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Objectives: Assessment of the literature on the ProtekDuo cannula when used as venopulmonary (V-P) extracorporeal membrane oxygenation (ECMO) in ARDS secondary to COVID-19. Method(s): Systematic literature search in EMBASE, Medline (Pubmed) and NHS library using appropriate keywords as well as PICOS and PRISMA approach. Result(s): We found 285 publications, of which 5 publications met the search criteria and were included in this review. A total of 194 patients with COVID-19 related ARDS had a ProtekDuo placed to establish venovenous (V-V) ECMO and right ventricular (RV) support. Patients treated with the ProtekDuo cannula had survival rates between between the studies of 59 and 89%, with a significant survival compared to an invasive ventilation group or when compared to dual site V-V ECMO or other double lumen ECMO cannulas. One of the studies focused on extubation and early discontinuation of ventilator support, which the authors achieved in 100% of ProtekDuo patients. The incidence of acute kidney injury (AKI) and use of continuous renal replacement therapy (CRRT) was significantly reduced in the ProtekDuo versus other groups. Conclusion(s): The ProtekDuo displayed lower mortality rates, AKI occurrence and CRRT need as compared to other respiratory support modalities and has shown to be a game changer for ECMO support in patients suffering from COVID-19 ARDS. Many authors suggested the ProtekDuo for first line use in these patients.
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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.
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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.
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Introduction: Orogastric tube insertion is a routine procedure in medical care. However, misplacement of the tube can cause a variety of complications, which can be life threatening in some instances. Case Description/Methods: 71-year-old male presented with dyspnea, fever, chills, cough, and myalgia for 2 weeks. He had tachycardia, tachypnea, and was hypoxic to 66% in room air. He was found to have acute hypoxic respiratory failure secondary to COVID-19 Pneumonia and was admitted to ICU. But, he continued to be hypoxic and was started on BiPAP. He eventually became altered, and was intubated. Post intubation orogastric tube (OGT) placement was unsuccessful on the first attempt due to resistance. On the second attempt, the nurse was able to advance partially (Figure). But, a chest XR showed OGT in the mediastinum, and OGT was removed. CT of neck and chest revealed pneumomediastinum with possible mid-thoracic esophageal perforation. The patient was started on broad-spectrum antibiotics and thoracic surgery was consulted. Given his mechanical ventilation requirement, surgery deemed him unfit to tolerate thoracotomy and the endoscopic procedure was not available in the hospital. So, recommendation was to manage conservatively. His hospital course was complicated by hypotension requiring vasopressors and metabolic acidosis in setting of acute renal failure requiring CRRT. Code status was changed by the family to Do Not Resuscitate due to his deteriorating condition. Eventually, he had a PEA arrest and was expired. Discussion(s): OGT intubation is performed at hospitals for feeding, medication administration or gastric decompression. Although it is considered a safe procedure, complications can arise due to OGT misplacement or trauma caused by the OGT itself or the intubation process. OGT misplacement is typically endotracheal or intracranial. Misplacement within the upper GI lumen is usually detected by a kink in the oropharynx or esophagus. The subsequent complications are identified by the structure that is perforated (e.g., mediastinitis or pneumothorax). Regardless of whether counteraction is perceived, the physician must be careful not to apply excessive force. The location of the OGT tip should be determined by a chest radiograph;visualization of the tip below the diaphragm verifies appropriate placement. Complications of OGT insertion are uncommon;however, the consequences are potentially serious, and the anatomy of the upper GI tract should be understood by all who are involved in the care.
