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1.
EuropePMC; 2020.
Preprint in English | EuropePMC | ID: ppcovidwho-314461

ABSTRACT

Background: To evaluate the switching of patients mechanically ventilated on Pressure Support or Volume Control to inverse-ratio Airway Pressure Release Ventilation (APRV) during the COVID-19 pandemic. Methods: : We performed a single-center retrospective observational analysis in two ICUs in a tertiary referral university teaching hospital in France. Were included patients with Covid-19 pneumonia requiring invasive ventilation with a PaO2:FiO2 ratio lower than 200 mmHg who performed a 6-hour trial of inverse-ratio APRV. Results: : Seventeen consecutive patients who completed a 6-hour APRV trial in April 2020 were included. Three patients who were unable to be maintained on APRV due to an immediate fall in SpO2 were not included. In 12/17 patients (71%), the increase in PaO2:FiO2 ratio was greater than 20%. Mean (± standard deviation) PaO2:FiO2 ratio increased from 126 (± 28) mmHg to 178 (± 53) mmHg after 6 hours of APRV (p<0.001). Two patients presented a decrease in PaO2:FiO2 ratio after 6 hours of APRV. There was no appearance of significant hemodynamic impairment during APRV and an eventual increase in PaCO2 during the first hour of APRV was managed by increasing the respiratory rate (i.e. shortening T-high) and/or increasing tidal volume (i.e. increasing T-low). Conclusions: : Switching from Conventional Ventilation (Pressure Support or Volume Assist Control) to inverse-ratio APRV for a 6-hour period in two ICUs that were not previously familiar with this ventilation technique was well tolerated, and associated with a marked improvement in oxygenation. Further studies evaluating inverse-ratio APRV in acute respiratory failure are warranted. Trial registration: NCT04386369

2.
Journal of Intensive Medicine ; 2021.
Article in English | ScienceDirect | ID: covidwho-1474758

ABSTRACT

Background : Accurate risk stratification of critically ill patients with coronavirus disease 2019 (COVID-19) is essential for optimizing resource allocation, delivering targeted interventions, and maximizing patient survival probability. Machine learning (ML) techniques are attracting increased interest for the development of prediction models as they excel in the analysis of complex signals in data-rich environments such as critical care. Methods : We retrieved data on patients with COVID-19 admitted to an intensive care unit (ICU) between March and October 2020 from the RIsk Stratification in COVID-19 patients in the Intensive Care Unit (RISC-19-ICU) registry. We applied the Extreme Gradient Boosting (XGBoost) algorithm to the data to predict as a binary outcome the increase or decrease in patients’ Sequential Organ Failure Assessment (SOFA) score on day 5 after ICU admission. The model was iteratively cross-validated in different subsets of the study cohort. Results : The final study population consisted of 675 patients. The XGBoost model correctly predicted a decrease in SOFA score in 320/385 (83%) critically ill COVID-19 patients, and an increase in the score in 210/290 (72%) patients. The area under the mean receiver operating characteristic curve for XGBoost was significantly higher than that for the logistic regression model {0.86 vs. 0.69, P < 0.01 (paired t-test with 95% confidence interval [CI])}. Conclusions : The XGBoost model predicted the change in SOFA score in critically ill COVID-19 patients admitted to the ICU and can guide clinical decision support systems (CDSSs) aimed at optimizing available resources.

4.
Swiss Med Wkly ; 151: w20553, 2021 07 19.
Article in English | MEDLINE | ID: covidwho-1320610

ABSTRACT

AIMS OF THE STUDY: During the ongoing COVID-19 pandemic, the launch of a large-scale vaccination campaign and virus mutations have hinted at possible changes in transmissibility and the virulence affecting disease progression up to critical illness, and carry potential for future vaccination failure. To monitor disease development over time with respect to critically ill COVID-19 patients, we report near real-time prospective observational data from the RISC-19-ICU registry that indicate changed characteristics of critically ill patients admitted to Swiss intensive care units (ICUs) at the onset of a third pandemic wave. METHODS: 1829 of 3344 critically ill COVID-19 patients enrolled in the international RISC-19-ICU registry as of 31 May 2021 were treated in Switzerland and were included in the present study. Of these, 1690 patients were admitted to the ICU before 1 February 2021 and were compared with 139 patients admitted during the emerging third pandemic wave RESULTS: Third wave patients were a mean of 5.2 years (95% confidence interval [CI] 3.2–7.1) younger (median 66.0 years, interquartile range [IQR] 57.0–73.0 vs 62.0 years, IQR 54.5–68.0; p <0.0001) and had a higher body mass index than patients admitted in the previous pandemic period. They presented with lower SAPS II and APACHE II scores, less need for circulatory support and lower white blood cell counts at ICU admission. P/F ratio was similar, but a 14% increase in ventilatory ratio was observed over time (p = 0.03) CONCLUSION: Near real-time registry data show that the latest COVID-19 patients admitted to ICUs in Switzerland at the onset of the third wave were on average 5 years younger, had a higher body mass index, and presented with lower physiological risk scores but a trend towards more severe lung failure. These differences may primarily be related to the ongoing nationwide vaccination campaign, but the possibility that changes in virus-host interactions may be a co-factor in the age shift and change in disease characteristics is cause for concern, and should be taken into account in the public health and vaccination strategy during the ongoing pandemic. (ClinicalTrials.gov Identifier: NCT04357275).


