ABSTRACT
It is estimated that 50% of patients with coronavirus disease 2019 (COVID-19) have varying degrees of renal involvement. In this clinical biomarker development research, we examined in a retrospective study design the temporal changes in biochemical laboratory parameters in relation to the development of acute kidney injury (AKI). In a sample of 399 patients admitted from May 2020 to May 2021 to a tertiary health care intensive care unit (ICU), the incidence of AKI was 27.3%, and the median time to AKI was on 7th day of ICU admission. Most common etiology of AKI was kidney hypoperfusion. Within 72 h of developmental of low blood pressure, 63.76% developed AKI. The likelihood of AKI was higher in those with elevated serum ferritin, aspartate transaminase, and thrombocytopenia (low platelet count). A cutoff value of 750.3 ng/mL [area under the ROC curve (AUC) = 0.777] for serum ferritin, and 40.05 U/L for alanine aminotransferase (AUC = 0.677) 1 day before development of AKI displayed, respectively, a sensitivity of 76.2% and 64.3%, whereas the specificity was 69.5% and 64.1%, respectively, for these two biochemical predictors. A cutoff value of platelets (152.50 × 109/L [AUC = 0.75]) measured 4 days before development of AKI, displayed 83.3% sensitivity and 16.4% specificity. Taken together, our study thoroughly examined the temporal association of various clinical and laboratory parameters with AKI and prediction models were developed as per results of the time series data. These observations in a tertiary health care setting contribute to ongoing efforts for biomarker discovery and development using routine biochemical tests so as to forecast AKI in patients with COVID-19.
ABSTRACT
Background: Data on outcomes of coronavirus disease 2019 (COVID-19) in pregnancy are scarce, although they represent a unique physiological state affecting both the mother and child. We present collated data from a tertiary care center in North India, encompassing the outcome, clinical characteristics, and management of these patients. Materials and Methods: Parturients ≥ 18 years old, with COVID-19 reverse transcriptase polymerase chain reaction positive for severe acute respiratory syndrome coronavirus 2, requiring intensive care unit (ICU) admission at a tertiary care hospital were included. Data were retrospectively collected from April 2020 to November 2021. Results: In all, 26 parturients were admitted to ICU with COVID-19. Five patients were admitted during the first wave, and all were asymptomatic. Twenty-one patients presented during the second wave (March 2021 onward), among which four were asymptomatic and 17 symptomatic (all with severe pneumonia). Three patients presented in the second trimester, all with critical disease, out of which one did not survive. Two patients had twin gestation, and others were singleton pregnancies. Seven patients (27%) were primigravida, and five patients (19.2%) had more than third pregnancy. Twenty critically ill women (77%) delivered during the hospital stay. Six patients died during the second wave, and four deaths (66.7%) were because of COVID-19 acute respiratory distress syndrome (ARDS). Conclusions: The number of admissions and mortality related to COVID-19 ARDS was higher in the second wave than in the first. We report the safe use of remdesivir and tocilizumab in our patients.
ABSTRACT
BackgroundSnake bite envenoming is a neglected tropical disease with variable clinical presentation, neurotoxic manifestations (respiratory paralysis), rhabdomyolysis, cardiotoxicity, autonomic hyperactivity, and/or coagulation abnormalities. There is limited data on the clinical course of the envenomation in an incidentally diagnosed COVID-19 patient.Case presentationA 17-year-old male with history of snake bite and neuroparalysis developed shortness of breath. He was treated with lyophilized polyvalent anti-snake venom (ASV) on admission in the emergency department and mechanical ventilation. Subsequently, he tested positive for COVID-19 infection. No immunomodulatory therapy was administered, and patient was extubated on the 5th day of ICU admission without any neurological deficit.ConclusionsCoinfections of the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) virus with snake bite poisoning lead to diagnostic dilemmas and controversies in management practices. Abnormalities of coagulation need to be cautiously addressed, and cause of development of pneumonia needs to be identified. The rapid recovery of the patient in our case theoretically can be explained on the organ-protective potential of snake-derived peptides;a large case series is however needed to prove the same.