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Introduction: Midazolam based continuous iv sedation became again prominent during the COVID-19 pandemic. However, this sedation therapy is associated with a high incidence of benzodiazepine-related delirium and an increased number of days spent in coma. Given the high midazolam dose requirements in some patients and due to the renal clearance (CL) of the active metabolite 1-OH-midazolam-glucuronide (OHmidazolamGluc), ICU patients with COVID-19 and continuous renal replacement therapy (CRRT) may are at risk of prolonged sedation. Therefore, the aim of the study was to investigate the CL of midazolam and metabolites in 5 critically ill COVID-19 patients with CRRT. Method(s): Pre-filter blood samples and ultrafiltrate samples were collected simultaneously. Midazolam, 1-OH-midazolam (OHmidazolam) and OHmidazolamGluc plasma samples were analysed by an UPLCMS/ MS method. CL of midazolam and metabolites were calculated by the delivered renal dose and sieving (SC) coefficient. Subsequently, the CL and delivered renal dose were corrected for downtime therapy and filter integrity by a filter urea ratio. Result(s): We included 4 cases of CVVHD and 2 cases of CVVHDF. Midazolam, OHmidazolam and OHmidazolamGluc concentrations in mug/l ranged from 0 to 6070, 0 to 295 and 1727 to 39,000, respectively. SCs ranged from 0.02 to 0.03 for midazolam, 0.05 to 0.06 for OHmidazolam and 0.23-0.43 for OHmidazolamGluc. The CL in ml/min by the delivered renal dose was 0.82-1.67 for midazolam, 2.20-3.46 for OHmidazolam and 4.0-27.65 for OHmidazolamGluc. The CL in ml/min by the corrected renal dose was 0.68-1.50, 1.83-2.33 and 3.40-25.4, respectively. The urea ratios were 0.53 to 1.0. Conclusion(s): Midazolam and OHmidazolam are not removed efficiently by CRRT and OHmidazolamGluc approximately up to 43%. Type of CRRT, filter integrity and downtime of CRRT affect the CL of midazolam and metabolites. Our results have implications for more personalized titration of midazolam in COVID-19 patients with CRRT, mainly to avoid oversedation.
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Hepatitis A is a common viral infection worldwide that is transmitted via the fecal-oral route. Since the introduction of an efficient vaccine, the incidence of infection has decreased but the number of cases has risen due to widespread community outbreaks among unimmunized individuals. Classic symptoms include fever, malaise, dark urine, and jaundice, and are more common in older children and adults. People are often most infectious 14 days prior to and 7 days following the onset of jaundice. We will discuss the case of a young male patient, diagnosed with acute hepatitis A, leading to fulminant hepatitis refractory to conventional therapy and the development of subsequent kidney injury. The medical treatment through the course of hospitalization was challenging and included the use of L-ornithine-L-aspartate and prolonged intermittent hemodialysis, leading to a remarkable outcome. Hepatitis A is usually self-limited and vaccine-preventable;supportive care is often sufficient for treatment, and chronic infection or chronic liver disease rarely develops. However, fulminant hepatitis, although rare, can be very challenging to manage as in the case of our patient.Copyright © 2023 The Author(s).
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Introduction: Acute kidney injury (AKI) appears to be prevalent in ICU COVID-19 patients. Nevertheless, there are few data in comparison with non-COVID-19 patients. The aim of our study was to compare the prevalence of AKI in COVID-19 and non-COVID-19 critically ill patients. Method(s): We performed a retrospective single-center study including all consecutively COVID-19 critically ill mechanically ventilated patients admitted from 03/2020 to 11/2021 to our ICU and all consecutively critically ill mechanically ventilated patients from 08/2020 to 01/2021 and from 03/2021 to 08/2021 admitted to our non-COVID-19 ICU. Patients' demographics, comorbidity including Charlson Comorbidity Index (CCI), outcome, as well as, admission, maximum and minimum creatinine blood values, as well as KDIGO stage were recorded. Two patient groups, i.e., COVID-19 and non-COVID-19 patients were compared in terms of AKI. Result(s): The study included 333 patients (183 COVID-19, 150 non- COVID-19), of an average age 66.3 +/- 14.36 years-old. Between the two patient groups there was no difference in age or sex. COVID-19 patients had a lower CCI score (84% had a score of < 5 compared to 68.8%, p = 0.004). COVID-19 patients had a lower admission creatinine (1.13 +/- 0.78 mg/dl vs 1.49 +/- 1.33 mg/dl, p 0.003), nevertheless, developed more often AKI (74.3% vs 54%, p 0001) during their ICU hospitalization. Among COVID-19 ICU patients that developed AKI 54.4% were stage 1, 18.8% stage 2 and 26.8% stage 3, while 10.27% (19/185) of patients underwent CRRT. Twenty-eight-day mortality was high in COVID-19 patients (66.18%, 90/136). There was no difference in KDIGO stage percentage among the two groups. Conclusion(s): COVID-19 critically-ill patients develop more often AKI compared to non-COVID-19 patients. More studies are required to assess this phenomenon, focusing also on the long-term follow-up of the kidney function of these patients.
