ABSTRACT
BACKGROUND Tocilizumab (TCZ) is an interleukin-6 (IL-6) inhibitor approved for use in patients severely affected by COVID-19, which has been shown to reduce mortality but has as yet undetermined effects on procalcitonin (PCT) and C-reactive protein (CRP). In Malta, TCZ started being administered to COVID-19 patients who experience worsening symptoms or increased oxygen requirements over a period of hours in January 2021. This study aimed to assess the effect of TCZ on PCT primarily, and white cell count (WCC), lymphocyte and neutrophil counts, neutrophil to lymphocyte ratio (NLR), CRP and PaO2/FiO2 (P/F) ratio as secondary measures. METHODS Fifty patients who received tocilizumab were recruited to the treatment group along with a matched control group of 50 patients who did not receive the drug. Serum PCT and other biochemical markers were recorded daily for both groups and differences in the values for the two groups extracted. Outcome measures included differences between the biomarkers at 5, 10 and 15 days. RESULTS PCT and CRP were significantly lowered by administration of TCZ on Day 5. WCC, lymphocyte and neutrophil counts and P/F ratios were not affected. There was no difference in positive blood culture results between the two groups. CONCLUSI ON PCT and CRP may not be reliable indicators of bacterial superinfection in severe COVID-19 pneumonia patients who have been given TCZ.Copyright © 2023, University of Malta. All rights reserved.
ABSTRACT
Introduction: The COVID-19 virus has caused a massive strain on medical services worldwide. Throughout 2020 and 2021, hospitals and their Intensive Care Units (ICUs) have been inundated with patients suffering from critical illness due to COVID-19, many of whom developed multiorgan failure and required prolonged ICU stays.1 Malta is a Mediterranean island with a population of 500,000 people, with one main acute general hospital (Mater Dei Hospital) with a single 20-bed ICU. This meant that the COVID-19 pandemic surge had to be managed locally by increasing ICU capacity without access to a referral network of other hospital ICUs at different phases of the pandemic or the possibility of referral to ECMO services abroad. Objectives: Establish the demographics and outcomes of all patients admitted to ICU with COVID-19 in Malta. Methods: A single centre prospective cohort study conducted in the Intensive Care Units caring for COVID-19 patients at Mater Dei Hospital, Malta. Data was collected on admission and then daily until death or discharge from ICU. Results: The COVID-19 pandemic resulted in 252 patients being admitted to ICU from March 2020 to May 2021. The peak of admissions occurred in March 2021 with a maximum of 21 admissions in a week resulting in a peak of 33 COVID-19 ICU beds being utilized. This represents 165% of the normal 20 bed ICU capacity. There were 9 readmissions, these were excluded from data analysis. All patients admitted to ICU were treated with Dexamethasone and Remdesivir, and Tocizulimab from January 2021, unless contraindicated. Overall ICU mortality was 34% and increased to 46% in those requiring mechanical ventilation. Males were responsible for 75% of admissions but gender was not associated with ICU mortality. Older patients and those with ischemic heart disease (IHD) and diabetes had a significantly increased mortality as were those patients with a higher Sequential Organ Failure Assessment (SOFA) and lower PaO2/FiO2 (P/F) on admission (Table 1). The total number of patients requiring intubation during their admission was 173 (69%) with a median time to intubation of two days [IQR 1-4]. Proning was used for 124 (69%) of the mechanically ventilated patients for a median of 2 days per patient [IQR: 1 -3], similarly muscle relaxant infusion was also used in 124 of mechanically ventilated patients (69%) for a median of three days per patient [IQR: 2 -5]. The median duration of mechanical ventilation was 11 days [IQR: 6 -22.2] with a maximum of 63 days. Tracheostomies were performed in 59 (34%) of mechanically ventilated patients with a median duration of 14.5 days intubated prior to tracheostomy [IQR: 13 -17]. The median length of stay was 11.5 days [7-23]. Conclusion: This observational study represents all COVID-19 ICU admissions that occurred in Malta from March 2020 to May 2021 in the single institution caring for these patients in the country. We have demonstrated a predominantly male, elderly admission population with an increased mortality associated with age, ischemic heart disease and diabetes. Overall ICU mortality was 34% and 46% in ventilated patients, which is comparable to that found in other national databases.2.
