Essential Multiorgan Pathophysiology of COVID-19

Typical manifestations of coronavirus disease-2019 (COVID-19) include mild-to-moderate "flu-like” symptoms, although more severe manifestations have been reported. The pathophysiology of COVID-19 is complex, and its clinical spectrum might not be limited to local pneumonia, but rather may represent a multisystem illness with potential for severe acute respiratory distress syndrome (ARDS) and multiorgan impairment. In this context, the aim of the present handbook is to provide an overview of possible multisystemic manifestations and therapeutic strategies, in order to guide the clinician to deal with COVID-19 critical illness and to prevent potential systemic consequences. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

COVID-19 Critical and Intensive Care Medicine Essentials

This book provides healthcare professionals in Critical Care setting an easy consultation guide to fight against COVID-19. The book is divided into sections: Fundamentals of COVID-19, Pneumological critical care, Neurological manifestations, Cardiovascular manifestations, Renal manifestations, Haemostasis and coagulation, Other multi-organs involvement, Principles of therapy. Each section includes: · brief pathophysiology of COVID-19 (ventilation, neurological, cardiovascular, etc.);· principles of management (enriched with flowcharts and figures);· principles of therapy;· tips and key messages. Readers can find the most updated advices on how to face the ongoing pandemic: from principles of conventional oxygen therapy, assisted and invasive mechanical ventilation in critically ill COVID-19 patients to the complications sometimes underestimated. Tables and flowcharts provided are based on current knowledge in COVID-19 to help the clinician managing COVID-19 patients by a multiple-organs prospective. Written by international key opinion leaders of each field, the book represents a point of reference for all professionals involved in the management of COVID-19 pandemic. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

Radiological Patterns and Lung Ultrasound

The early diagnosis of coronavirus disease 2019 (COVID-19) is one of the crucial points in order to reduce virus spread, also containing morbidity and mortality of the pandemic. Despite the utility of specific molecular tests (such as real time polymerase chain reaction, RT-PCR), imaging is considered one of the key strategies for an early diagnostic typing of the disease, and to individualize patient management [1-3]. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

The Role of Noninvasive Multimodal Neuromonitoring

The pathophysiology of neurological injury related to Coronavirus disease-2019 (COVID-19) is multifactorial. Several pathophysiological pathways have been described in patients with COVID-19 infection presenting neurological complications. Microangiopathy has been shown to be an important underlying process causing small vessel cerebral infarct [1] or hemorrhagic transformations;endotheliitis, has been reported in the context of systemic inflammatory response (SIRS) which is shared among other COVID-19 related clinical presentations [2]. Direct viral cytopathic injury has been described in anatomopathological samples in patients with encephalitis. Autoimmune processes leading to peripheral or central neuritis have also been described with COVID infection [3]. Therefore, neurological injury related to COVID-19 may present with a variety of overlapping syndromes. This pathological myriad impacts in the monitoring of these patients as there is no specific surveillance that can be used for the screening of evolving neurological complications. Early detection of neurological complications is warranted to prevent and manage neurological complications. However, there is no concrete monitoring to apply to each of these scenarios, physicians need to be guided by high level clinical suspicion and an approach of diagnostic exclusion in the daily management of these patients. In this context, the role of noninvasive multimodal neuromonitoring acquires a new perspective in COVID-19. This chapter overviews the possible ways to early detect patients at risk of neurological complications, highlighting the importance of multimodal neuromonitoring systems. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

Risk factors for mortality in COPD patients with COVID19 admitted to Intensive Care Unit

Background and aim: Patients with Chronic obstructive pulmonary disease (COPD) and COVID-19 have increased risk of hospitalization and Instensive Care Unit (ICU) admission (1). Aims and objectives: To indentify risk factors for intrahospital mortality in COPD patients with COVID-19 admitted to Spanish ICUs. Method(s): Demographic and clinical data during ICU admission were recorded using REDCap on all patients hospitalized for COVID-19 in 70 Spanish ICUs (2). We described the baseline clinical characteristics of COPD compared to other chronic respiratory disease (CRD) and to the overall population. We identified the risk factors for intrahospital mortality of COPD patients receiving invasive mechanical ventilation (IMV) and for those COPD receiving noninvasive respiratory support (NIRS). Result(s): Two hundred and sixty-eight ICU patients (5%) had COPD out of 5196 included. No differences were found between COPD, CRD or the overall population in the rates of IMV (76-78%) vs NIRS (22-24%). COPD intrahospital mortality was much higher in the IMV subgroup (58%). Independent risk factors for intrahospital mortality in the COPD+IMV or COPD+NIRS were: age and chronic Kidney disease or hypertension, respectively. Previous NIRS in COPD+IMV group was protective for intrahospital mortality (Figure). Conclusion(s): New strategies are needed to reduce the high intrahospital and 90-days mortality of COPD COVID-19 patients admitted to ICU.

