Long-term functional outcome of severe COVID19 pneumonia treated with venovenous extracorporeal membrane oxygenation support - learnings from a single centre

Objectives: Implementation of venovenous extracorporeal membrane oxygenation (VVECMO) allowed survival of patients with severe respiratory failure associated with SARS-CoV-2 infection. However, VVECMO treatment is usually associated with long ICU stays, prolonged sedation, and neuromuscular blockage days. Functional disability, due to delirium and acquired muscle weakness, is frequently an inevitable burden causing long term disability. This study aims to analyse main characteristics of patients under ECMO due to COVID-19 pneumonia, their outcomes and functional status six months after ICU discharge. Method(s): Retrospective review of a prospectively collected database in an ECMO referral centre. All patients receiving VVECMO for SARS-CoV-2 infection were included. Epidemiological and clinical data were reviewed. Functional status at 6 months after ICU discharge was assessed with modified Rankin Scale (mRS). Result(s): Ninety-three patients were included (29% female). Median age was 54+/-12 years, mean SOFA was 5.7+/-2.9, mean SAPS II was 35.6+/-13.6. Mean time from intubation to cannulation was 5+/-5.6 days in 91 patients;awake-ECMO was performed in 2 patients. Mean ECMO run duration was 33.1+/-30 days (longest ECMO run was 194 days). A period of awake-ECMO was performed on 36.5% of patients, during 16.4+/-21.2 days. ICU-acquired weakness was diagnosed on 64.5% of patients and delirium on 63.4%. Mortality was 24.7% (23 patients) with only 1 patient deceased in hospital after ICU discharge. At 6 months follow-up, all patients were still alive and most of them (65.1%) were independent on all daily activities (mRS <= 2). Conclusion(s): Patients with severe COVID-19 treated with VVECMO support had very good functional outcomes at six-month follow-up. Despite long ICU length-of-stay, high incidence of delirium and acquired muscle weakness, full recovery at six-month post-ICU discharge was achievable in most patients.

Extracorporeal membrane oxygenation instead of invasive ventilation in patients with COVID-19 acute respiratory distress syndrome (ARDS) and pneumomediastinum: A cohort trial

Objectives: In patients with severe respiratory failure, invasive ventilation may deteriorate the pneumomediastinum and hypoxia. This study aimed to compare the mortality and the complications of the patients with coronavirus disease 2019 (COVID-19) related severe ARDS treated with invasive ventilation or veno-venous ECMO (VV-ECMO) to avoid intubation. We hypothesized that VV-ECMO support without prior intubation is a feasible alternative strategy to invasive ventilation. Method(s): This retrospective study evaluated patients with COVID-19 related severe respiratory failure and radiological evidence of pneumomediastinum. The primary outcome was intensive care unit (ICU) survival at 90 days. Result(s): Out of 347 patients with COVID-19 disease treated in our unit, 22 patients developed spontaneous pneumomediastinum associated with deterioration of respiratory function. In 13 patients (59%), invasive ventilation was chosen as initial respiratory support;in 9 patients (41%), VV-ECMO was chosen as initial respiratory support. The median age of the patients in the invasive ventilation group was 62 years (IQR: 49-69) compared to 53 years (IQR: 46-62) in ECMO group (P=0.31). No statistically significant difference in SAPS II score between the groups was observed (39.7 (IQR: 33.2-45.3) vs. 28.9 (IQR:28.4-34.6), P=0.06). No elevated fluid balance within the first 4 days was observed in the ECMO group compared to the invasive ventilation group (162 mL (IQR: -366-2000) vs. 3905 mL (IQR: 2068-6192), P=0.07). VV-ECMO as the initial strategy for supporting patients with severe respiratory failure and pneumomediastinum, was associated with lower 90 days mortality (HR: 0.33 95%-CI: 0.11-0.97, P= 0.04) compared to patients treated with invasive ventilation (Figure). Conclusion(s): VV-ECMO can be an alternative strategy to invasive ventilation for treating patients with severe respiratory failure and spontaneous pneumomediastinum. (Figure Presented).

