ABSTRACT
Dès la fin du mois de février 2020, les urgentistes français ont été confrontés à une situation inédite et complexe dans la gestion des cas les plus sévères d'infections pulmonaires associées au nouveau coronavirus (SARSCoV- 2). Les informations en provenance de Chine et les recommandations initiales de l'Organisation mondiale de la santé ont rapidement amené à considérer l'intubation et la ventilation mécanique précoce des malades atteints par la pneumonie de la Covid-19. Or, dès la fin du mois de mars 2020, grâce aux retours d'expérience et de prise en charge, d'abord de la part des réanimateurs et urgentistes italiens, puis espagnols, les pratiques et les recommandations concernant les modalités d'oxygénation et de ventilation des patients Covid-19 ont évolué. Le caractère exceptionnel de cette pandémie et la grande adaptabilité des services de Samu/Smur de France, en l'espace de quelques semaines, pour prendre en charge ces patients oxygénodépendants, justifient que nous en fassions le retour d'expérience, et ce, d'autant plus que nous sommes exposés à un risque de recrudescence d'infections respiratoires graves associées au SARS-CoV-2 à court terme, risquant de saturer une nouvelle fois notre système de santé. Nous détaillons donc ici le retour d'expérience des prises en charge médicales préhospitalières concernant principalement les supports d'oxygénation et de ventilation mécanique.Alternate abstract: At the end of February 2020, French emergency physicians were faced with a new and complex situation in the management of critical cases of SARS-CoV-2 infection. First information from China and the initial recommendations of the World Health Organization (WHO) quickly led us to consider early intubation and mechanical ventilation of patients with hypoxemic COVID-19 pneumonia. However, since the end of March 2020, feedback from Italian intensive care and emergency physicians, then Spanish, led to change in clinical practices and guidelines about oxygenation and mechanical or noninvasive ventilation of COVID-19 patients have evolved. The exceptional character of this pandemic and the great adaptability of French pre-hospital emergency medical services (Samu/Smur) in a few weeks, to manage those oxygen dependent patients, justified our feedback, especially because we are exposed to a risk of resurgence of serious short-term SARS-CoV-2-associated acute respiratory distress syndrome (ARDS), which could once again saturate our health system. We therefore detail here the feedback of pre-hospital medical care, mainly concerning the management of oxygenation and ventilation supports.
ABSTRACT
Background : SARS-CoV-2 infection can trigger an important immune reaction, induce antiphospholipid antibodies, and is associated with a high-risk of venous thromboembolism (VTE), especially in patients with severe or critical disease. Hydroxychloroquine is an immunomodulator that had proven some efficacy in preventing thrombosis in antiphospholipid syndrome. Aims : To investigate if hydroxychloroquine prevents symptomatic VTE in patients with mild to moderate COVID-19. Methods : Ancillary study of HYCOVID trial, a prospective, multicenter, randomized, double-blind trial aiming to assess the efficacy of hydroxychloroquine with regard to the 14-day rate of death or invasive ventilation ( https://clini caltr ials.gov/ct2/show/NCT04 325893 ). COVID-19 patients were included, with their informed consent, if they had at least one of the following risk factors for worsening: need for supplemental oxygen, age ≥75 years, age between 60 -74 years and presence of at least one comorbidity. Eligible patients were randomized to receive either 800 mg hydroxychloroquine on Day 0 followed by 400 mg per day for 8 days, or a placebo. In the present study, we assessed the 28-day cumulative rate of symptomatic VTE. All suspected events were adjudicated by an independent committee, blinded to treatment allocation. Results : Two hundred and fifty patients were enrolled;124 and 123 patients received hydroxychloroquine or placebo and were included in the modified intention-to-treat analysis, respectively. Eightyseven percent of the patients received an anticoagulant treatment during hospitalization (104 [83.9%] and 111 [91.2%] in the hydroxychloroquine and the placebo group, respectively) (Table). Two patients in each group experienced VTE within the 28 days following inclusion. All events were pulmonary embolism (PE), including one fatal PE in the placebo group. The VTE rate was 1.61% (95%CI: 0.20 to 5.70) in the hydroxychloroquine group and 1.63% (95% confidence interval: 0.20 to 5.75) in the placebo group ( P = 1.00). Conclusions : In patients hospitalized for mild to moderate COVID-19, the rate of symptomatic VTE was low with no evidence of benefit of hydroxychloroquine.
