Tratamiento farmacológico de la COVID-19: revisión narrativa de los Grupos de Trabajo de Enfermedades Infecciosas y Sepsis (GTEIS) y del Grupo de Trabajo de Transfusiones Hemoderivados (GTTH) Pharmacological treatment of COVID-19: Narrative review of the Working Group in Infectious Diseases and Sepsis (GTEIS) and the Working Groups in Transfusions and Blood Products (GTTH)

La infección por el virus SARS-CoV-2, denominada COVID-19 (COronaVIrus Disease 19), fue detectada inicialmente en China en diciembre 2019, y posteriormente se ha diseminado rápidamente por todo el mundo, hasta el punto de que el 11 de marzo la Organización Mundial de la Salud declaró que el brote podría definirse como pandemia. La COVID-19 presenta un cuadro que oscila desde episodios leves seudogripales a otros graves e incluso potencialmente mortales debido, sobre todo, a insuficiencia respiratoria aguda. Es frecuente el ingreso de estos pacientes en nuestros servicios de Medicina Intensiva en relación con un síndrome de distrés respiratorio agudo. La falta de un tratamiento con evidencia científica ha llevado al empleo de diferentes pautas terapéuticas, en muchas ocasiones, con modificaciones rápidas de los protocolos. Recientes revisiones en revistas de prestigio han destacado la falta de terapias probadas y la necesidad de ensayo clínicos que permitan establecer pautas de tratamiento claras y objetivas. Este documento tiene por objeto ofrecer una actualización de la terapia que se está aplicando en la actualidad, y una ayuda en la asistencia diaria, sin pretender sustituir los protocolos adoptados en cada centro.

A differential therapeutic consideration for use of corticosteroids according to established COVID-19 clinical phenotypes in critically ill patients.

OBJECTIVE: To determine if the use of corticosteroids was associated with Intensive Care Unit (ICU) mortality among whole population and pre-specified clinical phenotypes. DESIGN: A secondary analysis derived from multicenter, observational study. SETTING: Critical Care Units. PATIENTS: Adult critically ill patients with confirmed COVID-19 disease admitted to 63 ICUs in Spain. INTERVENTIONS: Corticosteroids vs. no corticosteroids. MAIN VARIABLES OF INTEREST: Three phenotypes were derived by non-supervised clustering analysis from whole population and classified as (A: severe, B: critical and C: life-threatening). We performed a multivariate analysis after propensity optimal full matching (PS) for whole population and weighted Cox regression (HR) and Fine-Gray analysis (sHR) to assess the impact of corticosteroids on ICU mortality according to the whole population and distinctive patient clinical phenotypes. RESULTS: A total of 2017 patients were analyzed, 1171 (58%) with corticosteroids. After PS, corticosteroids were shown not to be associated with ICU mortality (OR: 1.0; 95% CI: 0.98-1.15). Corticosteroids were administered in 298/537 (55.5%) patients of "A" phenotype and their use was not associated with ICU mortality (HR=0.85 [0.55-1.33]). A total of 338/623 (54.2%) patients in "B" phenotype received corticosteroids. No effect of corticosteroids on ICU mortality was observed when HR was performed (0.72 [0.49-1.05]). Finally, 535/857 (62.4%) patients in "C" phenotype received corticosteroids. In this phenotype HR (0.75 [0.58-0.98]) and sHR (0.79 [0.63-0.98]) suggest a protective effect of corticosteroids on ICU mortality. CONCLUSION: Our finding warns against the widespread use of corticosteroids in all critically ill patients with COVID-19 at moderate dose. Only patients with the highest inflammatory levels could benefit from steroid treatment.

A differential therapeutic consideration for use of corticosteroids according to established COVID-19 clinical phenotypes in critically ill patients Una consideración terapéutica diferencial para el uso de corticoesteroides en COVID-19 según los diferentes fenotipos clínicos establecidos en pacientes críticos

Objective To determine if the use of corticosteroids was associated with Intensive Care Unit (ICU) mortality among whole population and pre-specified clinical phenotypes. Design A secondary analysis derived from multicenter, observational study. Setting Critical Care Units. Patients Adult critically ill patients with confirmed COVID-19 disease admitted to 63 ICUs in Spain. Interventions Corticosteroids vs. no corticosteroids. Main variables of interest Three phenotypes were derived by non-supervised clustering analysis from whole population and classified as (A: severe, B: critical and C: life-threatening). We performed a multivariate analysis after propensity optimal full matching (PS) for whole population and weighted Cox regression (HR) and Fine-Gray analysis (sHR) to assess the impact of corticosteroids on ICU mortality according to the whole population and distinctive patient clinical phenotypes. Results A total of 2017 patients were analyzed, 1171 (58%) with corticosteroids. After PS, corticosteroids were shown not to be associated with ICU mortality (OR: 1.0;95% CI: 0.98–1.15). Corticosteroids were administered in 298/537 (55.5%) patients of “A” phenotype and their use was not associated with ICU mortality (HR = 0.85 [0.55–1.33]). A total of 338/623 (54.2%) patients in “B” phenotype received corticosteroids. No effect of corticosteroids on ICU mortality was observed when HR was performed (0.72 [0.49–1.05]). Finally, 535/857 (62.4%) patients in “C” phenotype received corticosteroids. In this phenotype HR (0.75 [0.58–0.98]) and sHR (0.79 [0.63–0.98]) suggest a protective effect of corticosteroids on ICU mortality. Conclusion Our finding warns against the widespread use of corticosteroids in all critically ill patients with COVID-19 at moderate dose. Only patients with the highest inflammatory levels could benefit from steroid treatment.