CytoSorb on the Septic Shock

Background: Septic shock, defined as organ dysfunction caused by a dysregulated host response to infection, is a condition associated with high morbidity and mortality. One of the hallmarks of sepsis is the excessive release of cytokines and other inflammatory mediators that cause septic shock and multi-organ failure (MOF). New adsorbents are now available as adjuvant therapy aimed at modulating the cytokine "storm" in sepsis. They are thought to be useful if adopted early (within 8-24 hours of the diagnosis of septic shock) in patients who are unresponsive to standard therapy. Here we report our experience with CytoSorb. Method(s): From January 2021 to May 2022, 46 patients with septic shock were treated with continuous renal replacement therapy (CRRT) associated with hemoadsorption with CytoSorb. All cases presented organ failure including AKI. Surgical patients (n = 13) were treated with surgery, COVID patients (n = 15) and medical patients (n = 16) with medical therapy;all surgery cases were operated on before starting the haemadsorption and in some cases reoperation with the need to suspend the adsorption. The mean age was 69 +/- 17 years (SD). On admission the mean SAPSII score was 50 +/- 11 (SD). CRRT as hemodiafiltration (CVVHDF) was performed. All patients received at least one CytoSorb treatment and additional treatments (up to 21 filters in a Covid patient) according to our indication. The CytoSorb cartridge was installed in series to the high cut-off filter;blood flow rates were maintained between 120 and 150 mL/min while dialysis doses from 18 to 45 mL/kg/hour. CytoSorb was renewed every 24 hours. We evaluated the impact of CytoSorb on 30-day survival, haemodynamics and relevant outcomes. Result(s): The 30-day survival was 30%. During treatment with CytoSorb, patients had a hemodynamic stabilization with a significant improvement in MAP, a reduction in amines and a decrease in PCR and PCT (Figure 1). Mortality at 30 days among medical patients was almost comparable to that of COVID patients and higher than that of surgical patients (70%, 69% and 61%, respectively). It should be noted that almost half of the deceased patients arrived late in the hospital, thus leading to a late start of treatment. Conclusion(s): We confirm the efficacy and usefulness of the CytoSorb if adopted early in patients who do not respond to standard therapy. CytoSorb treatment was safe and well tolerated with no device-related adverse events during or after treatment sessions.

Membrane dysfunction in patients with severe COVID-19 treated with venovenous extracorporeal membrane oxygenation - analysis from a pooled data from a single centre

Objectives: It is well known that severe COVID-19 is associated with complex immunological and inflammatory dysregulation. Both these physiopathological events translate to a high risk of major thrombotic or hemorrhagic events. In patients treated with venovenous extracorporeal membrane oxygenation (VVECMO), membrane dysfunction might affect systemic oxygenation and limit its duration-expectancy. This study aimed to assess the possible causes of extracorporeal membrane failure in COVID-19 patients and its impact on outcome. Method(s): Retrospective, single-center, observational case-control study involving adult COVID-19 patients admitted to an ECMO referral centre in a tertiary university hospital. All patients required VVECMO for acute respiratory failure, including 48 cases who needed one or more extracorporeal membrane exchanges and 45 controls (no membrane exchange). These two groups were compared for demographic characteristics, severity of the disease using validated scores (SAPS II and SOFA), duration of ECMO run, coagulation assessment, cumulative anticoagulation dose, associated complications, and outcomes (ICU and hospital mortality). Result(s): Most patients were males (71.0%) and younger than 50 years (79.5%). Median ECMO run duration was significantly longer in the case group (35.0 vs 14.0 days, p <0.001), as well as ICU length-of-stay (45.5 vs 28 days, p <0.001). Membrane exchange tended to be associated with sepsis (56% vs 33%, p=0.037), major hemorrhage (58% vs 43%, p=0.022), heparin-induced thrombocytopenia (25% vs 9%, p=0.054), higher D-dimer title (17.36 ng/dL vs 7.5 ng/dL, p=0.07) and lower platelet counts (133.000/muL vs 154.000/muL). Median SAPS II (32.0 vs 33.0, p=0.20) and the mortality (27% vs 24%, p >0.99) were similar between these groups. Conclusion(s): In patients with SARS-CoV-2 pneumonia and severe hypoxemia treated with VVECMO support the emergence of infection, coagulopathy and inflammation were associated with high risk of membrane dysfunction. No impact on mortality could be confirmed from these data. Anticoagulation monitoring and dosing strategies should be reinforced to promote membrane protection.

Determinants of death in patients with COVID-19 pneumonia treated with venovenous extracorporeal membrane oxygenation support

Objectives: Death from SARS-CoV-2 pneumonia resulted from progressive respiratory failure in most patients. Whenever accessible, venovenous extracorporeal membrane oxygenation (VVECMO) was implemented to rescue patients with refractory hypoxemia. Reported mortality in this population reached values from 20 to 50 percent, but the direct causes of death were not so widely acknowledged. The aim of our study was to characterize mortality in patients treated with VVECMO support. Method(s): Retrospective review of a prospectively collected database in an ECMO referral centre. All patients with diagnosis of SARS-CoV-2 infection treated with VVECMO support were included. Survivors and nonsurvivors were compared using t-student and chi2 methods. A Cox regression analysis was performed to identify predictors of mortality at admission. Result(s): Ninety-three patients were included (29% female). Median age was 54+/-12 years, mean SOFA was 5.7+/-2.9 and SAPS II was 35.6+/-13.6. Hospital mortality was 24.7%. Main causes of death were septic shock in 39.1% (9 patients), irreversible lung fibrosis 30.4% (7 patients) and catastrophic hemorrhage in 4.3% (4 patients). End-of-life care measures (withdrawal or withholding) were adopted in 65.2% of non-survivals. Patients who died were older (55 vs 48 years, p<0.05), had longer disease course (19 vs 15.3 days, p<0.05), longer invasive mechanical ventilation course before cannulation (8.5 vs 5 days, p<0.05), lower static lung compliance (25.5 vs 31.8 mL/cmH2O, p<0.05) and were ventilated with lower PEEP (8 vs 10 cmH2O, p<0.05) on cannulation. On a Cox-regression model, only prone ventilation before cannulation (HR 9,7;CI 95% 1,4- 68,6;p<0.05) and SAPS II (HR 1.04;CI 95% 1,001- 1,083;p<0.05) predicted mortality. Conclusion(s): Mortality in patients with severe SARSCoV-2 pneumonia treated with VVECMO was exceedingly low in our study, when compared with other series. Only one-third died from progressive lung disease, which suggests that protocol improvement can further reduce mortality.

