Medical Nutrition Therapy in Critically Ill Patients with COVID-19—A Single-Center Observational Study

Medical nutrition should be tailored to cover a patient's needs, taking into account medical and organizational possibilities and obstacles. This observational study aimed to assess calories and protein delivery in critically ill patients with COVID-19. The study group comprised 72 subjects hospitalized in the intensive care unit (ICU) during the second and third SARS-CoV-2 waves in Poland. The caloric demand was calculated using the Harris–Benedict equation (HB), the Mifflin–St Jeor equation (MsJ), and the formula recommended by the European Society for Clinical Nutrition and Metabolism (ESPEN). Protein demand was calculated using ESPEN guidelines. Total daily calorie and protein intakes were collected during the first week of the ICU stay. The median coverages of the basal metabolic rate (BMR) during day 4 and day 7 of the ICU stay reached: 72% and 69% (HB), 74% and 76% (MsJ), and 73% and 71% (ESPEN), respectively. The median fulfillment of recommended protein intake was 40% on day 4 and 43% on day 7. The type of respiratory support influenced nutrition delivery. A need for ventilation in the prone position was the main difficulty to guarantee proper nutritional support. Systemic organizational improvement is needed to fulfill nutritional recommendations in this clinical scenario.

Medical Nutrition Therapy in Critically Ill Patients with COVID-19-A Single-Center Observational Study.

Medical nutrition should be tailored to cover a patient's needs, taking into account medical and organizational possibilities and obstacles. This observational study aimed to assess calories and protein delivery in critically ill patients with COVID-19. The study group comprised 72 subjects hospitalized in the intensive care unit (ICU) during the second and third SARS-CoV-2 waves in Poland. The caloric demand was calculated using the Harris-Benedict equation (HB), the Mifflin-St Jeor equation (MsJ), and the formula recommended by the European Society for Clinical Nutrition and Metabolism (ESPEN). Protein demand was calculated using ESPEN guidelines. Total daily calorie and protein intakes were collected during the first week of the ICU stay. The median coverages of the basal metabolic rate (BMR) during day 4 and day 7 of the ICU stay reached: 72% and 69% (HB), 74% and 76% (MsJ), and 73% and 71% (ESPEN), respectively. The median fulfillment of recommended protein intake was 40% on day 4 and 43% on day 7. The type of respiratory support influenced nutrition delivery. A need for ventilation in the prone position was the main difficulty to guarantee proper nutritional support. Systemic organizational improvement is needed to fulfill nutritional recommendations in this clinical scenario.

Mortality in critically ill COVID­19 patients with fungal infections: a comprehensive systematic review and meta­analysis.

INTRODUCTION: Patients with COVID­19 may develop concomitant viral, bacterial, or fungal infections. Such patients are at a higher risk of death, especially from a critical illness. Although much attention has been recently given to fungal infections that may have devastating consequences, data on this issue are scarce. OBJECTIVES: The aim of the study was to assess the impact and prevalence of fungal infections in critically ill patients with COVID 19. METHODS: We systematically searched for studies that focused on critically ill adults diagnosed with COVID­19 and a fungal coinfection. Mortality was our outcome of interest. The search was conducted within MEDLINE, Web of Science, clinicaltrials.gov, Embase, and Cochrane Library on January 8, 2022. RESULTS: We reviewed 38 papers covering 17 695 patients, 1182 (6.7%) of whom had an acquired fungal infection. The overall mortality in the papers retrieved for a systematic review (n = 38) varied from 29% to 100% (median [IQR], 56% [40%-77%]). In a meta­analysis (19 studies), the patients with a fungal infection were more likely to die than the controls (odds ratio [OR], 2.987; 95% CI, 2.369-3.767; P <0.001; I2 = 26.63%). Subgroup analyses showed that COVID­19-associated pulmonary aspergillosis (CAPA) increased mortality by 3 times (OR, 3.279; 95% CI, 2.692-3.994; P <0.001; I2 = 0%), and that COVID­19-associated candidiasis (CAC) increased mortality by 2 times (OR, 2.254; 95% CI, 1.322-3.843; I2 = 26.14%). CONCLUSIONS: In critically ill patients with COVID­ 19, CAPA is rather common and significantly increases mortality. The evidence regarding other fungal infections is weaker, with CAC occurring less frequently but also impacting mortality. Therefore, clinical awareness and screening are needed, followed by personalized antifungal therapy stewardship, which is strongly recommended in order to improve the patients' prognosis.

Usefulness of Selected Peripheral Blood Counts in Predicting Death in Patients with Severe and Critical COVID-19.

