High-Flow Nasal Cannula Combined with Prone Positioning as an Intubation Alternative in Covid-19: A Case Report and Review of the Literature

The use of high-flow nasal cannula (HFNC) in COVID-19 patients is a contro-versial topic due to the benefits and risks which may occur in patients and healthcare workers. The goal of this treatment modality is potential avoidance of invasive mechanical ventilation, but generation of aerosol and increased healthcare professional infection risk must be considered. We present a case of a SARS-CoV-2-positive 71-year-old male with acute hypoxemic respiratory failure, who was success-fully treated with HFNC combined with prone positioning. Furthermore, we discuss recent literature concerning potential issues of HFNC treatment in COVID-19 patients.

Acute thrombosis of portal, lienal, superior mesenteric and inferior mesenteric veins as a rare complication of COVID-19

Since the first SARS-CoV-2 case in humans wasreported at the end of 2019, a pandemic of COVID-19 disease spread around theworld, causing not only respiratory symptoms, but also a hypercoagulable statein some patients with severe forms of infection. In this case report we present a young male patient with nocomorbidities, who presents in the ER with severe abdominal pain. Physical examination,laboratory tests and imaging showed acute portal, splenic and mesenteric veinthrombosis. After he had been hospitalised the nasopharyngeal swab was positivefor SARS-CoV-2. He was treated in ICU UH Dubrava for COVID-19 patients (PRIC) withtherapeutic doses of low molecular weight heparin, and when the PCR swab forSARS-CoV-19 was negative, he was transferred to Haematology ward where theyperformed tests and excluded some of the most common diseases associated withhypercoagulability, and in a good condition he was discharged from thehospital. © 2022 Hrvatski Lijecnicki Zbor. All rights reserved.

Correlation between inflammatory parameters and bloodstream infections caused by multidrug resistant Gram-negative bacteria in critically ill COVID-19 patients – retrospective single-center study

Objectives: During the COVID-19 pandemics we have seen in critically ill COVID-19 patients treated in the intensive care unit the parallel outbreak of multidrug resistant Gram-negative bacteria bloodstream infections, mainly Acinetobacter baumannii and Klebsiella pneumoniae. Methods: We conducted a retrospective cohort single-center study. The aim was to investigate the incidence, etiology and impact of intensive care unit bloodstream infections in COVID-19 patients admitted to the COVID-19 intensive care unit with a known burden of multidrug resistance and to evaluate the possibility that inflammatory parameters levels measured at two different time points of treatment can early predict multidrug resistant Gram-negative bacteria bloodstream infections and enable timely beginning of bacterial targeted antimicrobial therapy. Results: Our study confirmed that procalcitonin values of 2,46 mcg/L and neutrophil/lymphocyte ratio of 28,9 could be a reliable indicators for high risk stratification of multidrug resistant Gram-negative bacterial infection origin in critically ill COVID-19 patients (Mann Whitney U test, P=0,02). Conclusion: Monitoring dynamic shift of inflammatory parameters in critically ill COVID-19 patients could reliably help clinician to recognize the multidrug resistant Gram-negative bacteria bloodstream infections and start with the antimicrobial therapy in a timely manner. © 2022 Hrvatski Lijecnicki Zbor. All rights reserved.

Bacterial superinfections in critically ill COVID-19 patients – experiences from University Hospital Dubrava tertiary COVID-19 center

Goal:To determine incidence of bacterial superinfections, causative pathogens demographic data, relevant laboratory parameters and outcomes in critically ill COVID-19 patients treated in primary respiratory intensivist center (PRIC) UH Dubrava. Patients and methods: In this retrospective observational study, clinical and laboratory data of 692 critically ill patients treated in PRIC UH Dubrava between March 1st 2020. and February 1st 2021. was collected using the hospital information system software (BIS) and statistical analysis was performed using the jamovi statistical package. Results: Out of 692 patients admitted to the ICU, 383 acquired bacterial or fungal superinfections. 305 acquired pneumonia, 133 bloodstream infections and 120 urinary infections. 66.3% of patients were males, and bacterial superinfections were more common in patients admitted from hospital wards or external ICUs. Out of 305 patients with pneumonia, 295 were receiving mechanical ventilation and satisfied the criteria for ventilator associated pneumonia. Patients with bloodstream infections maintained elevated neutrophil lymphocyte ratio, lymphopenia and elevated CRP levels on day 7 compared to those without BSI. Urinary infections were more common in females, and did not have an effect on outcomes. All patients that developed superinfections had prolonged ICU and hospital stay. Conclusion: Incidence of bacterial superinfections in critically ill COVID-19 patients is 55.3%. Most common infections are ventilator associated pneumonia, bloodstream infections and urinary infections. Most common pathogens are multi-drug resistant pathogens. Patients with bacterial superinfections have longer ICU and hospital stay, and in these patients, persistent elevation of NLR ratio and worsening of lymphopenia are characteristic for patients with worse outcomes © 2022 Hrvatski Lijecnicki Zbor. All rights reserved.