Hemoadsorption by CytoSorb in septic no-Covid and Covid patients: a case series

Background: Septic shock is a life-threatening organ dysfunction caused by a dysregulated host response to infection. The reduction of pro-inflammatory and anti-inflammatory mediators by hemoadsorption represents a new tool in the treatment of sepsis. In the present case series, we evaluated the impact of CytoSorb on adult patients with septic shock. Method(s): Patients with septic shock, admitted to Intensive Care Unit (ICU) from March 1, 2021 to February 28, 2022 who received CytoSorb therapy within 72 hours of admission were enrolled in the study. The severity of clinical conditions at admission was assessed by the SAPS II and SOFA scores;The magnitude of the inflammatory response was estimated using the plasmatic levels of C reactive protein (CRP) and interleukin-6 (IL-6). The effect of CytoSorb therapy on the inflammatory state, was evaluated measuring the percentage reduction of IL-6 and CRP. Time elapsed from ICU admission and the start of CytoSorb therapy was also assessed. T-test was used to compare the means of the groups of Survivors and No survivors. Fisher's test was used to evaluated the difference in mortality between Covid and No covid patients. Result(s): Twelve patients were evaluated. Six patients tested positive for covid-19, while the other six did not. Table 1 shows the values of age, SAPSII, SOFA, IL-6, CRP, PCT and timing between the survivors and the no survivors. Overall, there was no significant difference between the two groups in terms of SAPSII, SOFA, age, CRP. There was a significant difference in the timing of Cytosorb start and percentage of IL-6 removal: In surviving patients the timing of intervention was shorter (3,3+/-1,8 vs 23,5+/-18,9 hours) than in non- survivors. The IL-6 removal rate was significantly higher in the survivor group (70,8+/-15,87 vs 33,2+/-12,26). Conclusion(s): In survivors the timing of CytoSorb therapy was shorter and the IL-6 removal rate was higher than in non-survivors. This suggest that the early applying of CytoSorb adsorber in combination with Continuous Renal Replacement Therapy (CRRT) techniques, could increase the survival rate of septic shock patients. Using CytoSorb was safe and well tolerated with no device-related adverse events during or after the treatment.

Trauma: a stress during pandemic?

Introduction: Coronavirus disease 2019 pandemic significantly impacted on trauma systems, since emergency departments (ED) suddenly were overwhelmed by patients requiring intensive care unit (ICU) admission. Once, trauma volume was supposed to decrease due to lockdown policies, we aimed to describe ICU trauma admissions during this period. Method(s): Retrospective observational study of all trauma patients admitted to the ICU of a Portuguese Trauma Center between January 2020 and December 2021. Data were collected from clinical hospital records. Result(s): 437 trauma patients (15% of all admissions), mostly male (71%), with a median age of 59 years-old (42-74) were included. At least one comorbidity was present in 71% of the patients. Median severity scores were: SAPS II 26 (19-38), SOFA 3 (1-6), ISS 13 (9-22), RTS 8 (6-8) and TRISS 96,75 (81.1-98.6). The most frequent mechanisms of injury were falls (59%) and road traffic accidents (25%). The majority consisted of blunt trauma (88%), 65% of brain trauma and 35% of musculoeskeletal trauma. Trauma Team assessment was started in < 3 min in all cases and median length of stay (LOS) in the ED was 261 min (154-418). Surgical intervention was performed in < 4 h in 56% of surgical brain trauma injuries, in < 6 h in 67% of extremity open fractures and in < 1 h in 6% of a penetrating trauma. Shock, mainly hemorrhagic, was present in 8% of the patients on hospital admission. 38% were submitted to invasive mechanical ventilation and 34% to vasopressors. The most common complication was nosocomial infection (18%). The median LOS in the UCI was 12 days (5-24). Only 8% of the patients died in the ICU and 11% in the hospital. Conclusion(s): During pandemic, trauma persisted a major health problem with a significant consumption of time and critical care resources. The high influx of patients may have influenced the LOS in the ED before ICU admission and the time until the surgical intervention. Despite it, mortality remained low.