New insights in mechanical ventilation and adjunctive therapies in ARDS

Patients with acute respiratory distress syndrome (ARDS) often require mechanical ventilation (MV) and may experience high morbidity and mortality. The ventilatory management of ARDS patients has changed over the years to mitigate the risk of ventilator-induced lung injury (VILI) and improve outcomes. Current recommended MV strategies include the use of low tidal volume (VT) at 4–6 mL/kg of predicted body weight (PBW) and plateau pressure (PP LAT) below 27 cmH2O. Some patients achieve better outcomes with low VT than others, and several strategies have been proposed to individualize VT, including standardization for end-expiratory lung volume or inspiratory capacity. To date, no strategy for individualizing positive-end expiratory pressure (PEEP) based on oxygenation, recruitment, respiratory mechanics, or hemodynamics has proven superior for improving survival. Driving pressure, transpulmonary pressure, and mechanical power have been proposed as markers to quantify risk of VILI and optimize ventilator settings. Several rescue therapies, including neuromuscular blockade, prone positioning, recruitment maneuvers (RMs), vasodilators, and extracorporeal membrane oxygenation (ECMO), may be considered in severe ARDS. New ventilator strategies such as airway pressure release ventilation (APRV) and time-controlled adaptive ventilation (TCAV) have demonstrated potential benefits to reduce VILI, but further studies are required to evaluate their clinical relevance. This review aims to discuss the cornerstones of MV and new insights in ARDS ventilatory management, as well as their rationales, to guide the physician in an individually tailored rather than a fixed, sub-physiological approach. We recommend that MV be individualized based on physiological targets to achieve optimal ventilatory settings for each patient. © 2022 The Author(s). Published by MRE Press.

Mid and Long-term Neurological and Neuropsychiatric Manifestations of PostCOVID-19 Syndrome: A Meta-analysis

Objective: To determine the prevalence of neurological and neuropsychiatric symptoms reported 12 weeks (3 months) or more after acute COVID-19 onset in adults. Background: Neurological and neuropsychiatric symptoms that persist or develop three months after the onset of COVID-19 pose a significant threat to the global healthcare system. These symptoms are yet to be synthesized and quantified via meta-analysis. Design/Methods: A systematic search of PubMed, EMBASE, Web of Science, Google Scholar and Scopus was conducted for studies published between January 1 , 2020 and August 1 , 2021. Studies were included if the length of follow-up satisfied the National Institute for Healthcare Excellence definition of post-COVID-19 syndrome. Additional criteria included reporting of neurological or neuropsychiatric symptoms in individuals with COVID-19. The primary outcome was the prevalence of neurological and neuropsychiatric symptoms reported ≥3 months post onset of COVID-19. Results: Of 1,458 articles, 19 studies, encompassing a total of 11,324 patients, were analysed. Overall prevalence for neurological post-COVID-19 symptoms were: fatigue (37%, 95% CI: 24%- 50%), brain fog (32%, 9%-55%), memory issues (27%, 18%-36%), attention disorder (22%, 10%- 34%), myalgia (18%, 4%-32%), anosmia (12%, 7%-17%), dysgeusia (11%, 4%-17%) and headache (10%, 1%-21%). Neuropsychiatric conditions included sleep disturbances (31%, 18%-43%), anxiety (23%, 13%-33%) and depression (12%, 7%-21%). Neuropsychiatric symptoms substantially increased in prevalence between mid- and long-term follow-up. Compared to non-hospitalised patients, patients hospitalised for acute COVID-19 had reduced risk of anosmia, anxiety, depression, dysgeusia, fatigue, headache, myalgia, and sleep disturbance at three (or more) months post-infection. Conversely, hospital admission was associated with higher frequency of memory issues (OR: 1.9, 95% CI: 1.4-2.3). Conclusions: Fatigue, brain fog and sleep disturbances appear to be key features of post-COVID19 syndrome. Psychiatric manifestations (sleep disturbances, anxiety, and depression) increase significantly in prevalence over time. Randomised controlled trials are necessary to develop intervention strategy to reduce disease burden.

Long covid syndrome: Why efforts like aftercor are needed

Introduction: The AFTERCOR study was developed by the COVID-19 Critical Care Consortium (>7000 intensive care unit [ICU] and >400 extracorporeal membrane oxygenation [ECMO] patients currently) to enhance understanding of occurrence and progression of long-term dysfunction post-COVID-19. Design: Prospective longitudinal (24 months) study of ICU survivors of COVID-19 to describe recovery of the following aspects: a) health-related quality of life b) dynamics of organ dysfunction and recovery and c) pulmonary function. Countries involved Italy, Spain, Ireland, Austria, South Africa, Australia, USA, Argentina, Brazil, Colombia. Protocol specifics available at https://www.aftercorstudy.com. Inclusion Criteria: 1) COVID-19 infection requiring ICU admission;2) informed consent;3) age ≥18 years. Exclusion Criteria: 1) pregnancy;2) pre-COVID paralysis;3) history of pulmonary resection;4) prior lung transplant;5) inability to perform 6-min walk test or participate in interview. Methods: Goal enrollment is 1000 patients. Follow-up visits are at 3, 6, 12, 18 and 24-month post-ICU discharge. Assessments include: 1) Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36);2) Montreal Cognitive Assessment;3) any subsequent admission 4) St. George's Respiratory Questionnaire;5) Pulmonary function testing;6) chest radiography;7) 6-minute-walk test;8) Patient Health Questionnaire 9 (PHQ-9) and 9) full blood count and biochemistry. CT chest at 6 months and repeat ECHO at 3, 12 and 24 months if performed during COVID-19 hospitalization. If results are normal, subsequent testing will not be performed. Summary: The AFTERCOR study represents a comprehensive evaluation for long-term effects from COVID-19. Interested centers are sought and invited to participate.