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Introduction: COVID-19 causes a major inflammatory response, which may progress to shock and multiple organ failure. We explored whether continuous renal replacement therapy (CRRT) using adsorption membrane (oXiris) could reduce the inflammatory response in critically ill COVID-19 patients with acute renal failure (ARF) [1, 2]. Method(s): Case-control study including 24 critically ill COVID-2019 patients requiring RRT using an oXiris filter. We measured cytokines before and during treatment as well as relevant clinical endpoints. The control group was selected among COVID-19 patients included into our ongoing RECORDS trial (NCT04280497) who received RRT without adsorbing filters. Result(s): 24 severe COVID-19 patients, admitted to the intensive care unit (ICU) and treated with CRRT using the oXiris filter between March and April 2020 (20 males and 4 females);median age 67. The average time from COVID-19 symptoms to initiation of oXiris treatment was 18 +/- 7 days, and from ICU admission to initiation of oXiris treatment 9.5 +/- 7.8 days and from ARF to oXiris treatment was 3 +/- 5 days. The average length of treatment was 152.8 +/- 92.3 h. Treatment was associated with cytokine decreases for IL-1beta (p = 0.00022), MCP-1 (p = 0.03), and MIP-1 alpha (p = 0.03). The SOFA scores also showed a reduction over 48 h of therapy without reaching statistical significance. Our study found no significant effect of hemodynamic status. The average ICU stay length was 14 +/- 5 days and the mortality rate was 79% in the Oxiris group. We compared the mortality across the two matched groups, there was no evidence of any difference in mortality (Fig. 1). Conclusion(s): In our study, CRRT using the oXiris filter seemed to effectively remove IL-1 beta, MCP-1, and MIP-1 alpha in COVID-19 patients. These exploratory results should be confirmed in a randomized controlled study.
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Background. Pregnant women are at high risk of Coronavirus disease 2019 (COVID-19) complications, including acute respiratory distress syndrome. Currently, one of the cornerstones in the treatment of this condition is lung-protective ventilation (LPV) with low tidal volumes. However, the occurrence of hypercapnia may limit this ventilatory strategy. So, different extracorporeal CO2 removal (ECCO2R) procedures have been developed. ECCO2R comprises a variety of techniques, including low-flow and high-flow systems, that may be performed with dedicated devices or combined with continuous renal replacement therapy (CRRT). Case description. Here, we report a unique case of a pregnant patient affected by COVID-19 who required extracorporeal support for multiorgan failure. While on LPV, because of the concomitant hypercapnia and acute kidney injury, the patient was treated with an ECCO2R membrane inserted in series after a hemofilter in a CRRT platform. This combined treatment reducing hypercapnia allowed LPV maintenance at the same time while providing kidney replacement and ensuring maternal and fetal hemodynamic stability. Adverse effects consisted of minor bleeding episodes due to the anticoagulation required to maintain the extracorporeal circuit patency. The patient's pulmonary and kidney function progressively recovered, permitting the withdrawal of any extracorporeal treatment. At the 25th gestational week, the patient underwent spontaneous premature vaginal delivery because of placental abruption. She gave birth to an 800-gram female baby, who three days later died because of multiorgan failure related to extreme prematurity. Conclusions. This case supports using ECCO2R-CRRT combined treatment as a suitable approach in the management of complex conditions, such as pregnancy, even in the case of severe COVID-19.