The impact of proning on nutritional therapy in mechanically ventilated COVID-19 patients

Introduction: Critically ill COVID-19-patients are at high risk of developing ICU-related malnutrition. This study aimed to examine the impact of proning on providing nutritional therapy for mechanically ventilated COVID-19-patients by comparing the achievement of nutritional goals and possible complications in patients who were proned vs. those who were not. Method(s): This is a single-center retrospective cohort study. We included all adult COVID-19 patients admitted to the ICU from 01/03/2020 until 31/05/2020 who required invasive mechanical ventilation (IMV), excluding those referred for ECMO. Data were extracted from electronic patient files. Weight-based nutrition targets were set in agreement with ESPEN guidelines [1]. Result(s): 32 patients were included (prone n = 16). Both groups were comparable in age, sex, comorbidities, biochemical markers and Nutrition Risk Screening on admission. Time on IMV was longer in the prone group (p = 0.032). The total time in prone position ranged from 19.5 h to 13.16 d. All patients received a NG tube, 1 proned patient received a jejunal tube. 6 received TPN (p = 0.654). Metoclopramide was used more often in the prone group (p = 0.028). The prevalence of vomiting (n = 4 vs. n = 5), large gastric residuals (n = 0 vs. n = 3) and VAP (n = 11 vs. n = 10) were comparable for the non-prone vs. prone group, resp. Table 1 shows the percentage of targets reached. These were lower in the prone group, though not statistically significant. However, when correcting for SAPS III-score, the impact of proning declined. Conclusion(s): These limited data suggest there is no significant difference in feeding COVID-19 patients on IMV that need proning vs. those who do not, except for metoclopramide use. Overall, reaching nutrition targets in these patients is challenging. This model suggests that disease impact is a greater influence on reaching nutritional goals than proning itself.

Use of viscoelastic tests in the intensive care unit for the evaluation of haemostasis in SARS-CoV-2 infection

Introduction: COVID-19 coagulopathy is associated with poor prognosis and a state of coexisting 'hypercoagulopathy' (HyperC) and hypofibrinolysis, only detected by viscoelastic tests (VET). VET technology has been useful in areas where conventional tests are inadequate, such as screening for HyperC, thrombotic risk assessment and systemic anticoagulants' effect. We aim to characterize the evolution profile of coagulopathy in patients with COVID-19 infection during their intensive care unit (ICU) stay. Method(s): Consecutive recruitment of adult COVID-19 patients admitted to our hospital's ICU, during a 6 months period. Patients with thrombosis in the previous 3 months, pregnancy, under hormone therapy, and congenital coagulopathies were excluded. VET were executed every 5 days, at discharge and in complications and all of them were under low weight molecular heparin (LMWH) therapy. Group 1 (G1), n = 24-less than 10 days in ICU and group 2 (G2), n = 16-more than 10 days in ICU. In G1 there was 1 death (day 3) and in G2 there were 5 deaths (between days 15 and 42). We focused current analysis on VET-Rotem parameters (see Fig. 1). Result(s): Prognostic scores APACHE II, SAPS II and SOFA were higher in G2, but surprisingly G1 patients are more obese. G2 patients had shorter aPTT and lower platelets. The variables CT-HepTem and MCF Extem-MCF-Fib-Tem present a greater difference between groups, but no statistical significance. We observed an initial correlation between basophils number (which is lower) on CT Intem and CT Hep-Tem, lost as progression to cure, probably due to cytoplasm heparin granules. As expected, VET were in accordance with HyperC: short CTs, increased MCFs, and decreased lysis. Conclusion(s): We expected to guide/adjust LMWH dosage, using Rotem profiles, however these were not corrected by LMWH, used transversally, and remained unchanged in all patients during their stay in ICU.

Delayed intubation with high flow nasal cannula in COVID: a comparison between a first and second pandemic wave

Introduction: High flow nasal cannula (HFNC) treatment is an efficient treatment for hypoxemia in acute respiratory distress syndrome (ARDS). Before the COVID pandemic, non-invasive ventilation was associated with higher mortality in ARDS, and early intubation was advocated. We hypothesized that HFNC treatment was more restrictive in the first wave of the COVID pandemic compared to the second wave respecting the pre-COVID conceptual consensus of early intubation in ARDS. Method(s): We conducted this retrospective observational singlecenter study in a tertiary ICU in Brussels during the COVID pandemic. The first flare-up ranged from March to May 2020, and the second flare-up from September to January 2021. All patients with COVID pneumonia and HFNC before intubation were included. We considered a delayed intubation a ROXi < 3.85 at the start of HFNC. ROXi is the ratio of SpO2/ FiO2 to the respiratory rate. The primary outcome was delayed intubation based on the ROXi in the number of days. The secondary outcome was mortality. Result(s): We included 60 patients in the first wave and 70 in the second wave. The duration of HFNC treatment before intubation was longer during the second wave, based on ROXi < 3.85: 1.6 days versus 2.8 days, p < 0.05 (Fig. 1). There was no significant difference in mortality, 18% versus 29%. The length of intubation was similar in both groups. The CCI, SOFA, APACHE III and SAPS II scores were similar in both groups. Conclusion(s): The duration of HFNC treatment in COVID-19-related ARDS before intubation has significantly been extended in the second pandemic wave. The delayed intubation based on the ROXi was in this study without significantly increased mortality. However, a trend toward higher mortality after prolonged HFNC was seen in the second pandemic wave.