BACKGROUND: Immune dysregulation and hypoxemia are two important pathophysiological problems in patients with COVID-19 that affect peripheral blood count parameters. We hypothesized that assessment of the neutrophil-lymphocyte ratio (NLR) and red blood cell distribution width index (RDW-SD) could predict death in patients with severe and critical COVID-19. METHODS: Seventy patients admitted to the intensive care unit (ICU) for COVID-19 acute respiratory failure were included in the study. RDW-SD and NLR on the day of ICU admission and peak values during the entire hospitalization were assessed. The primary endpoint was death before ICU discharge. RESULTS: Patients who died had higher NLR on admission (20.3, IQR 15.3-30.2 vs. 11.0, IQR 6.8-16.9; p = 0.003) and higher RDW-SD (48.1 fL; IQR 43.1-50.5 vs. 43.9 fL; IQR 40.9-47.3, p = 0.01) than patients discharged from the ICU. NLR and RDW-SD values on ICU admission accurately predicted death in 76% (AUC = 0.76; 95%CI 0.65-0.86; p = 0.001; cut-off > 14.38) and 72% of cases (AUC = 0.72; 95%CI 0.60-0.82; p = 0.003; cut-off > 44.7 fL), respectively. Multivariable analysis confirmed that NLR > 14.38 on the day of ICU admission was associated with a 12-fold increased risk of death (logOR 12.43; 95%CI 1.61-96.29, p = 0.02), independent of other blood counts, clinical and demographic parameters. CONCLUSIONS: Neutrophil-lymphocyte ratio determined on the day of ICU admission may be a useful biomarker predicting death in patients with severe and critical COVID-19.

Electrical impedance tomography as a tool for monitoring mechanical ventilation. An introduction to the technique.

Electrical impedance tomography (EIT) is a non-invasive, radiation-free method of diagnostics imaging, allowing for a bedside, real-time dynamic assessment of lung function. It stands as an alternative for other imagining methods, such as computed tomography (CT) or ultrasound. Even though the technique is rather novel, it has a wide variety of possible applications. In the era of modern mechanical ventilation, a dynamic assessment of patient's respiratory condition appears to fulfil the idea of personalized treatment. Additionally, an increasing frequency of respiratory failure among intensive care populations raises demand for improved monitoring tools. This review aims to raise awareness and presents possible implications for the use of EIT in the intensive care setting.

What Is the Role of Therapeutic Plasma Exchange as an Adjunctive Treatment in Severe COVID-19: A Systematic Review.

INTRODUCTION: Since the COVID-19 pandemic outbreak, multiple promising treatment modalities have been tested, however, only several of them were proven to be effective. Therapeutic plasma exchange (TPE) has been recently discussed as a possible supportive treatment for severe cases. METHODS: To investigate a possible role of TPE in severe COVID-19 we used a structured systematic search strategy to retrieve all relevant publications in the field. We screened in PubMed, EMBASE, Web of Science, Cochrane Library and clinicaltrials.gov for data published until the 4 June 2021. RESULTS: We identified 18 papers, enrolling 384 patients, 220 of whom received TPE. The number of TPE sessions ranged from 1 to 9 and the type of replacement fluid varied markedly between studies (fresh frozen plasma or 5% albumin solution, or convalescent plasma). Biochemical improvement was observed in majority of studies as far as C-reactive protein (CRP), interleukin-6 (IL-6), ferritin, lactate dehydrogenase (LDH), D-dimer concentrations and lymphocyte count are concerned. The improvement at a laboratory level was associated with enhancement of respiratory function. Adverse effects were limited to five episodes of transient hypotension and one femoral artery puncture and thrombophlebitis. CONCLUSIONS: Although the effect of therapeutic plasma exchange on mortality remains unclarified, the procedure seems to improve various secondary end-points such as PaO2/FiO2 ratio or biomarkers of inflammation. Therapeutic plasma exchange appears to be a safe treatment modality in COVID-19 patients in terms of side effects.

Veno-Venous Extracorporeal Membrane Oxygenation in COVID-19-Where Are We Now?

The recent development in extracorporeal life support (ECLS) has created new therapeutic opportunities for critically ill patients. An interest in extracorporeal membrane oxygenation (ECMO), the pinnacle of ECLS techniques, has recently increased, as for the last decade, we have observed improvements in the survival of patients suffering from severe acute respiratory distress syndrome (ARDS) while on ECMO. Although there is a paucity of conclusive data from clinical research regarding extracorporeal oxygenation in COVID-19 patients, the pathophysiology of the disease makes veno-venous ECMO a promising option.

Basics of mechanical ventilation for non-anaesthetists. Part 1: Theoretical aspects.

The expanding number of chronic respiratory diseases and the new Covid-19 outbreak create an increasing demand for mechanical ventilation (MV). As MV is no longer limited to intensive care units (ICU) and operating rooms (OR), more clinicians should acquaint themselves with the principles of mechanical ventilation. To fully acknowledge contemporary concepts of MV, it is crucial to understand the elemental physiology and respiratory machine nuances. This paper addresses the latter issues and provides insight into ventilation modes and essential monitoring of MV.