Impact of one year of pandemic on Spanish Intensive Care Units.

OBJECTIVE: To measure the impact of the pandemic in Spanish ICUs. METHODS: On-line survey, conducted in April 2021, among SEMICYUC members. Participants were asked about number of patients admitted, increase in the number of beds and staff, structures created in the hospital and self-assessment of the work performed. RESULTS: We received 246 answers from 157 hospitals. 67.7% of the ICUs were expanded during the pandemic, overall increase in beds of 58.6%. The ICU medical staff increased by 6.1% and there has been a nursing shortage in 93.7% of units. Patients exceeded 200% the pre-pandemic ICU capacity. In 88% of the hospitals the collaboration of other specialists was necessary. The predominant collaboration model consisted of the intensive care medicine specialist being responsible for triage and coordinating patient management. Despite that 53.2% centres offered training for critical care, a deterioration in the quality of care was perceived. 84.2% hospitals drew up a Contingency Plan and in 77.8% of the hospitals a multidisciplinary committee was set up to agree on decision-making. Self-evaluation of the work performed was outstanding and 91.9% felt proud of what they had achieved, however, up to 15% considered leaving their job. CONCLUSIONS: The Spanish ICUs assumed an unprecedented increase in the number of patients. They achieved it without hardly increasing their staff and, while intensive care medicine training was carried out for other specialists who collaborated. The degree of job satisfaction was consistent with pre-pandemic levels.

Recommendations for the management of critically ill patients with COVID-19 in Intensive Care Units☆ Recomendaciones para el manejo de los pacientes críticos con COVID-19 en las Unidades de Cuidados Intensivos

The COVID-19 pandemic has led to the admission of a high number of patients to the ICU, generally due to severe respiratory failure. Since the appearance of the first cases of SARS-CoV-2 infection, at the end of 2019, in China, a huge number of treatment recommendations for this entity have been published, not always supported by sufficient scientific evidence or with methodological rigor necessary. Thanks to the efforts of different groups of researchers, we currently have the results of clinical trials, and other types of studies, of higher quality. We consider it necessary to create a document that includes recommendations that collect this evidence regarding the diagnosis and treatment of COVID-19, but also aspects that other guidelines have not considered and that we consider essential in the management of critical patients with COVID-19. For this, a drafting committee has been created, made up of members of the SEMICYUC Working Groups more directly related to different specific aspects of the management of these patients.

Recommendations for the management of critically ill patients with COVID-19 in Intensive Care Units.

The COVID-19 pandemic has led to the admission of a high number of patients to the ICU, generally due to severe respiratory failure. Since the appearance of the first cases of SARS-CoV-2 infection, at the end of 2019, in China, a huge number of treatment recommendations for this entity have been published, not always supported by sufficient scientific evidence or with methodological rigor necessary. Thanks to the efforts of different groups of researchers, we currently have the results of clinical trials, and other types of studies, of higher quality. We consider it necessary to create a document that includes recommendations that collect this evidence regarding the diagnosis and treatment of COVID-19, but also aspects that other guidelines have not considered and that we consider essential in the management of critical patients with COVID-19. For this, a drafting committee has been created, made up of members of the SEMICYUC Working Groups more directly related to different specific aspects of the management of these patients.

[Recommendations for the management of critically ill patients with COVID-19 in Intensive Care Units]. / Recomendaciones para el manejo de los pacientes críticos con COVID-19 en las Unidades de Cuidados Intensivos.

The COVID-19 pandemic has led to the admission of a high number of patients to the ICU, generally due to severe respiratory failure. Since the appearance of the first cases of SARS-CoV-2 infection, at the end of 2019, in China, a huge number of treatment recommendations for this entity have been published, not always supported by sufficient scientific evidence or with methodological rigor necessary. Thanks to the efforts of different groups of researchers, we currently have the results of clinical trials, and other types of studies, of higher quality. We consider it necessary to create a document that includes recommendations that collect this evidence regarding the diagnosis and treatment of COVID-19, but also aspects that other guidelines have not considered and that we consider essential in the management of critical patients with COVID-19. For this, a drafting committee has been created, made up of members of the SEMICYUC Working Groups more directly related to different specific aspects of the management of these patients.