Critical illness in patients with omicron variant COVID-19: different but crucial

Introduction: During the COVID-19 pandemic, various virus variants evolved worldwide. COVID-19 omicron (CO) was associated with a decrease in length of hospital stay, ICU admission and death [1] as compared to COVID-19 delta (CD). To estimate impact of CO on ICUs worldwide, we investigated characteristics, disease course and outcome of critically ill CO patients. Method(s): Of 8562 critically ill COVID-19 patients included in the prospective international multicenter RISC-19-ICU registry [2,3], characteristics and outcome were compared for 1890 CD and 272 CO patients admitted to ICU between 1-2021 and 9-2022. Mixed model analysis corrected for individual center effects and adjusted for age, sex, vaccination status, use of steroids and anticoagulants was used. Result(s): There was no difference in age, sex and BMI between groups. CO patients had more comorbidities [mean difference (MD) 0.7, 95% CI (0.5-1.0), p = 0.02], especially arterial hypertension, and higher SAPS II score [MD 0.0 (0-0.1), p < 0.001], SOFA score [MD 0.1 (0.1-0.3), p < 0.0001]. CO patients presented with higher cardiovascular system SOFA subscore, but better PF-ratio at ICU admission and smaller risk for intubation and mechanical ventilation throughout their ICU stay [OR 0.5 (0.3-0.8)]. There was no difference in ECMO treatments, ICU length of stay [MD 0.6 (0-11.4), p = 0.72] or ICU survival [HR 1 (0.7-1.5), p = 0.88] between the two groups. Conclusion(s): We show that critically ill CO patients present with more comorbidities, less severe respiratory disease but more severe hemodynamic instability at ICU admission as compared to CD patients, although the ICU length of stay and mortality was similar. These differences could be explained by differences in disease characteristics caused by CO, or by the increasing prevalence of CO as co-factor to preexisting disease. Continued monitoring of critically ill CO patients in ICUs worldwide is warranted.

Mortality in patients with COVID-19-related ARDS treated with venovenous extracorporeal membrane oxygenation: a retrospective observational study

Introduction: Venovenous extracorporeal membrane oxygenation (VV ECMO) is a technique that provides blood oxygenation and CO2 removal, allowing a protective ventilation strategy until the resolution of respiratory failure. A delay in ECMO initiation could worsen the outcome and prolong the duration of treatment. The study aims to describe the incidence of mortality in our intensive care unit (ICU) in patients with severe COVID-19-related acute respiratory distress syndrome (ARDS) treated with VV ECMO. Method(s): We performed an observational retrospective study, including patients with severe COVID-19-related ARDS admitted to our ICU and treated with VV ECMO between February 2020 and February 2022. We collected data on demographic characteristics, comorbidities, mechanical ventilation, therapies, laboratory results, VV ECMO and ICU mortality. SOFA score, SAPS II and Charlson Comorbidity Index were calculated at ICU admission. Result(s): The average age of our cohort of 60 patients was 54.4 +/- 7.7 years and 51 (85%) were males. The mean value of the SOFA score at ICU admission was 7 +/- 2.3 points, and the median value of the SAPS II score was 41 [31-48] points. The incidence of mortality in the whole cohort was 48.3%. The differences between the two groups of patients, Survivors and Non-survivors, are presented in Table 1. Through a multivariate logistic regression model we found that age (OR 1.09 [95% CI 1.00-1.19], p = 0.03) and lymphocytes (OR 0.09 [95% CI 0.01-0.59], p = 0.01) were significantly associated with ICU mortality. Mechanical ventilation before ECMO placement higher than 10 days and superinfections at ICU admission were not significantly associated with the outcome in the same model. Conclusion(s): In patients with COVID-19-related ARDS treated with VV ECMO, advanced age and lymphopenia at ICU admission are risk factors for ICU mortality. A longer duration of mechanical ventilation before ECMO placement and traditional ICU prognostic scores seem not to be relevant for the prognosis.

