Immunohistologic Features of Cerebral Venous Thrombosis Due to Vaccine-Induced Immune Thrombotic Thrombocytopenia.

OBJECTIVES: Vaccine-induced immune thrombotic thrombocytopenia (VITT), a recently described entity characterized by thrombosis at unusual locations such as cerebral venous sinus and splanchnic vein, has been rarely described after adenoviral-encoded COVID-19 vaccines. In this study, we report the immunohistological correlates in 3 fatal cases of cerebral venous thrombosis related to VITT analyzed at an academic medical center. METHODS: Detailed neuropathologic studies were performed in 3 cases of cerebral venous thrombosis related to VITT after adenoviral COVID-19 vaccination. RESULTS: Autopsy revealed extensive cerebral vein thrombosis in all 3 cases. Polarized thrombi were observed with a high density of neutrophils in the core and a low density in the tail. Endothelial cells adjacent to the thrombus were largely destroyed. Markers of neutrophil extracellular trap and complement activation were present at the border and within the cerebral vein thrombi. SARS-CoV-2 spike protein was detected within the thrombus and in the adjacent vessel wall. DISCUSSION: Data indicate that neutrophils and complement activation associated with antispike immunity triggered by the vaccine is probably involved in the disease process.

Decompressive surgery in cerebral venous sinus thrombosis due to vaccine-induced immune thrombotic thrombocytopenia.

BACKGROUND AND PURPOSE: Cerebral venous sinus thrombosis due to vaccine-induced immune thrombotic thrombocytopenia (CVST-VITT) is an adverse drug reaction occurring after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. CVST-VITT patients often present with large intracerebral haemorrhages and a high proportion undergoes decompressive surgery. Clinical characteristics, therapeutic management and outcomes of CVST-VITT patients who underwent decompressive surgery are described and predictors of in-hospital mortality in these patients are explored. METHODS: Data from an ongoing international registry of patients who developed CVST within 28 days of SARS-CoV-2 vaccination, reported between 29 March 2021 and 10 May 2022, were used. Definite, probable and possible VITT cases, as defined by Pavord et al. (N Engl J Med 2021; 385: 1680-1689), were included. RESULTS: Decompressive surgery was performed in 34/128 (27%) patients with CVST-VITT. In-hospital mortality was 22/34 (65%) in the surgical and 27/94 (29%) in the non-surgical group (p < 0.001). In all surgical cases, the cause of death was brain herniation. The highest mortality rates were found amongst patients with preoperative coma (17/18, 94% vs. 4/14, 29% in the non-comatose; p < 0.001) and bilaterally absent pupillary reflexes (7/7, 100% vs. 6/9, 67% with unilaterally reactive pupil, and 4/11, 36% with bilaterally reactive pupils; p = 0.023). Postoperative imaging revealed worsening of index haemorrhagic lesion in 19 (70%) patients and new haemorrhagic lesions in 16 (59%) patients. At a median follow-up of 6 months, 8/10 of surgical CVST-VITT who survived admission were functionally independent. CONCLUSIONS: Almost two-thirds of surgical CVST-VITT patients died during hospital admission. Preoperative coma and bilateral absence of pupillary responses were associated with higher mortality rates. Survivors often achieved functional independence.

Perioperative Risk Assessment of Patients Using the MyRISK Digital Score Completed Before the Preanesthetic Consultation: Prospective Observational Study.