Management of infectious complications associated with coronavirus infection in severe patients admitted to ICU.

Infections have become one of the main complications of patients with severe SARS-CoV-2 pneumonia admitted in ICU. Poor immune status, frequent development of organic failure requiring invasive supportive treatments, and prolonged ICU length of stay in saturated structural areas of patients are risk factors for infection development. The Working Group on Infectious Diseases and Sepsis GTEIS of the Spanish Society of Intensive Medicine and Coronary Units SEMICYUC emphasizes the importance of infection prevention measures related to health care, the detection and early treatment of major infections in the patient with SARS-CoV-2 infections. Bacterial co-infection, respiratory infections related to mechanical ventilation, catheter-related bacteremia, device-associated urinary tract infection and opportunistic infections are review in the document.

[Management of infectious complications associated with coronavirus infection in severe patients admitted to ICU]. / Manejo de las complicaciones infecciosas asociadas con la infección por coronavirus en pacientes graves ingresados en UCI.

Infections have become one of the main complications of patients with severe SARS-CoV-2 pneumonia admitted in ICU. Poor immune status, frequent development of organic failure requiring invasive supportive treatments, and prolonged ICU length of stay in saturated structural areas of patients are risk factors for infection development. The Working Group on Infectious Diseases and Sepsis GTEIS of the Spanish Society of Intensive Medicine and Coronary Units SEMICYUC emphasizes the importance of infection prevention measures related to health care, the detection and early treatment of major infections in the patient with SARS-CoV-2 infections. Bacterial co-infection, respiratory infections related to mechanical ventilation, catheter-related bacteremia, device-associated urinary tract infection and opportunistic infections are review in the document.

COVID-19 and Acute Respiratory Distress Syndrome. Impact of corticosteroid treatment and predictors of poor outcome.

OBJECTIVE: To assess the impact of corticosteroids on inflammatory and respiratory parameters of patients with COVID-19 and acute respiratory distress syndrome (ARDS). METHODS: Longitudinal, retrospective, observational study conducted in an ICU of a second level hospital. Adult patients with COVID-19 were included. Baseline characteristics, data on SARS-CoV-2 infection, treatment received, evolution of respiratory and inflammatory parameters, and ICU and hospital stay and mortality were analyzed. RESULTS: A total of 27 patients were included, 63% men, median age: 68.4 (51.8, 72.2) years. All patients met ARDS criteria and received MV and corticosteroids. After corticosteroids treatment we observed a reduction in the O2 A-a gradient [day 0: 322 (249, 425); day 3: 169 (129.5, 239.5) p<0.001; day 5: 144 (127.5, 228.0) p<0.001; day 7: 192 (120, 261) p=0.002] and an increase in the pO2/FiO2 ratio on days 3 and 5, but not on day 7 [day 0: 129 (100, 168); day 3: 193 (140, 236) p=0.002; day 5: 183 (141, 255) p=0.004; day 7: 170 (116, 251) p=0.057]. CRP also decreased on days 3 and 5 and increased again on day 7 [day 0: 16 (8.6, 24); day 3: 3.4 (1.7, 10.2) p<0.001; day 5: 4.1 (1.4, 10.2) p<0.001; day 7: 13.5 (6.8, 17.3) p=0.063]. Persistence of moderate ARDS on day 7 was related to a greater risk of poor outcome (OR 6.417 [1.091-37.735], p=0.040). CONCLUSIONS: Corticosteroids appears to reduce the inflammation and temporarily improve the oxygenation in COVID-19 and ARDS patients. Persistence of ARDS after 7 days treatment is a predictor of poor outcome.

Pharmacological treatment of COVID-19: Narrative review of the Working Group in Infectious Diseases and Sepsis (GTEIS) and the Working Groups in Transfusions and Blood Products (GTTH)