Long-Term Sequelae of severe COVID-19: Outpatient assessment of radiological and pulmonary function tests

Objective: Identify lung sequelae of COVID-19 through radiological and pulmonary function assessment. Design(s): Prospective, longitudinal, cohort study from March 2020 to March 2021. Setting(s): Intensive Care Units (ICU) in a tertiary hospital in Portugal. Patient(s): 254 patients with COVID-19 admitted to ICU due to respiratory illness. Intervention(s): A chest computed tomography (CT) scan and pulmonary function tests (PFT) were performed at 3 to 6 months. Main variables of interest: CT-scan;PFT;decreased diffusion capacity of carbon monoxide (DLCO). Result(s): All CT scans revealed improvement in the follow-up, with 72% of patients still showing abnormalities, 58% with ground glass opacities and 62% with evidence of fibrosis. PFT had abnormalities in 94 patients (46%): thirteen patients (7%) had an obstructive pattern, 35 (18%) had a restrictive pattern, and 58 (30%) had decreased DLCO. There was a statistically significant association between abnormalities in the follow-up CT scan and older age, more extended hospital and ICU stay, higher SAPS II and APACHE scores and invasive ventilation. Mechanical ventilation, especially with no lung protective parameters, was associated with abnormalities in PFT. Multivariate regression showed more abnormalities in lung function with more extended ICU hospitalization, chronic obstructive pulmonary disease (COPD), chronic kidney disease, invasive mechanical ventilation, and ventilation with higher plateau pressure, and more abnormalities in CT-scan with older age, more extended ICU stay, organ solid transplants and ventilation with higher positive end-expiratory pressure (PEEP). Conclusion(s): Most patients with severe COVID-19 still exhibit abnormalities in CT scans or lung function tests three to six months after discharge.Copyright © 2023

High severity and mortality of non-COVID-19 critically ill patients during the COVID-19 pandemic

Background: The transmission and the fatality rates of coronavirus disease 2019 (COVID-19) are high enough to cause the strain of intensive care resources, and even influence the treatment and prognosis of non-COVID-19 patients. Therefore, the collateral damages to non-COVID-19 critically ill patients before and during the COVID-19 pandemic were evaluated. Method(s): Demographic data, severity, clinical course, and prognosis of non-COVID-19 patients admitted to the intensive care unit (ICU) via the emergency room (ER) before and during the COVID-19 pandemic were acquired from electronic medical records from three university-affiliated tertiary hospitals. Result(s): A total of 619 patients before and 542 patients during the pandemic were enrolled. During the COVID-19 pandemic, simplified acute physiology score (SAPS) 3 and the sequential organ failure assessment score (SOFA) on ER admission (SAPS3 72.7 +/- 20.3 versus 65.9 +/- 18.6, p <0.001, respectively;SOFA score 8.1 +/- 4.2, versus 7.2 +/-4.2, p <0.001, respectively) were significantly higher than those before the pandemic. The length of stay in the ER, ICU, and hospital was longer (p<0.05 in all). Finally, the hospital mortality rate was significantly higher during the pandemic than those before (39.7% versus 28.4%, p<0.001). The overall survival in the Kaplan-Meier curve analysis with log-rank test was significantly higher during the pandemic (p=0.04). Conclusion(s): These result of increased severity, hospital day and mortality in non-COVID-19 patients indicate the collateral damage to non-COVID-19 patients due to shortages in medical resources for them. Strategic management of medical resources is required to halt these consequences.

Delay of intensive care admission of severe COVID-19 patients : what impact on mortality ?

Following COVID-19 pandemic, rationning in intensive care unit (ICU) became common. This can lead to delay ICU admissions of severe patients and affect global prognosis. we aimed to assess clinical characteristics and outcomes of COVID-19 patients requiring ICU admission in terms of hospitalisation's delay. This study was performed at the zaghouan's hospital ICU, a 10-bed secondary ICU in Tunisia. It was a retrospective observationnal study including all severly COVID-19 patients admitted between March 20th, 2020 and February 15th, 2022. 2 groups were identified : Early ICU transfer (G1) was defined as admission within 48 hours of hospital stay, and late transfer (G2) was defined as an admission after 48 hours of hospital stay. During the study period, 1609 patients had required hospitalisation in our hospital, among them 365 (22.7%) were secondary transfered to ICU. A total of 163 patients were included in G1 and 202 patients were assigned to G2. Comorbidities were similar between the 2 groups. Mean ages were respectively 54.7+/-14.8 vs 58+/-12.5 years (p=0.019). Means SAPS II and APACHE II scores were respectively 22.3+/-9 vs 24+/-8.5 (p=0.03) and 7.5+/-4 vs 7.6+/-4.5 (p=0.8). On ICU admission, PaO2/FiO2 was higher in G1 (137+/-84mmHg vs 128+/-77 mmHg, p=0.4). There was no difference in ventilatory strategy between the two groups. Need for tracheal intubation was lower in G1 (37.4% vs 44%) (p=0.25). Length of ICU stay was similar in two groups (8.8+/-3.4 days vs 9+/-4.5 days). In-ICU mortality was significantly lower in G1 (35.6% vs 48.5%;p=0.028). Delay of ICU admission was associated with higher mortality. Better organizaion was needed to establisch optimal decision-making process.