ABSTRACT
Background and objectives Recent randomized controlled trials (RCTs) have indicated potential therapeutic benefits with high-dose dexamethasone (HDD) or tocilizumab (TCZ) plus standard care in moderate to severe coronavirus disease 2019 (COVID-19) with acute respiratory distress syndrome (ARDS). No study has compared these two against each other. We aimed to compare the efficacy and safety of HDD against TCZ in moderate to severe COVID-ARDS. Methods Patients admitted with moderate to severe COVID-19 ARDS with clinical worsening within 48 hours of standard care were randomly assigned to receive either HDD or TCZ plus standard care. The primary outcome was ventilator-free days (VFDs) at 28 days. The main secondary outcomes were 28-day all-cause mortality and the incidence of adverse events. Our initial plan was to perform an interim analysis of the first 42 patients. Results VFDs were significantly lower in the HDD arm (median difference: 28 days; 95% confidence interval (CI): 19.35-36.65; Cohen's d = 1.14;p < 0.001). We stopped the trial at the first interim analysis due to high 28-day mortality in the HDD arm (relative risk (RR) of death: 6.5; p = 0.007; NNT (harm) = 1.91). The incidence of secondary infections was also significantly high in the HDD arm (RR: 5.5; p = 0.015; NNT (harm) = 2.33). Conclusions In our study population, HDD was associated with a very high rate of mortality and adverse events. We would not recommend HDD to mitigate the cytokine storm in moderate to severe COVID-19 ARDS. TCZ appears to be a much better and safer alternative.
ABSTRACT
Background Coronavirus-2019 (COVID-19) patients admitted to the intensive care unit (ICU) have mortality rates between 30%-50%. Identifying patient factors associated with mortality can help identify critical patients early and treat them accordingly. Patients and methods In this retrospective study, the records of patients admitted to the COVID-19 ICU in a single tertiary care hospital from April 2020 to September 2020 were analysed. The clinical and laboratory parameters between patients who were discharged from the hospital (survival cohort) and those who died in the hospital (mortality cohort) were compared. A multivariate logistic regression model was constructed to identify parameters associated with mortality. Results A total of 147 patients were included in the study. The age of the patients was 55 (45, 64), median (IQR), years. At admission, 23 (16%) patients were on mechanical ventilation and 73 (50%) were on non-invasive ventilation. Sixty patients (40%, 95% CI: 32.8 to 49.2%) had died. Patients who died had a higher Charlson comorbidity index (CCI): 3 (2, 4) vs. 2 (1, 3), p = 0.0019, and a higher admission sequential organ failure assessment (SOFA) score: 5 (4, 7) vs. 4 (3, 4), p < 0.001. Serum urea, serum creatinine, neutrophils on differential leukocyte count, neutrophil to lymphocyte ratio (N/L ratio), D-dimer, serum lactate dehydrogenase (LDH), and C-reactive protein were higher in the mortality cohort. The ratio of partial pressure of arterial oxygen to fraction of inspired oxygen, platelet count, lymphocytes on differential leukocyte count, and absolute lymphocyte count was lower in the mortality cohort. The parameters and cut-off values used for the multivariate logistic regression model included CCI > 2, SOFA score > 4, D-dimer > 1346 ng/mL, LDH > 514 U/L and N/L ratio > 27. The final model had an area under the curve of 0.876 (95% CI: 0.812 to 0.925), p < 0.001 with an accuracy of 78%. All five parameters were found to be independently associated with mortality. Conclusions CCI, SOFA score, D-dimer, LDH, and N/L ratio are independently associated with mortality. A model incorporating the combination of these clinical and laboratory parameters at admission can predict COVID-19 ICU mortality with good accuracy.