Subject(s)
COVID-19 , Continuous Renal Replacement Therapy , Pregnancy , Humans , Female , Carbon Dioxide , Hypercapnia/therapy , Continuous Renal Replacement Therapy/adverse effects , Extracorporeal Circulation/adverse effects , Extracorporeal Circulation/methods , COVID-19/complications , COVID-19/therapy , Placenta , Renal Replacement Therapy/adverse effectsABSTRACT
Rationale & Objective: Continuous kidney replacement therapy (CKRT) is the predominant form of acute kidney replacement therapy used for critically ill adult patients with acute kidney injury (AKI). Given the variability in CKRT practice, a contemporary understanding of its epidemiology is necessary to improve care delivery. Study Design: Multicenter, prospective living registry. Setting & Population: 1,106 critically ill adults with AKI requiring CKRT from December 2013 to January 2021 across 5 academic centers and 6 intensive care units. Patients with pre-existing kidney failure and those with coronavirus 2 infection were excluded. Exposure: CKRT for more than 24 hours. Outcomes: Hospital mortality, kidney recovery, and health care resource utilization. Analytical Approach: Data were collected according to preselected timepoints at intensive care unit admission and CKRT initiation and analyzed descriptively. Results: Patients' characteristics, contributors to AKI, and CKRT indications differed among centers. Mean (standard deviation) age was 59.3 (13.9) years, 39.7% of patients were women, and median [IQR] APACHE-II (acute physiologic assessment and chronic health evaluation) score was 30 [25-34]. Overall, 41.1% of patients survived to hospital discharge. Patients that died were older (mean age 61 vs. 56.8, P < 0.001), had greater comorbidity (median Charlson score 3 [1-4] vs. 2 [1-3], P < 0.001), and higher acuity of illness (median APACHE-II score 30 [25-35] vs. 29 [24-33], P = 0.003). The most common condition predisposing to AKI was sepsis (42.6%), and the most common CKRT indications were oliguria/anuria (56.2%) and fluid overload (53.9%). Standardized mortality ratios were similar among centers. Limitations: The generalizability of these results to CKRT practices in nonacademic centers or low-and middle-income countries is limited. Conclusions: In this registry, sepsis was the major contributor to AKI and fluid management was collectively the most common CKRT indication. Significant heterogeneity in patient- and CKRT-specific characteristics was found in current practice. These data highlight the need for establishing benchmarks of CKRT delivery, performance, and patient outcomes. Data from this registry could assist with the design of such studies.
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Objectives: In this study, it was aimed to determine demographic and clinical characteristics, supportive treatments in intensive care unit (ICU), mortality rates and factors affecting mortality by grouping COVID-19 intensive care patients as octogenarian and nonagenarian groups, and patients younger than 80-years-old. Method(s): The patients aged >=18 years diagnosed with COVID-19 with PCR positivity in ICUs between March 19, 2020 and March 31, 2021 were included in this retrospective observational study. Result(s): Of the 1004 PCR positive patients, 58.7% were male. The youngest patient was 20, the oldest patient was 100-years-old. There were 738 patients in Group 1 (20-79 years) and 266 patients in Group 2 (>=80 years). Between the two groups, gender, APACHE II score, need for intubation, need for vasopressor/inotrope, and patients in need of care were higher in Group 2 (p<0.001 for all). Only the patients in Group 1 were established ECMO. Hypertension (HT), cardiovascular, respiratory and neurological diseases, number of comorbidity, and mortality rate were higher significantly in Group 2 (p<0.001, p=0.001, p=0.006, p<0.001, p<0.001, and p<0.001;respectively). Age, male gender, HT, intubation, and vasopressor/inotrope requirement were found to be predictors of mortality. Conclusion(s): COVID-19 may have a more severe and fatal course in the octogenerian and nonagenerian age group with high comorbidity in the ICU.©Copyright 2022 by The Cardiovascular Thoracic Anaesthesia and Intensive Care.