Chest CT scan lesions as predictors of poor prognosis in critically ill COVID-19 patients

Chest CT scan lesions as predictors of poor prognosis in critically ill COVID-19 patients Background: Chest computed tomography (CT) scan was suggested to be an early tool for the diagnosis of COVID19 pneumonia. However, little is known about the role of chest CT-scan to predict outcomes in patients admitted in intensive care unit (ICU) for COVID-19 pneumonia. Aim(s): To determine the association between the extent of chest CT scan lesions and poor outcomes in critically ill COVID-19 patients. Method(s): A retrospective observational study performed in a 9-bed ICU from 1rst January 2021 to December 31, 2021 including adult admitted for COVID-19 pneumonia who underwent a chest CT scan. Patients' charaterisics, chest CT findings, management and outcomes were collected. Result(s): During the study period, 146 patients underwent a chest CT scan. Patients' characteristics were: mean age 50.62+/-14.95years, median SAPSII, 24[16-31];median SOFA, 3[2-4] and median PaO2/FiO2 ratio 92[69-123]. High flow nasal cannula was performed in 128(87.7%) and 12(8.2%) patients required invasive mechanical ventilation (IMV) at admission. Median ICU length of stay was 8[5-14] days, mortality rate was at 55(37.7%) and the 4C mortality score was 1[0-1]. Severe lesions were identified in 89(61%) patients. Prolonged ICU stay was significantly more common in patients with severe lesions (p=0.02). However, mortality rate and IMV use (p=0.746) did not differ between mild to moderate lesion group and severe lesion group (p=0.869). Conclusion(s): Prolonged ICU stay was significantly associated with severe chest CT scan lesions and interestingly, mortality did not differ between severe lesions and mild to moderate lesions.

CT scan in COVID-19 patients in ICU: Two evaluative methods

Background: During COVID-19 pneumonia management, CT scan is highly contributive. It represents the gold standard examination for both positive and severity diagnosis. Objective(s): We aimed to compare 2 methods of evaluation of CT scan involvement. Method(s): We conducted a prospective cohort study in the ICU of Abderrahmen Mami hospital between January and December 2021. We included critically-ill patients COVID-19 who had a CT scan. We considered two ways to evaluate severity of lung damage: 1/Percentage of lung damage extent (< 50%, 50 to 75% and >= 75%), 2/ CT score (assimilated to Lung Ultrasound Score): Subdivision of each hemithorax into 6 regions: antero-superior and inferior, latero-superior and inferior, postero-superior and inferior. A score was attributed according to the patterns: 0 if normal parenchyma, 1 if few ground-glass lesions, 2 if extensive ground-glass lesions, and 3 if condensations. CT score was the sum of the scores of the 12 regions, thus varying between 0 and 36 Results: We included 158 patients with mean age of 56 +/- 13 years and gender ratio of 1.6. Mean values of SAPS II and APACHE II were respectively 25.4+/-7.7 and 8.7+/-5. Mean initial PaO2/FiO2 was 127.4 +/- 59.7mmHg and ARDS was diagnosed in 153 (98%) patients. The CT extent was distributed as <50 % (27.3 %), [50% - 75 %] (37.8 %) and > 75 % (34.9 %). Mean CT score was 19.4+/-5.8 [5 - 34]. The comparison of the 2 methods, showed a statistically significant result between the CT score and a damage < 50% (p = 0.002), and also between CT score and a damage >= 75% (p = 0.003). Conclusion(s): In COVID-19 pneumonia, lung damage extent seems to be appreciated with percentages as well as CT score. An external validity is mandatory for CT-scan score.

A Comparison of ICU Mortality Scoring Systems Applied to COVID-19.

Background Over the past three years, COVID-19 has been a major source of mortality in intensive care units around the world. Many scoring systems have been developed to estimate mortality in critically ill patients. Our intent with this study was to compare the efficacy of these systems when applied to COVID-19. Methods The was a multicenter, retrospective cohort study of critically ill patients with COVID-19 admitted to 16 hospitals in Texas from February 2020 to March 2022. The Simplified Acute Physiology Score (SAPS) II, Acute Physiology and Chronic Health Evaluation (APACHE) II, Sequential Organ Failure Assessment (SOFA) score, and 4C Mortality scores were calculated on the initial day of ICU admission. Primary endpoints were all-cause mortality, ICU length of stay, and hospital length of stay. Results Initially, 62,881 patient encounters were assessed, and the cohort of 292 was selected based on the inclusion of the requisite values for each of the scoring systems. The median age was 56 +/- 14.93 years and 61% of patients were male. Mortality was defined as patients who expired or were discharged to hospice and was 78%. The different scoring systems were compared using logistic regression, receiver operating characteristic (ROC) curve, and area under the ROC curve (AUC) analysis to compare the accuracy of prediction of the mortality and length of stay. The multivariate analysis showed that SOFA, APACHE II, SAPS II, and 4C scores were all significant predictors of mortality. The SOFA score had the highest AUC, though the confidence intervals for all of the models overlap therefore one model could not be considered superior to any of the others. Linear regression was performed to evaluate the models' ability to predict ICU and hospital length of stay, and none of the tested systems were found to be significant predictors of length of stay. Conclusion The SOFA, APACHE II, ISARIC 4-C, and SAPS II scores all accurately predicted mortality in critically ill patients with COVID-19. The SOFA score trended to perform the best.

A first-level customization study of SAPS II with Norwegian Intensive Care and Pandemic Registry (NIPaR) data.

BACKGROUND: Severity scores and mortality prediction models (MPMs) are important tools for benchmarking and stratification in the intensive care unit (ICU) and need to be regularly updated using data from a local and contextual cohort. Simplified acute physiology score II (SAPS II) is widely used in European ICUs. METHODS: A first-level customization was performed on the SAPS II model using data from the Norwegian Intensive Care and Pandemic Registry (NIPaR). Two previous SAPS II models (Model A: the original SAPS II model and Model B: a SAPS II model based on NIPaR data from 2008 to 2010) were compared to the new Model C. Model C was based on patients from 2018 to 2020 (corona virus disease 2019 patients omitted; n = 43,891), and its performances (calibration, discrimination, and uniformity of fit) compared to the previous models (Model A and Model B). RESULTS: Model C was better calibrated than Model A with a Brier score 0.132 (95% confidence interval 0.130-0.135) versus 0.143 (95% confidence interval 0.141-0.146). The Brier score for Model B was 0.133 (95% confidence interval 0.130-0.135). In the Cox's calibration regression α ≈ 0 and ß ≈ 1 for both Model C and Model B but not for Model A. Uniformity of fit was similar for Model B and for Model C, both better than for Model A, across age groups, sex, length of stay, type of admission, hospital category, and days on respirator. The area under the receiver operating characteristic curve was 0.79 (95% confidence interval 0.79-0.80), showing acceptable discrimination. CONCLUSIONS: The observed mortality and corresponding SAPS II scores have significantly changed during the last decades and an updated MPM is superior to the original SAPS II. However, proper external validation is required to confirm our findings. Prediction models need to be regularly customized using local datasets in order to optimize their performances.

SAPS 3 as a 28-day mortality predictor in critically ill COVID-19 patients

Background: The case fatality rate (CFR) of COVID-19 was 8.7% in Indonesia on April 2020. Simplified Acute Physiology Score 3 (SAPS 3) has been used to predict the hospital mortality based on different variables including acute physiologic derangements, current conditions and interventions, and previous health status assess the severity of condition during the first hour of admission to the ICU. We assessed SAPS 3 to predict the outcome and mortality of critical COVID-19 patients in ICU over a period of 28 days. Methodology: This retrospective cohort study consisted of adult patients admitted to ICU with probable or confirmed COVID-19 in our hospital. We recorded the patients SAPS 3 score from the medical record as well as the 28-day mortality. Validity of the SAPS 3 score was done by the Area Under Curve (AUC) measurement and Hosmer-Lemeshow calibration test. Result(s): The mortality rate of critical COVID-19 patients was 43.8%. The age, intra-hospital location before ICU admission, use of vasoactive drugs (P < 0.0001), focal neurological deficits (P < 0.0001), respiratory failure (P = 0.004), creatinine >= 3.5 mg/dL (P = 0.005), and platelets < 50,000 /microL (P = 0.032) were significantly associated with 28-days mortality in the ICU. SAPS 3 showed good discrimination and predictability. The optimal cut-off point was 39 with 70.3% sensitivity and 74.4% specificity. Conclusion(s): SAPS3 score system was valid in predicting the 28-day mortality of COVID-19 patients in the ICU with good discrimination and calibration value;therefore, it is an important predictor tool for early prognosis screening that will help reduce the strain over the ICU resources. Abbreviations: CFR: Case Fatality Rate;SAPS 3: Simplified Acute Physiology Score 3;COVID-19: The Coronavirus Disease 2019;ICU: Intensive Care Unit;APACHE: Acute Physiology and Chronic Health Evaluation;SPSS: Statistical Package for Social Sciences;GCS: Glasgow Coma Scale;ROC: Receiver Operating Characteristic;PHEIC: Public Health Emergency of International Concern;OR: Odds Ratio Copyright © 2022 Faculty of Anaesthesia, Pain and Intensive Care, AFMS. All rights reserved.