Epidemiological characteristics, baseline clinical features, and outcomes of critically ill patients treated in a coronavirus disease 2019 tertiary center in continental Croatia

AIM: To describe epidemiological characteristics and baseline clinical features, laboratory findings at intensive care unit (ICU) admission, and survival rates of critically ill coronavirus disease 2019 (COVID-19) patients treated at a tertiary institution specialized for COVID-19 patients. METHODS: This retrospective study recruited 692 patients (67.1% men). Baseline demographic data, major comorbidities, anthropometric measurements, clinical features, and laboratory findings at admission were compared between survivors and non-survivors. RESULTS: The median age was 72 (64-78) years. The median body mass index was 29.1 kg/m2. The most relevant comorbidities were diabetes mellitus (32.6%), arterial hypertension (71.2%), congestive heart failure (19.1%), chronic kidney disease (12.6%), and hematological disorders (10.3%). The median number of comorbidities was 3 and median Charlson Comorbidity Index (CCI) was 5. A total of 61.8% patients received high-flow nasal oxygen therapy (HFNO) and 80.5% received mechanical ventilation (MV). Median duration of HFNO was 3, and that of MV was 7 days. ICU mortality rate was 72.7%. Survivors had significantly lower age, number of comorbidities, CCI, sequential organ failure assessment score, serum ferritin, C-reactive protein, D-dimer, and procalcitonin, interleukin-6, lactate, white blood cell, and neutrophil counts. They also had higher lymphocyte counts, PaO2/FiO2 ratio, and glomerular filtration rate at admission. Length of ICU stay was 9 days. The median survival was 11 days for mechanically ventilated patients, and 24 days for patients who were not mechanically ventilated. CONCLUSION: The parameters that differentiate survivors from non-survivors are in agreement with published data. Further multivariate analyses are warranted to identify individual mortality risk factors.

Knowledge, awareness and impact of the COVID-19 pandemic on students of biomedical faculties of the University of Zagreb

Introduction: The COVID-19 pandemic has affected all fields of life, including the student population. In a short period students had to get used to online teaching and a different approach to learning. The purpose of this research was to investigate and compare whether there is a difference in knowledge, attitudes, behavior and psychological impact of the COVID-19 pandemic among students of biomedical faculties at the University of Zagreb (School of Dental Medicine, School of Medicine, Faculty of Pharmacy and Biochemistry, Faculty of Veterinary Medicine). Materials and methods: The survey was conducted between November 2020 and January 2021. Participants were students of biomedical faculties of the University of Zagreb from 1st to 6th year through online survey (n =518). We distributed the survey through closed Facebook groups and student representatives of mentioned faculties. The survey questionnaire consisted of 4 parts: 13 questions about the SARS-COV-2 virus and COVID- 19 infection for knowledge assessment purposes, 13 questions on personal attitudes towards the COVID-19 pandemic, 10 questions on behavior and preventive measures during a pandemic and 23 questions on psychological impact of the pandemic on the lives of the respondents. Results: No statistically significant difference in knowledge was found between the exam- ined faculties H (3, N = 518) =7.814111;p = 0.05. 41% of students believe that the pandemic will last for another 6 months (from the moment of conducting a survey) while 58% of students disagree with the decisions of the National Civil Protection Headquarters Of the Republic of Croatia. Conclusion: In conclusion, although of different views, students of biomedical faculties have equal knowledge about pandemic COVID-19 and adhere to the directed guidelines to a greater extent. Variety of responses to questions about the psychological impact of a pandemic point to the importance of mental health and the support to overcome pandemic from a psychiatric and psychological aspect.

Specific aspects of respiratory support in COVID-19 patients

Acute hypoxemic respiratory failure is the main clinical feature of COVID-19 responsible for ICU admission. In patients who develop respiratory failure,the choice of respiratory support depends on changes in respiratory mechanics, and the goal of this article is to differentiate between clinical and pathophysiological features beneath the respiratory failure in order to select optimal treatment. In patients with preserved respiratory mechanics, lung compliance is normal and hypoxemia is caused by loss of hypoxic pulmonary vasoconstriction. Prone positioning combined with high flow nasal oxygen (HFNO) or non-invasive ventilation (NIV) is the therapy of choice in these patients. When acute respiratory distress syndrome (ARDS) is present, therapeutic approach is similar as with other viral pneumonias - initiation of mechanical ventilation via endotracheal tube, positive end expiratory pressure (PEEP) set to levels in which cyclic opening and closure of alveoli is avoided and fraction of inspired oxygen (FIO2) set to lowest possible levels needed to achieve arterial oxygen saturation of 90%.In order to avoid patient-ventilator dyssynchrony the use of sedatives (such as midazolam or dexmedetomidine) and neuromuscular relaxants is recommended. Extracorporeal support methods, such as extracorporeal membrane oxygenation and carbon dioxide removal which are proven to be effective when treating ARDS caused by other causes have not shown adequate efficacy in COVID-19 patients. © 2020 Hrvatski Lijecnicki Zbor. All rights reserved.