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1.
EuropePMC; 2022.
Preprint in English | EuropePMC | ID: ppcovidwho-331327

ABSTRACT

Introduction: With the COVID-19 pandemic, a “new normal” on how surgeons and intensivists perform tracheotomy in COVID-19 patients is essential. We aim to summarize the recommendations and present the supporting evidence of these recommendations. Methods A search of published works on tracheotomy, tracheostomy, COVID-19, novel coronavirus, SARS-CoV-2 was performed on PubMed/MEDLINE/Cochrane Library. Articles relevant to the practice of tracheotomy on patients with COVID-19 were selected. The articles were then reviewed and divided into 4 key categories: 1) Personal protective equipment (PPE) in COVID-19 positive patients, 2) Adjunctive measures of airway management before definitive intervention in COVID-19 positive patients;3) Timing of tracheotomy in COVID-19 positive patients;and 4) Perioperative considerations in performing tracheotomy in COVID-19 positive patients. Results and key points Firstly, enhanced PPE is recommended during tracheotomy of COVID-19 positive patients. Secondly, adjunctive airway management before definitive intervention includes the use of high flow nasal cannulas (HFNC). Thirdly, non-invasive ventilation via continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP) machines are not recommended. Fourth, the general consensus suggests that timing of tracheotomy should be at least 10 days after intubation. Finally, percutaneous dilatational tracheotomy (PDT) is likely to be associated with a lower risk of transmission of the virus to healthcare workers (HCW) than a surgical tracheotomy (ST). Other key precautions would include minimizing the use of diathermy. Conclusions The “new normal” workflow summarizes the ideal recommendations across published societal guidelines. Enhanced PPE should be recommended whenever possible. Adjunctive measures before definitive intervention of COVID-19 patients should be limited to the use of HFNC, and CPAP/BiPAP should be avoided. Tracheotomy should be performed after 10 days, although the long term sequelae of tracheal stenosis and pulmonary fibrosis should be ascertained with this approach.

2.
Ann Acad Med Singap ; 50(9): 686-694, 2021 09.
Article in English | MEDLINE | ID: covidwho-1464249

ABSTRACT

INTRODUCTION: Acute respiratory distress syndrome (ARDS) in COVID-19 is associated with a high mortality rate, though outcomes of the different lung compliance phenotypes are unclear. We aimed to measure lung compliance and examine other factors associated with mortality in COVID-19 patients with ARDS. METHODS: Adult patients with COVID-19 ARDS who required invasive mechanical ventilation at 8 hospitals in Singapore were prospectively enrolled. Factors associated with both mortality and differences between high (<40mL/cm H2O) and low (<40mL/cm H2O) compliance were analysed. RESULTS: A total of 102 patients with COVID-19 who required invasive mechanical ventilation were analysed; 15 (14.7%) did not survive. Non-survivors were older (median 70 years, interquartile range [IQR] 67-75 versus median 61 years, IQR 52-66; P<0.01), and required a longer duration of ventilation (26 days, IQR 12-27 vs 8 days, IQR 5-15; P<0.01) and intensive care unit support (26 days, IQR 11-30 vs 11.5 days, IQR 7-17.3; P=0.01), with a higher incidence of acute kidney injury (15 patients [100%] vs 40 patients [46%]; P<0.01). There were 67 patients who had lung compliance data; 24 (35.8%) were classified as having high compliance and 43 (64.2%) as having low compliance. Mortality was higher in patients with high compliance (33.3% vs 11.6%; P=0.03), and was associated with a drop in compliance at day 7 (-9.3mL/cm H2O (IQR -4.5 to -15.4) vs 0.2mL/cm H2O (4.7 to -5.2) P=0.04). CONCLUSION: COVID-19 ARDS patients with higher compliance on the day of intubation and a longitudinal decrease over time had a higher risk of death.


Subject(s)
COVID-19 , Respiratory Distress Syndrome , Humans , Lung Compliance , Phenotype , Respiratory Distress Syndrome/epidemiology , Respiratory Distress Syndrome/therapy , SARS-CoV-2
3.
Sci Rep ; 11(1): 7477, 2021 04 05.
Article in English | MEDLINE | ID: covidwho-1169408

ABSTRACT

We aim to describe a case series of critically and non-critically ill COVID-19 patients in Singapore. This was a multicentered prospective study with clinical and laboratory details. Details for fifty uncomplicated COVID-19 patients and ten who required mechanical ventilation were collected. We compared clinical features between the groups, assessed predictors of intubation, and described ventilatory management in ICU patients. Ventilated patients were significantly older, reported more dyspnea, had elevated C-reactive protein and lactate dehydrogenase. A multivariable logistic regression model identified respiratory rate (aOR 2.83, 95% CI 1.24-6.47) and neutrophil count (aOR 2.39, 95% CI 1.34-4.26) on admission as independent predictors of intubation with area under receiver operating characteristic curve of 0.928 (95% CI 0.828-0.979). Median APACHE II score was 19 (IQR 17-22) and PaO2/FiO2 ratio before intubation was 104 (IQR 89-129). Median peak FiO2 was 0.75 (IQR 0.6-1.0), positive end-expiratory pressure 12 (IQR 10-14) and plateau pressure 22 (IQR 18-26) in the first 24 h of ventilation. Median duration of ventilation was 6.5 days (IQR 5.5-13). There were no fatalities. Most COVID-19 patients in Singapore who required mechanical ventilation because of ARDS were extubated with no mortality.


