ABSTRACT
Background: Lung-protective ventilation (LPV) with low tidal volumes (TV), aimed to reduce ventilator-induced lung injury, is one of the cornerstones in the treatment of acute respiratory distress syndrome (ARDS), including that secondary to Coronavirus disease 2019 (COVID-19). To allow LPV, and avoid the risk of progressive hypercapnia and respiratory acidosis, a wide range of extracorporeal CO2 removal (ECCO2R) techniques have been developed. These treatments may be performed alone or in combination with other organ support therapies. Here, we report our experience with a pregnant woman with multiorgan failure (MOF), occurring as a sequela of COVID-19, who was successfully treated with ECCO2R coupled with continuous renal replacement therapy (CRRT). Case Presentation: A 34-year-old pregnant patient at the 16th gestational week affected by COVID-19 was admitted for dyspnea, rapidly complicated by MOF. Because of concomitant hypercapnia and acute kidney injury the patient was treated with an ECCO2R membrane inserted in series after a hemofilter in a common CRRT platform. ECCO2R was provided using a polymethyl pentene, hollow fiber, gas-exchanger membrane of 1.35 m2. ECCO2R+CRRT was set in continuous venovenous hemodialysis (CVVHD) mode with blood flow of 300 mL/min and a sweep gas blood flow of 5 l/min. Systemic anticoagulation was obtained by continuous administration of unfractionated heparin (UFH), with a target activated partial thromboplastin time (aPTT) of 70-80 seconds. (In table 1, ventilatory and hemodynamic parameters collected during ECCO2R+CRRT treatment are reassumed). The combined treatment was effective in reducing hypercapnia, allowing the maintenance of LPV. Moreover, it was associated with the hemodynamic stability of both mother and fetus and it was well-tolerated. Anyway, the treatment was complicated by minor bleeding episodes mainly linked to the anticoagulation required to maintain the patency of the extracorporeal circuit. After ECCO2R+CRRT termination, the patient progressively recovered pulmonary and kidney function, so that it was possible to withdraw any support therapy. Moreover, she underwent a preterm spontaneous vaginal delivery of an alive baby. Conclusion(s): Our case supports the use of ECCO2R+CRRT as a suitable approach in complex patients, including those with severe COVID-19, being aware of the potential complications linked to this treatment.
ABSTRACT
Background: Occurrence of acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT) in patients with Coronavirus disease-19 (COVID-19) is associated with an elevated mortality rate. However, due to the high clinical impact, the COVID-19 has been the object of extensive studies that have potentially changed disease presentation and outcomes. In this regard, the development of vaccination has shown high effectiveness in preventing severe disease, hospitalization, and death related to COVID- 19. Thus, this study aimed at investigating whether any difference exists in clinical presentation, management, and mortality of COVID- 19 critically ill patients requiring CRRT before and after the vaccination campaigns. Method(s): We performed a retrospective study on critically ill adult COVID-19 patients with AKI undergoing CRRT in the Intensive care Unit (ICU) before (from March 2020 to March 2021- 1st Group) and after (from April 2021 to March 2022- 2nd Group) the availability of COVID-19 vaccines. Result(s): Overall, we considered 111 patients, aged 64 (62-65) years, 75.7 % males. The main comorbidities were diabetes (DM), lung diseases, cardiovascular disease, and hypertension. Among them, 88 (79%) were in 1st and 23 (21%) in the 2nd group, respectively. The 2nd group included 5 (22%) patients vaccinated against COVID-19, a percentage significantly lower than that reported for the Italian age-matched general population (i.e. 84.4%) There were no significant differences in general characteristics, such as in comorbidities, except for a higher prevalence of hypertension in the 1st group. Lab examinations at ICU admission were similar between the two groups except for procalcitonin and lactate dehydrogenase, which were higher in the 2nd group. While ventilation strategies were not different between the two groups, ECMO was used in a significantly higher number of patients in the 2nd group (30 vs 4%, p<0.001). Regarding specific drug therapy, while hydroxychloroquine was abandoned in the 2nd group, the use of heparin significantly increased, and monoclonal antibodies were introduced in the clinical practice (and prescribed in 4/23 patients of the 2nd group). CRRT was mostly provided according to CVVHD modality (about 87% in both groups) and sepsis devices were used in 45.4 and 56.5% of the 1st and the 2nd group, respectively. Looking at the outcomes, in terms of length of ICU stay and mortality, we found no significant difference between the two groups. Indeed, 58 (66%) and 15 (68%) patients died in ICU in the 1st and the 2nd group, respectively. Finally, considering the whole population at multivariate Cox regression, the length of ICU hospitalization, days on CRRT, invasive ventilation, and DM were independently related to the 90-day mortality rate. Conclusion(s): Despite the recent acquisitions and progress in COVID-19 pathogenesis and management, when compared with patients undergoing CRRT during the first phases of the pandemic, patients critically ill COVID-19 requiring CRRT after the availability of vaccines presented similar clinical characteristics and poor outcomes. This population was characterized by a low vaccination rate when compared with the general population, suggesting that this factor could be a key determinant of the clinical course of these patients. These data further reinforce the concept that in absence of established effective treatments, the most useful strategy to reduce COVID-19-related mortality is constituted by the prevention of the severe form of the disease, through the wide diffusion and universal implementation of vaccines.
ABSTRACT
The coronavirus (COVID-19) pandemic affected teaching modality worldwide. Indeed, there was an immediate urge to transition from face-to-face to online teaching to avoid the COVID-19 spread. The speed of such process led to the employment of emergency remote teaching. While the effectiveness and the advantages of planned online teaching modalities were well-assessed, little is known about implementing emergency remote teaching on learning processes. Accordingly, the present study aimed to evaluate the differences between face-to-face teaching and remote modality in terms of engagement, perceived learning, and the goodness of the learning environment from a student's perspective. Results showed that students perceived no differences between face-to-face and remote modalities. Such findings suggest that a remote intervention can provide high engagement, perceived learning, and a positive learning environment in emergencies, such as the COVID-19 pandemic. © 2021, The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd.