were significantly associated with infection. This study documents the clinical impression that prevalence rates of intensive care unit-acquired infections are high and suggests that preventive measures are important for reducing the occurrence of infection in critically ill patients.