Subject(s)
COVID-19/pathology , Adult , Area Under Curve , C-Reactive Protein/metabolism , COVID-19/virology , Dyspnea/etiology , Female , Humans , Intensive Care Units , L-Lactate Dehydrogenase/metabolism , Logistic Models , Male , Middle Aged , Neutrophils/cytology , Prospective Studies , ROC Curve , Respiration, Artificial , Respiratory Rate , SARS-CoV-2/isolation & purification , Severity of Illness Index , Singapore
4.
Annals Academy of Medicine Singapore ; 49(8):605-607, 2020.
Article in English | Web of Science | ID: covidwho-937889
7.
Am J Kidney Dis ; 76(3): 392-400, 2020 09.
Article in English | MEDLINE | ID: covidwho-526769

ABSTRACT

With the exponential surge in patients with coronavirus disease 2019 (COVID-19) worldwide, the resources needed to provide continuous kidney replacement therapy (CKRT) for patients with acute kidney injury or kidney failure may be threatened. This article summarizes subsisting strategies that can be implemented immediately. Pre-emptive weekly multicenter projections of CKRT demand based on evolving COVID-19 epidemiology and routine workload should be made. Corresponding consumables should be quantified and acquired, with diversification of sources from multiple vendors. Supply procurement should be stepped up accordingly so that a several-week stock is amassed, with administrative oversight to prevent disproportionate hoarding by institutions. Consumption of CKRT resources can be made more efficient by optimizing circuit anticoagulation to preserve filters, extending use of each vascular access, lowering blood flows to reduce citrate consumption, moderating the CKRT intensity to conserve fluids, or running accelerated KRT at higher clearance to treat more patients per machine. If logistically feasible, earlier transition to intermittent hemodialysis with online-generated dialysate, or urgent peritoneal dialysis in selected patients, may help reduce CKRT dependency. These measures, coupled to multicenter collaboration and a corresponding increase in trained medical and nursing staffing levels, may avoid downstream rationing of care and save lives during the peak of the pandemic.


Subject(s)
Betacoronavirus , Continuous Renal Replacement Therapy/trends , Coronavirus Infections/therapy , Health Services Needs and Demand/trends , Pandemics , Pneumonia, Viral/therapy , Acute Kidney Injury/epidemiology , Acute Kidney Injury/therapy , Anticoagulants/administration & dosage , Anticoagulants/supply & distribution , COVID-19 , Continuous Renal Replacement Therapy/instrumentation , Coronavirus Infections/epidemiology , Dialysis Solutions/administration & dosage , Dialysis Solutions/supply & distribution , Humans , Pneumonia, Viral/epidemiology , Renal Insufficiency/epidemiology , Renal Insufficiency/therapy , SARS-CoV-2
8.
Int J Infect Dis ; 96: 615-617, 2020 Jul.
Article in English | MEDLINE | ID: covidwho-459437

ABSTRACT

Patients with COVID-19 infection have an increased risk of cardiovascular complications and thrombotic events. Statins are known for their pleiotropic anti-inflammatory, antithrombotic and immunomodulatory effects. They may have a potential role as adjunctive therapy to mitigate endothelial dysfunction and dysregulated inflammation in patients with COVID-19 infection.


Subject(s)
Anti-Inflammatory Agents/therapeutic use , Coronavirus Infections/drug therapy , Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use , Inflammation/drug therapy , Pneumonia, Viral/drug therapy , Angiotensin-Converting Enzyme 2 , Betacoronavirus , COVID-19 , Humans , Inflammation/virology , Pandemics , Peptidyl-Dipeptidase A , SARS-CoV-2
9.
Transplant Direct ; 6(6): e554, 2020 Jun.
Article in English | MEDLINE | ID: covidwho-208897

ABSTRACT

The current coronavirus disease 2019 (COVID-19) pandemic has not only caused global social disruptions but has also put tremendous strain on healthcare systems worldwide. With all attention and significant effort diverted to containing and managing the COVID-19 outbreak (and understandably so), essential medical services such as transplant services are likely to be affected. Closure of transplant programs in an outbreak caused by a highly transmissible novel pathogen may be inevitable owing to patient safety. Yet program closure is not without harm; patients on the transplant waitlist may die before the program reopens. By adopting a tiered approach based on outbreak disease alert levels, and having hospital guidelines based on the best available evidence, life-saving transplants can still be safely performed. We performed a lung transplant and a liver transplant successfully during the COVID-19 era. We present our guidelines and experience on managing the transplant service as well as the selection and management of donors and recipients. We also discuss clinical dilemmas in the management COVID-19 in the posttransplant recipient.

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