Subject(s)
COVID-19 , SARS-CoV-2 , Critical Illness , Hospital Mortality , Humans , Intensive Care Units , Pandemics , Prevalence , Prospective Studies , Switzerland/epidemiology
5.
EClinicalMedicine ; 25: 100449, 2020 Aug.
Article in English | MEDLINE | ID: covidwho-631768

ABSTRACT

BACKGROUND: Coronavirus disease 2019 (COVID-19) is associated with a high disease burden with 10% of confirmed cases progressing towards critical illness. Nevertheless, the disease course and predictors of mortality in critically ill patients are poorly understood. METHODS: Following the critical developments in ICUs in regions experiencing early inception of the pandemic, the European-based, international RIsk Stratification in COVID-19 patients in the Intensive Care Unit (RISC-19-ICU) registry was created to provide near real-time assessment of patients developing critical illness due to COVID-19. FINDINGS: As of April 22, 2020, 639 critically ill patients with confirmed SARS-CoV-2 infection were included in the RISC-19-ICU registry. Of these, 398 had deceased or been discharged from the ICU. ICU-mortality was 24%, median length of stay 12 (IQR, 5-21) days. ARDS was diagnosed in 74%, with a minimum P/F-ratio of 110 (IQR, 80-148). Prone positioning, ECCO2R, or ECMO were applied in 57%. Off-label therapies were prescribed in 265 (67%) patients, and 89% of all bloodstream infections were observed in this subgroup (n = 66; RR=3·2, 95% CI [1·7-6·0]). While PCT and IL-6 levels remained similar in ICU survivors and non-survivors throughout the ICU stay (p = 0·35, 0·34), CRP, creatinine, troponin, d-dimer, lactate, neutrophil count, P/F-ratio diverged within the first seven days (p<0·01). On a multivariable Cox proportional-hazard regression model at admission, creatinine, d-dimer, lactate, potassium, P/F-ratio, alveolar-arterial gradient, and ischemic heart disease were independently associated with ICU-mortality. INTERPRETATION: The European RISC-19-ICU cohort demonstrates a moderate mortality of 24% in critically ill patients with COVID-19. Despite high ARDS severity, mechanical ventilation incidence was low and associated with more rescue therapies. In contrast to risk factors in hospitalized patients reported in other studies, the main mortality predictors in these critically ill patients were markers of oxygenation deficit, renal and microvascular dysfunction, and coagulatory activation. Elevated risk of bloodstream infections underscores the need to exercise caution with off-label therapies.

6.
J Exp Med ; 217(6)2020 06 01.
Article in English | MEDLINE | ID: covidwho-72158

ABSTRACT

Coronavirus disease 2019 (COVID-19) is a novel, viral-induced respiratory disease that in ∼10-15% of patients progresses to acute respiratory distress syndrome (ARDS) triggered by a cytokine storm. In this Perspective, autopsy results and literature are presented supporting the hypothesis that a little known yet powerful function of neutrophils-the ability to form neutrophil extracellular traps (NETs)-may contribute to organ damage and mortality in COVID-19. We show lung infiltration of neutrophils in an autopsy specimen from a patient who succumbed to COVID-19. We discuss prior reports linking aberrant NET formation to pulmonary diseases, thrombosis, mucous secretions in the airways, and cytokine production. If our hypothesis is correct, targeting NETs directly and/or indirectly with existing drugs may reduce the clinical severity of COVID-19.


Subject(s)
Betacoronavirus , Coronavirus Infections/pathology , Extracellular Traps , Lung Diseases , Neutrophils/pathology , Pneumonia, Viral/pathology , COVID-19 , Coronavirus Infections/complications , Cytokines/metabolism , Humans , Lung Diseases/etiology , Lung Diseases/metabolism , Lung Diseases/pathology , Pandemics , Pneumonia, Viral/complications , SARS-CoV-2
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