Infection by the SARS-CoV-2 virus, known as COVID-19 (COronaVIrus Disease-19) was initially detected in China in December 2019, and has subsequently spread rapidly throughout the world, to the point that on March 11 the World Health Organization (WHO) reported that the outbreak could be defined as a pandemic. COVID-19 disease ranges from mild flu-like episodes to other serious and even life-threatening conditions, mainly due to acute respiratory failure. These patients are frequently admitted to our Intensive Care Units in relation to acute respiratory distress syndrome (ARDS). The lack of a treatment based on scientific evidence has led to the use of different management guidelines, in many cases with rapid changes in the applied protocols. Recent reviews in reputed journals have underscored the lack of proven therapies and the need for clinical trials to establish clear and objective treatment guidelines. The present study provides an update on the currently applied treatment, and intends to offer help in relation to daily care, without seeking to replace the protocols adopted in each individual center. Resumen La infección por el virus SARS-CoV-2, denominada COVID-19 (COronaVIrus Disease 19), fue detectada inicialmente en China en diciembre 2019, y posteriormente se ha diseminado rápidamente por todo el mundo, hasta el punto de que el 11 de marzo la OMS declaró que el brote podría definirse como pandemia. La COVID-19 presenta un cuadro que oscila desde episodios leves pseudogripales a otros graves e incluso potencialmente mortales debido, sobre todo, a insuficiencia respiratoria aguda. Es frecuente el ingreso de estos pacientes en nuestros Servicios de Medicina Intensiva en relación con un Síndrome de Distrés Respiratorio Agudo (SDRA). La falta de un tratamiento con evidencia científica ha llevado al empleo de diferentes pautas terapéuticas, en muchas ocasiones, con modificaciones rápidas de los protocolos. Recientes revisiones en revistas de prestigio han destacado la falta de terapias probadas y la necesidad de ensayo clínicos que permitan establecer pautas de tratamiento claras y objetivas. Este documento tiene por objeto ofrecer una actualización de la terapia que se está aplicando en la actualidad, y una ayuda en la asistencia diaria, sin pretender sustituir los protocolos adoptados en cada centro.

[Pharmacological treatment of COVID-19: Narrative review of the Working Group in Infectious Diseases and Sepsis (GTEIS) and the Working Groups in Transfusions and Blood Products (GTTH)]. / Tratamiento farmacológico de la COVID-19: revisión narrativa de los Grupos de Trabajo de Enfermedades Infecciosas y Sepsis (GTEIS) y del Grupo de Trabajo de Transfusiones Hemoderivados (GTTH).

Infection by the SARS-CoV-2 virus, known as COVID-19 (COronaVIrus Disease-19) was initially detected in China in December 2019, and has subsequently spread rapidly throughout the world, to the point that on March 11 the World Health Organization (WHO) reported that the outbreak could be defined as a pandemic. COVID-19 disease ranges from mild flu-like episodes to other serious and even life-threatening conditions, mainly due to acute respiratory failure. These patients are frequently admitted to our Intensive Care Units in relation to acute respiratory distress syndrome. The lack of a treatment based on scientific evidence has led to the use of different management guidelines, in many cases with rapid changes in the applied protocols. Recent reviews in reputed journals have underscored the lack of proven therapies and the need for clinical trials to establish clear and objective treatment guidelines. The present study provides an update on the currently applied treatment, and intends to offer help in relation to daily care, without seeking to replace the protocols adopted in each individual center.

[Recommendations of the Working Groups from the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of adult critically ill patients in the coronavirus disease (COVID-19)]. / Recomendaciones de «hacer¼ y «no hacer¼ en el tratamiento de los pacientes críticos ante la pandemia por coronavirus causante de COVID-19 de los Grupos de Trabajo de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC).

On March 11, 2020, the Director-General of the World Health Organization (WHO) declared the disease caused by SARS-CoV-2 (COVID-19) as a pandemic. The spread and evolution of the pandemic is overwhelming the healthcare systems of dozens of countries and has led to a myriad of opinion papers, contingency plans, case series and emerging trials. Covering all this literature is complex. Briefly and synthetically, in line with the previous recommendations of the Working Groups, the Spanish Society of Intensive, Critical Medicine and Coronary Units (SEMICYUC) has prepared this series of basic recommendations for patient care in the context of the pandemic.

Recommendations of the Working Groups from the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of adult critically ill patients in the coronavirus disease (COVID-19)

On March 11, 2020, the Director-General of the World Health Organization (WHO) declared the disease caused by SARS-CoV-2 (COVID-19) as a pandemic. The spread and evolution of the pandemic is overwhelming the healthcare systems of dozens of countries and has led to a myriad of opinion papers, contingency plans, case series and emerging trials. Covering all this literature is complex. Briefly and synthetically, in line with the previous recommendations of the Working Groups, the Spanish Society of Intensive, Critical Medicine and Coronary Units (SEMICYUC) has prepared this series of basic recommendations for patient care in the context of the pandemic. Resumen El 11 de marzo de 2020 el director general de la Organización Mundial de la Salud (OMS) declaró la enfermedad causada por el SARS-CoV-2 (COVID-19) como una pandemia. La propagación y evolución de la pandemia está poniendo a prueba los sistemas sanitarios de decenas de países y ha dado lugar a una miríada de artículos de opinión, planes de contingencia, series de casos e incipientes ensayos. Abarcar toda esta literatura es complejo. De forma breve y sintética, en la línea de las anteriores recomendaciones de los Grupos de Trabajo, la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC) ha elaborado esta serie de recomendaciones básicas para la asistencia a pacientes en el contexto de la pandemia.