BACKGROUND: The ongoing COVID-19 pandemic has highlighted the potential of digital health solutions to adapt the organization of care in a crisis context. OBJECTIVE: Our aim was to describe the relationship between the MyRISK score, derived from self-reported data collected by a chatbot before the preanesthetic consultation, and the occurrence of postoperative complications. METHODS: This was a single-center prospective observational study that included 401 patients. The 16 items composing the MyRISK score were selected using the Delphi method. An algorithm was used to stratify patients with low (green), intermediate (orange), and high (red) risk. The primary end point concerned postoperative complications occurring in the first 6 months after surgery (composite criterion), collected by telephone and by consulting the electronic medical database. A logistic regression analysis was carried out to identify the explanatory variables associated with the complications. A machine learning model was trained to predict the MyRISK score using a larger data set of 1823 patients classified as green or red to reclassify individuals classified as orange as either modified green or modified red. User satisfaction and usability were assessed. RESULTS: Of the 389 patients analyzed for the primary end point, 16 (4.1%) experienced a postoperative complication. A red score was independently associated with postoperative complications (odds ratio 5.9, 95% CI 1.5-22.3; P=.009). A modified red score was strongly correlated with postoperative complications (odds ratio 21.8, 95% CI 2.8-171.5; P=.003) and predicted postoperative complications with high sensitivity (94%) and high negative predictive value (99%) but with low specificity (49%) and very low positive predictive value (7%; area under the receiver operating characteristic curve=0.71). Patient satisfaction numeric rating scale and system usability scale median scores were 8.0 (IQR 7.0-9.0) out of 10 and 90.0 (IQR 82.5-95.0) out of 100, respectively. CONCLUSIONS: The MyRISK digital perioperative risk score established before the preanesthetic consultation was independently associated with the occurrence of postoperative complications. Its negative predictive strength was increased using a machine learning model to reclassify patients identified as being at intermediate risk. This reliable numerical categorization could be used to objectively refer patients with low risk to teleconsultation.

Mass Training In Situ During COVID-19 Pandemic: Enhancing Efficiency and Minimizing Sick Leaves.

INTRODUCTION: Avoiding coronavirus disease 2019 (COVID-19) work-related infection in frontline healthcare workers is a major challenge. A massive training program was launched in our university hospital for anesthesia/intensive care unit and operating room staff, aiming at upskilling 2249 healthcare workers for COVID-19 patients' management. We hypothesized that such a massive training was feasible in a 2-week time frame and efficient in avoiding sick leaves. METHODS: We performed a retrospective observational study. Training focused on personal protective equipment donning/doffing and airway management in a COVID-19 simulated patient. The educational models used were in situ procedural and immersive simulation, peer-teaching, and rapid cycle deliberate practice. Self-learning organization principles were used for trainers' management. Ordinary disease quantity in full-time equivalent in March and April 2020 were compared with the same period in 2017, 2018, and 2019. RESULTS: A total of 1668 healthcare workers were trained (74.2% of the target population) in 99 training sessions over 11 days. The median number of learners per session was 16 (interquartile range = 9-25). In the first 5 days, the median number of people trained per weekday was 311 (interquartile range = 124-385). Sick leaves did not increase in March to April 2020 compared with the same period in the 3 preceding years. CONCLUSIONS: Massive training for COVID-19 patient management in frontline healthcare workers is feasible in a very short time and efficient in limiting the rate of sick leave. This experience could be used in the anticipation of new COVID-19 waves or for rapidly preparing hospital staff for an unexpected major health crisis.

Systematic Screening for Deep Vein Thrombosis in Critically Ill Inpatients With COVID-19: Impact on the Incidence of Venous Thromboembolism.

Background: Several studies suggest an increased incidence of thrombosis in COVID-19 patients. However, evidence on how to prevent and even treat it is scarce. The aim of this study was to compare the cumulative incidence of venous thromboembolism (VTE) of two different methods for lower extremity deep vein thrombosis (LE-DVT) diagnosis: systematic vs. clinically guided complete compression venous ultrasonography (CCUS). We conducted a monocentric, prospective, open-label, non-randomized study. All consecutive patients admitted in three intensive care units (ICUs) of University Hospital of Toulouse for COVID-19 pneumonia were included: one performed systematic screening for LE-DVT, the others did not. The primary outcome was the 21-day cumulative incidence of VTE. The secondary end points were the 21-day cumulative incidences of major bleeding and death. Results: Among the 78 patients included, 27 (34.6%) underwent systematic screening for DVT 7 ± 2 days after ICU admission. Thirty-two patients (41.0%) were diagnosed with VTE, with a 21-day cumulative incidence of 42.3% (95% CI, 31.4-55.2), without difference between screened and non-screened patients (hazard ratio 1.45, 95% CI, 0.72-2.93). In the screened group, the frequency of isolated DVT was higher (25.9 vs. 5.9%, p-value = 0.027), but the frequency of pulmonary embolism was not reduced (25.9 vs. 29.4%, p-value = 0.745). The 21-day cumulative incidences of major bleeding and death were 9.6% (95% CI, 4.7-19.2) and 10.3% (95% CI, 5.0-20.8), respectively, without difference between the two groups. Conclusions: A systematic screening for DVT in patients hospitalized in ICU was not associated with a higher diagnosis of VTE or a reduced diagnosis of PE.