ABSTRACT
Introduction: The aim of the study was to determine the impact of COVID-19 pandemic on intensive care workload [1,2] at our only acute main general hospital on the island. During the pandemic surge in March 2021, our intensive care was running at 200% capacity. Mater Dei Hospital has a 20-bedded adult intensive care catering for a population of 500,000. Methods: This is a prospective cohort study conducted in the COVID- 19 Intensive Care Unit at Mater Dei Hospital, Malta. Data analysed is from March 2020 to May 2021. Data collected daily from admission until death or discharge from ICU. Results: A total of 261 patients with severe acute respiratory distress syndrome coronavirus 2 (SARS-Cov-2) required admission to our intensive care. ICU facilities required expansion into a total of 5 Intensive Care Units, therefore reaching a capacity of 44 intensive care beds during the peak month of March 2021. A maximum of 21 patients were admitted per week culminating to a total of 33 COVID-19 Intensive Care beds during the month of March 2021. A total of 179 patients (68.6%) required mechanical ventilation for a median duration of 11 days per patient. Proning was required in 124 mechanically ventilated patients (70.5%). 50 patients (20%) required CRRT with a maximum number of 7 patients per day requiring CRRT. Conclusions: COVID-19 pandemic transformed the way how we provide critical care with improved bed capacity, ICU triage and ICU devices. This study highlighted the need for more clinical guidelines and their availability for online use. This will positively impact the care of non-COVID patients. It also highlighted the need for more training of non-ICU staff to allow for surges in ICU capacity. The COVID-19 pandemic has seen Mater Dei hospital already investing in ICU personnel and equipment as this cannot be reactive to large scale events but must be a proactive planned strategy to enhance resilience of our ITU.
ABSTRACT
Introduction: The aim of this study was to describe the use of high flow nasal oxygen (HFNO) in COVID-19 intensive care unit (ICU) patients [1] locally, and establish their demographics and outcomes. Mater Dei Hospital is the only main acute general hospital on the island. It houses a 20-bedded adult ICU catering for a population of 500,000. Methods: We conducted a single-centre prospective observational cohort study at the ICU at Mater Dei Hospital in Malta between March 2020 and May 2021. Data collected included use of HFNO, mechanical ventilation (MV), duration of MV, length of stay, and 28-day survival. Results: 240 COVID-19 ICU patients were included. 108 (45%) received HFNO for a median of 3 days, the rest received MV for a median of 12 days. No major differences in demographics were noted (age: 66.5 vs 68 years, p = 0.225;70% male, 30% female vs 79% male, 21% female, p = 0.191). Forty-two (38.2%) patients failed HFNO after a median of 2 days, needing MV for a median of 10 days (p < 0.001). Median length of stay was lower in HFNO patients (6 vs 13 days;p < 0.001). 28-day survival was highest in the HFNO-only group (94%), followed by the HFNO + MV group (61%), and finally the MV-only group (52%;p < 0.0001). This is not simply due to severity since FiO2 was higher for HFNO patients and PaO2 tended to be lower. Cox proportional hazards analysis showed that respiratory support was more significant than admission P/F ratios, PaO2s, or SOFA, with MV being linked to a hazards ratio of 8.4 (p < 0.001) when adjusted for the above criteria. Conclusions: HFNO offers considerable practical advantages over MV. Avoiding MV might be linked to a reduced incidence of ventilator-associated pneumonias, shorter ICU stay and lower mortality. It is also a safe tool to use and the risk of aerosolization should not deter from its use.