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During intensive care unit (ICU) management of COVID-19, blood tests are often conducted for close monitoring of patients, a poor prognostic factor for survival, especially in hypoxemic patients. This study aimed to determine the degree of anemia and its effect on prognosis in ICU COVID-19 patients. This retrospective study included COVID-19 patients admitted to the ICU between 1 October 2020 and 1 May 2021. All the patients included were aged > 18 years and stayed in the ICU for >=14 days. Patients aged <18 years, those with major bleeding, and those recovering from surgery were excluded. The total blood samples (mL) taken in the ICU were calculated. From among the 395 patients screened for inclusion, 112 patients were included in the study. Mean age of the patients was 71.3 +/- 13.2 years (Male/Female: 1.8). Mean hemoglobin (Hb) at admission was 13.2 +/- 1.8 g dL-1. At the end of the ICU stay mean Hb was 9.74 +/- 1.98 g dL-1. During ICU stay, the mean reduction in Hb was 3.47 +/- 2.11 g dL-1. Age (p= 0.049), drawn blood volume per day (p= 0.001), and higher hemoglobin at admission (p= 0.001) were determined by multivariate analysis as independent risk factors for hemoglobin reduction. Hemoglobin reduction (OR: 1.34), and intubation status (OR: 57.50) were independent risk factors for mortality. Considering that most COVID-19 patients are admitted to the ICU due to acute respiratory failure (ARF), it is vital to maintain the Hb level as high as possible, so as to maintain oxygenation.Copyright © 2022, UHOD - Uluslararasi Hematoloji Onkoloji Dergisi. All rights reserved.
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Introduction: Evidence shows that continuous renal replacement therapy (CRRT) and hemodialysis may be effective in the treatment of Coronavirus disease-2019 (COVID-19). This study aimed to compare the effects of CRRT and hemodialysis on complications, vital signs, and laboratory parameters in patients with COVID-19. Material(s) and Method(s): This cross-sectional study was performed on 113 patients with COVID-19 who underwent hemoperfusion in Kosar Hospital of Semnan city (Iran) between 2020 and 2021. The patients were divided into two groups, the CRRT hemoperfusion group (n=49) and the hemodialysis group (n=64). A checklist was used for collecting data, which included demographic variables, history of underlying diseases, vital signs, laboratory parameters, complications, and various outcomes, which were extracted through interviews with patients or companions and in medical records. IBM Statistical Package for the Social Sciences Statistics for Windows version 26 was used for data analysis. Result(s): The time from hemoperfusion to hospital discharge (3.84+/-4.51 vs. 5.92+/-4.16 day), duration of intubation (0.33+/-0.94 vs. 1.84+/-3.42), death after hemoperfusion (64.06 vs. 26.5%), situational instability (21.9 vs. 8.2%), and death during hemoperfusion (14.1 vs. 0%) were significantly lower in the CRRT group than in the hemodialysis group (p<0.05). In the repeated-measures analysis of variance (ANOVA) test, the two groups demonstrated a statistically significant difference in lactate dehydrogenase, alkaline phosphatase, white blood cell count, and C-reactive protein at different time points;thus, the mean of these variables was significantly lower after hemoperfusion in the CRRT group than in the hemodialysis group (p<0.05). Conclusion(s): Continuous renal replacement therapy hemoperfusion can be effective in the recovery process of patients with COVID-19 because the length of hospital stay, intubation period, situational instability, and mortality during and after hemoperfusion are less than those of hemodialysis. © Copyright 2022 by the Infectious Diseases and Clinical Microbiology Specialty Society of Turkey Mediterranean Journal of Infection, Microbes and Antimicrobials published by Galenos Yayinevi.
