ABSTRACT
Introduction: The respiratory mechanics, particularly static compliance of the respiratory system ( CRS) in COVID-19 acute respiratory distress syndrome (CARDS) is poorly understood. Whether or not distinct ARDS phenotypes based on CRS exist is still widely debated. Methods: We conducted a systematic review and meta-analysis, searching three international databases from 1st December 2019 to 15th July 2021 for studies reporting on the respiratory mechanics of patients with CARDS. The primary outcome was the CRS of both COVID-19 ARDS. Secondary outcomes included the mortality rates, lengths of stay, and ventilator free days. Random-effects (DerSimonian and Laird) meta-analyses were conducted. Results: 45 studies (13,334 patients) were included for analysis. The pooled CRS in patients mechanically ventilated for COVID-19 was 34.6 (95%-CI: 33.4-35.8), and displayed a normal distribution (Shapiro- Wilk test: p = 0.35). CRS was significantly associated with an PaO2/FiO2 ratio, positive end-expiratory pressure, and tidal volume;driving pressure was negatively associated with CRS. The pooled mortality rate was 36.2% (95%-CI: 30.3-42.4%, ICU) and 38.9% (95%- CI: 32.3-45.7%, 28-day). Conclusions: The respiratory mechanics of CARDS at the time closest to the initiation of invasive mechanical ventilation was normally distributed and did not reveal any distinct CRS- based phenotypes. However, to what extent the proposed unique pathophysiology of CARDS affects the current definition of ARDS and “exposes” its potential limitations remains a question for a high-quality, large prospective dataset to answer. Nonetheless, from our study-level analysis, CRS appears to be a heterogenous metric affected by both disease and intervention factors (Fig. 1) and physicians should treat patients with personalised and precise interventions in this context. (Table Presented).
ABSTRACT
Objective: To identify the incidence of infections in those receiving immunomodulatory drugs for COVID- 19 during ECMO and the risk factors for infection. Methods: Deidentified data on all patients who had ECMO for COVID-19 till July 2020 were analysed from the ELSO Registry. A comparison cohort of patients who did not acquire superinfections during ECMO was used to identify risk factors for infection. Our primary outcome measure was incidence of infections pre- or on ECMO in patients receiving immunomodulatory drugs. Univariate analysis assessed potential associations between survival and various pre-ECMO/ECMOrelated factors. Variables (p< 0.1) entered a logistic regression model which identified predictors of infections in this cohort. Results: Of the 1237 patients who required ECMO for COVID-19 related complications, 911 patients (73.6%) received immunomodulatory drugs. 47% of these patients had superinfections, predominantly with gram negative bacteria (56%). Pre-ECMO factors associated with a higher odds of infection included immunodeficiency and treatment with selective cytokine blockers. ECMO complications (mechanical, renal, pulmonary, infectious and metabolic) increased the odds of infection. (Table 1) Patients who developed an infection preor on ECMO had significantly longer ECMO runs than those who did not (491.1±308.9 hours vs 293.4± 240.6hours, p< 0.001) with no mortality difference (45.7% Vs 43.4%, p = 0.45). Conclusions: Of the three quarter of patients who received immunomodulatory drugs for COVID-19 during ECMO, 47% had superinfections. Immunodeficiency and use of selective cytokine blockers were risk factors for infections pre or on ECMO in addition to ECMO related complications.
ABSTRACT
INTRODUCTION: Coronavirus disease 2019 (COVID-19)-induced coagulopathy (CIC) has been widely reported in the literature. However, the spectrum of abnormalities associated with CIC has been highly variable. METHODS: We conducted a systematic review of the literature (until 1 June 2020) to assess CIC and disease severity during the early COVID-19 pandemic. Primary outcomes were pooled mean differences in platelet count, D-dimer level, prothrombin time, activated partial thromboplastin time (aPTT) and fibrinogen level between non-severe and severe patients, stratified by degree of hypoxaemia or those who died. The risk factors for CIC were analysed. Random-effects meta-analyses and meta-regression were performed using R version 3.6.1, and certainty of evidence was rated using the Grading of Recommendation, Assessment, Development, and Evaluation approach. RESULTS: Of the included 5,243 adult COVID-19 patients, patients with severe COVID-19 had a significantly lower platelet count, and higher D-dimer level, prothrombin time and fibrinogen level than non-severe patients. Pooled mean differences in platelet count (-19.7×109/L, 95% confidence interval [CI] -31.7 to -7.6), D-dimer level (0.8μg/mL, 95% CI 0.5-1.1), prothrombin time (0.4 second, 95% CI 0.2-0.6) and fibrinogen level (0.6g/L, 95% CI 0.3-0.8) were significant between the groups. Platelet count and D-dimer level were significant predictors of disease severity on meta-regression analysis. Older men had higher risks of severe coagulopathic disease. CONCLUSION: Significant variability in CIC exists between non-severe and severe patients, with platelet count and D-dimer level correlating with disease severity. Routine monitoring of all coagulation parameters may help to assess CIC and decide on the appropriate management.