Rescue Therapies

This chapter will discuss four rescue therapies-prone positioning, extracorporeal membrane oxygenation (ECMO) and CO2 removal (ECCO2R), inhaled nitric oxide (INO), and renal replacement therapy (RRT)-and their role in the management of critically ill patients with COVID-19. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

Sedation, Analgesia, and Myorelaxants

Sedation in patients with coronavirus severe acute respiratory distress syndrome (SARS-CoV-2) is a challenge. Deep sedation favors adaptation to mechanical ventilation, promotes tolerance to hypercapnia and may reduce the risk of self-extubation, but it is not always necessary. It is essential to individualize sedation and analgesia, always prioritizing pain control. In situations of persistent ventilatory asynchrony, need for deep sedation, prone ventilation or persistently high plateau pressures, continuous infusion of a neuromuscular blocker is required, which should be used for up to 48 hours. The weaning process can be difficult, and the association of antipsychotics and alpha-2 agonists is indicated. Key words: SARS-CoV-2, sedation, analgesia, myorelaxants, weaning, mechanical ventilation, alpha-2 agonists, propofol. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

Mortality rate, intensive care unit length of stay and time to orotracheal intubation of COVID-19 patients under different non-invasive ventilatory therapies: retrospective cohort study

Introduction: COVID-19 may lead to heterogeneous needs for ventilator therapy, whether oxygen therapy (OT), noninvasive ventilation (NIV), high-flow nasal catheter (HFNC) or their combination (NIV + HFNC). The purpose of the study was to describe, retrospectively, the mortality rate, intensive care unit length of stay (ICU-LOS) and time to orotracheal intubation of COVID-19 patients under OT, NIV, HFNC or combined (NIV + HFNC). A retrospective cohort study was done analyzing official medical data from March 2020 up to July 2021. (CAAE: 52534221.5.0000.5249). Method(s): The inclusion criteria were age > 18 years-old, and positive swab test for COVID-19 or computed tomography consistent of COVID-19. The exclusion criteria were hospital LOS less than 3 days, patients whose therapy (OT, NIV, HFNC or NIV + HFNC) lasted less than 48 h, and missing data about the outcome variables. The primary outcome was mortality rate, while secondary outcomes were ICU-LOS and time to orotracheal intubation. Chi-Square test was used to assess mortality rate. The Mann-Whitney U test was applied to assess differences in ICU-LOS and time to orotracheal intubation (p < 0.05). Result(s): Overall, 1371 patients were enrolled. 880, 120, 35, and 148 patients were submitted to OT, NIV, HFNC or NIV + HFNC, respectively. The mortality rates were 8.4%, 29.6%, 22.2%, and 33.2% for OT, NIV, HFNC or NIV + HFNC, respectively (p < 0.001). The ICU-LOS was higher in NIV + HFNC (median [IQR] 15 days [16]) than NIV (9 days [10]) and OT (4 days [5], p < 0.001). The time to orotracheal intubation was higher in NIV (6 days [6]), HFNC (6 days [4.5]), and NIV + HFNC (6 days [6]) than OT (2 days [4]), p < 0.001. Mortality rate and ICU-LOS were higher in those patients requiring the combination of NIV and HFNC. Conclusion(s): Although the type of ventilator therapy may be associated to increased mortality rate and ICU-LOS, we cannot assure causality due to exploratory nature of the retrospective study, but a marker of severity.

Perspectivas Inovadoras Na Abordagem Na Doenca Do Olho Seco (Dos) E O Interfaceamento Com Bancos De Sangue De Cordao Umbilical Humano