Brain MRI Findings in Severe COVID-19: A Retrospective Observational Study.

Background Brain MRI parenchymal signal abnormalities have been associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Purpose To describe the neuroimaging findings (excluding ischemic infarcts) in patients with severe coronavirus disease 2019 (COVID-19) infection. Materials and Methods This was a retrospective study of patients evaluated from March 23, 2020, to April 27, 2020, at 16 hospitals. Inclusion criteria were (a) positive nasopharyngeal or lower respiratory tract reverse transcriptase polymerase chain reaction assays, (b) severe COVID-19 infection defined as a requirement for hospitalization and oxygen therapy, (c) neurologic manifestations, and (d) abnormal brain MRI findings. Exclusion criteria were patients with missing or noncontributory data regarding brain MRI or brain MRI showing ischemic infarcts, cerebral venous thrombosis, or chronic lesions unrelated to the current event. Categorical data were compared using the Fisher exact test. Quantitative data were compared using the Student t test or Wilcoxon test. P < .05 represented a significant difference. Results Thirty men (81%) and seven women (19%) met the inclusion criteria, with a mean age of 61 years ± 12 (standard deviation) (age range, 8-78 years). The most common neurologic manifestations were alteration of consciousness (27 of 37, 73%), abnormal wakefulness when sedation was stopped (15 of 37, 41%), confusion (12 of 37, 32%), and agitation (seven of 37, 19%). The most frequent MRI findings were signal abnormalities located in the medial temporal lobe in 16 of 37 patients (43%; 95% confidence interval [CI]: 27%, 59%), nonconfluent multifocal white matter hyperintense lesions seen with fluid-attenuated inversion recovery and diffusion-weighted sequences with variable enhancement, with associated hemorrhagic lesions in 11 of 37 patients (30%; 95% CI: 15%, 45%), and extensive and isolated white matter microhemorrhages in nine of 37 patients (24%; 95% CI: 10%, 38%). A majority of patients (20 of 37, 54%) had intracerebral hemorrhagic lesions with a more severe clinical presentation and a higher admission rate in intensive care units (20 of 20 patients [100%] vs 12 of 17 patients without hemorrhage [71%], P = .01) and development of the acute respiratory distress syndrome (20 of 20 patients [100%] vs 11 of 17 patients [65%], P = .005). Only one patient had SARS-CoV-2 RNA in the cerebrospinal fluid. Conclusion Patients with severe coronavirus disease 2019 and without ischemic infarcts had a wide range of neurologic manifestations that were associated with abnormal brain MRI scans. Eight distinctive neuroradiologic patterns were described. © RSNA, 2020.

Guidelines: Anaesthesia in the context of COVID-19 pandemic.

OBJECTIVES: The world is currently facing an unprecedented healthcare crisis caused by the COVID-19 pandemic. The objective of these guidelines is to produce a framework to facilitate the partial and gradual resumption of intervention activity in the context of the COVID-19 pandemic. METHODS: The group has endeavoured to produce a minimum number of recommendations to highlight the strengths to be retained in the 7 predefined areas: (1) protection of staff and patients; (2) benefit/risk and patient information; (3) preoperative assessment and decision on intervention; (4) modalities of the preanaesthesia consultation; (5) specificity of anaesthesia and analgesia; (6) dedicated circuits and (7) containment exit type of interventions. RESULTS: The SFAR Guideline panel provides 51 statements on anaesthesia management in the context of COVID-19 pandemic. After one round of discussion and various amendments, a strong agreement was reached for 100% of the recommendations and algorithms. CONCLUSION: We present suggestions for how the risk of transmission by and to anaesthetists can be minimised and how personal protective equipment policies relate to COVID-19 pandemic context.