ABSTRACT
Background : Severely ill patients with SARS-CoV-2 have at increased risk of venous thromboembolism (VTE). However, the VTE risk in patients with mild to moderate COVID-19 remains uncertain. Aims : To assess the risk of VTE in patients with mild to moderate COVID-19 patients versus similar patients without COVID-19 and to define VTE risk factors in COVID-19 patients. Methods : A prospective cohort of patients presented to ED for acute dyspnea or chest pain and having confirmed or probable mild to moderate COVID-19 was retrospectively compared to a prospective cohort of similar ED patients using propensity score matching. Patients having diagnostic testing for suspected PE and for whom PE was initially ruled-out were included. Univariate and multivariate analysis of possible VTE risk factors were performed in the COVID-19 patients. The main outcome was the rate of symptomatic VTE, deep venous thrombosis or pulmonary embolism, within the 28 days after ED presentation. Results : A total of 2292 patients were included in the COVID-19 cohort and 1539 in the comparison cohort. After adjustment, the 28-day rate of symptomatic VTE was 1.87% (95%CI: 0.95 to 3.24) in the COVID-19 cohort and 0.18% (95%CI: 0.01 to 1.63) in the comparison cohort. The absolute difference was +1.69% (95%CI: 0.88 to 2.51, P < 0.001), +3.45% (95%CI: 1.80 to 5.11) in hospitalized patients and +0.50% (95%CI: 0.22 to 1.23) in patients treated at home. In the COVID-19 cohort, hospitalization and age > 65 years were independent risk factors of symptomatic VTE but not the lack of thromboprophylaxis. Conclusions : Patients with mild-to-moderate COVID-19 presenting to ED had a higher risk of subsequent VTE than similar patients, especially if they are older than 65 years and required hospitalization.
ABSTRACT
We aim to assess physicians' level of resilience and define factors that improve or decrease the resilience level during the COVID-19 pandemic. Physicians from hospitals located in areas with different COVID-19 caseload levels, were invited to participate in a national e-survey between April and May 2020. Study participants were mainly emergency physicians, and anaesthesiologists, infectious disease consultants, and intensive care. The survey assessed participant's characteristics, factors potentially associated with resilience, and resilience using the Connor-Davidson Resilience Scale (RISC-25), with higher scores indicative of greater resilience. Factors associated with the resilience score were assessed using a multivariable linear regression. Of 451 responding physicians involved in the care of COVID-19 patients, 442 were included (98%). Age was 36.1 ± 10.3 years and 51.8% were male; 63% worked in the emergency department (n = 282), 10.4% in anesthesiology (n = 46), 9.9% in infectious disease department (n = 44), 4.8% in intensive care unit (n = 21) or other specialties (n = 49). The median RISC-25 score was at 69 (IQR 62-75). Factors associated with higher RISC scores were anesthesia as a specialty, parenthood, no previous history of anxiety or depression and nor increased anxiety. To conclude, this study is the first to characterize levels of resilience among physicians involved in COVID-19 unit. Our data points to certain protective characteristics and some detrimental factors, such as anxiety or depression, that could be amenable to remediating or preventing strategies to promote resilience and support caregivers in a pandemic.
Subject(s)
COVID-19 , Physicians , Resilience, Psychological , Adult , Anxiety , Female , Humans , Male , Middle Aged , Pandemics , SARS-CoV-2ABSTRACT
In the context of the COVID-19 pandemic and overloaded hospitals, a central issue is the need to define reliable and consensual criteria for hospitalization or outpatient management in mild cases of COVID-19. Our aim was to define an easy-to-use clinical rule aiming to help emergency physicians in hospitalization or outpatient management decision-making for patients with suspected or confirmed SARS-CoV-2 infection (the HOME-CoV Rule). The Delphi method was used to reach a consensus of a large panel of 51 experts: emergency physicians, geriatricians, infectious disease specialists, and ethical consultants. A preliminary list of eligible criteria was compiled based on a literature review. Four rounds of anonymized expert consultations were performed. The experts were asked to score each item as relevant, possibly relevant and non-relevant, as major or minor, and to choose the cut-off. They were also able make suggestions and remarks. Eight criteria constituting the HOME-CoV were selected: six correspond to the severity of clinical signs, one to the clinical course (clinically significant worsening within the last 24 hours), and the last corresponds to the association of a severe comorbidity and an inadequate living context. Hospitalization is deemed necessary if a patient meets one or more of the criteria. In the end, 94.4% of the experts agreed with the defined rule. Thanks to the Delphi method, an absolute consensus was obtained of a large panel of experts on the HOME-CoV rule, a decision-making support mechanism for clinicians to target patients with suspected or confirmed COVID-19 requiring hospitalization.Trial registration: NCT04338841