Os bancos de sangue de cordao umbilical e placentario (BSCUP), os laboratorios de processamento de medula ossea/ sangue periferico para transplante e os centros de tecnologia celular, passaram a receber a denominacao comum de Centros de Processamento Celular - CPC. O pais tem BSCUP 14 unidades publicas e 19 de natureza privada, totalizando 33 BSCUP. Uma analise retrospectiva dos relatorios da ANVISA identifica que em 2003 foram coletadas 26 unidades, com desqualificacao de 15,38% delas, o crescimento da coleta foi exponencial e dez anos depois, em 2013, foram coletadas 13.995 unidades (5,82% de desqualificacao). Em 2020, houve uma diminuicao expressiva de coletas, reflexo da pandemia de COVID-19: 4.918 unidades (desqualificacao de 12,69%). Este tipo de produtividade compromete a viabilidade financeira destes servicos, e encontrar formas de otimizar bolsas desqualificadas por volume ou quantidade de celulas para demais finalidades e uma vertente de gestao que deve ser estabelecida. O objetivo deste projeto foi a coleta de segmentos de cordao umbilical das unidades ja previamente validadas pelos BSCUP para extracao de celulas tronco, caracterizacao imunofenotipica e producao de meio condicionado isento de soro fetal bovino. A obtencao do meio condicionado (MC) da cultura de celulas tronco. Tem crescido cada vez mais o interesse pelo uso dos fatores de crescimento, citocinas e moleculas sinalizadoras livres no MC alem das vesiculas extracelulares, que se tornaram relevantes, tanto para diagnostico como para terapeutica, inclusive para aplicacoes oftalmologicas. Neste campo, identificamos a DOS que impacta profundamente a qualidade de vida das pessoas. Ha 15 anos o Laboratorio de Biologia Celular tem desenvolvido o soro autologo, para atendimento dos pacientes refratarios aos tratamentos convencionais e farmacologicos disponiveis, em especial aqueles pacientes submetidos ao Transplante de Medula Ossea e que desenvolveram DOS2ario a doenca de enxerto versus hospedeiro. No entanto, existem pacientes com impossibilidade de acesso venoso ou com sorologias reagentes para doencas infecciosas que sao impedidos de utilizar o produto. Diante disto, optou-se por produzir o MC de celulas tronco de cordao umbilical de parturientes jovens e sem comorbidades para obtencao do secretoma das celulas para avaliacao terapeutica na DOS. Um segmento do cordao umbilical foi retirado e processado seguido de plaqueamento e expansao para posterior identificacao de adesao ao plastico, caracterizacao imunofenotipica por citometria de fluxo utilizando marcadores como CD11b, CD13, CD14, CD34, CD31, CD36, CD45,CD73, CD90, CD 105, CD106 e HLA-DR. Todas as amostras tiveram adesao ao plastico com aspecto fibroblastoides e perfil imunofenpotipico corrobora com o determinado pela SITC. Para a obtencao de MC foram semeadas CTMcup ate 70% de confluencia e foram submetidas ao wash out, recebendo meio de cultura DMEM-F12 aditivado por 48 horas. Apos isto, foi coletado 60mL do secretoma das celulas para o experimento especificos in vitro. Copyright © 2022

Time course of chest computed tomography findings and biomarkers in COVID-19 pneumonia patients

RATIONALE: Chest computed tomography (CT) has a potential role in the diagnosis, detection of complications, and prognosis of coronavirus disease 2019 (COVID-19). The value of chest CT can be further amplified when associated to physiological variables. Some studies have done efforts to correlate chest CT findings with overall oxygenation and respiratory mechanics, which although they are easily obtained may not be specifically related to COVID-19. Very few studies have tried to correlate chest CT findings with specific biomarkers related to COVID-19. For this purpose, temporal changes of chest CT were evaluated and then correlated with laboratory data in multicenter randomized clinical trial. METHODS: Adult patients who presented chest CT scan features compatible with viral pneumonia were admitted in the hospital and followed during 7 days (NCT: 04561219). CT scans and laboratory data [D-dimer, ferritin, and lactate dehydrogenase (LDH)] in blood were obtained at the moment of admission (Baseline) and on day 7 (Final). Qualitative and quantitative chest CT scan parameters were evaluated in ventral, middle and dorsal regions of interest (ROI) and classified as: hyper-, normal-, poor-, and non-aerated. RESULTS: In this study involving 45 COVID-19 patients no statistically significant differences in the overall Hounsfield Units (HU) ranges and percent of whole lung mass were found overtime. Normally aerated lung tissue reduced from Baseline to Final (p=0.004), mainly associated with a decrease in ventral (p=0.001) and middle (p=0.026) ROIs. At dorsal ROI, a reduction in CT lung mass in poorly aerated areas was observed from Baseline to Final. Poorly aerated and non-aerated lung areas were well correlated only with D-dimer blood levels (r=0.55, p<0.001;and r=0.52, p=0.001, respectively). CONCLUSION: In patients with COVID-19 pneumonia, changes in poor-and non-aerated were associated to changes in D-dimer blood levels, which may be a specific biomarker to be follow in facilities without CT as a way to infer radiologic changes.