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BACKGROUND AND OBJECTIVES: Paediatric dengue-associated acute liver failure (PALF) is a rare and fatal complication. To date, clinical data regarding the combination of therapeutic plasma exchange (TPE) and continuous renal replacement therapy (CRRT) for the treatment of dengue-associated PALF are limited. METHODS: We conducted a single-center, retrospective study of all children with dengue-associated PALF admitted to the paediatric intensive care unit of Children Hospital No.2, Vietnam, who were treated with TPE+CRRT between January 2021 and March 2022. The main study outcomes were in-hospital survival, normalisation of hepatic function, and hepatic encephalopathy improvement. RESULTS: Twelve patients aged from 06 to 12 years underwent TPE+CRRT procedures. Among them, three (25 %) patients died of severe sepsis and septic shock confirmed by Enterobacteriaceae spp. haemocultures (stable on maintenance treatment of COVID-19-associated MIS-C with low dose of oral steroids on hospital admission), acute respiratory distress syndrome (ARDS), and clinically apparent intracranial haemorrhage. Nine patients (75 %) survived. The paediatric mortality risk score improved significantly at discharge compared with PICU admission (P < 0.01). Markedly, all twelve patients were diagnosed with hepatoencephalopathy of grades III and IV on PICU admission. After the combined TPE+CRRT interventions, there were substantial improvements in liver transaminases levels, coagulation profiles, and metabolic biomarkers. Normal neurological functions were observed in nine alive patients at hospital discharge. Only one patient experienced an adverse event of slightly low blood pressure, which rapidly self-resolved. INTERPRETATION AND CONCLUSIONS: Combined TPE+CRRT significantly improved survival outcome, neurological status, and rapid normalisation of liver functions in dengue-associated PALF.
Subject(s)
Acute Kidney Injury , COVID-19 , Continuous Renal Replacement Therapy , Dengue , Liver Failure, Acute , Child , Humans , Plasma Exchange/methods , Retrospective Studies , Vietnam , COVID-19/therapy , Liver Failure, Acute/etiology , Liver Failure, Acute/therapyABSTRACT
The novel severe acute respiratory syndrome coronavirus 2, SARS-CoV-2 (coronavirus Disease 19 (COVID-19)) was identified as the causative agent of viral pneumonias in Wuhan, China in December 2019, and has emerged as a pandemic causing acute respiratory distress syndrome (ARDS) and multiple organ dysfunction. Interim guidance by the World Health Organization states that extracorporeal membrane oxygenation (ECMO) should be considered as a rescue therapy in COVID-19-related ARDS. International registries tracking ECMO in COVID-19 patients reveal a 21%-70% incidence of acute renal injury requiring renal replacement therapy (RRT) during ECMO support. The indications for initiating RRT in patients on ECMO are similar to those for patients not requiring ECMO. RRT can be administered during ECMO via a temporary dialysis catheter, placement of a circuit in-line hemofilter, or direct connection of continuous RRT in-line with the ECMO circuit. Here we review methods for RRT during ECMO, RRT initiation and timing during ECMO, anticoagulation strategies, and novel cytokine filtration approaches to minimize COVID-19's pathophysiological impact.
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PURPOSE/HYPOTHESIS: To compare mobility, medical complexity, and adverse events in patients without COVID-19 (non-COV) and with COVID-19 (COV) while on extracorporeal membrane oxygenation (ECMO) and undergoing physical therapy (PT). NUMBER OF SUBJECTS: All patients on ECMO for>=3 days and receiving PT while on ECMO were included. MATERIALS AND METHODS: Retrospective collection of data from records from2015 to June 30, 2022. Descriptive analysis was used to summarize data. RESULT(S): From 156 patients on ECMO, 36 underwent PT while on ECMO. Five patients had venoarterial configuration. The non-COV group included 15 patients with 142 sessions, and the COV group included 21 patients with 270 sessions. Non-COV and COV groups had a median age of 40 and 43 years, were 73% and 43% male, and had BMI of 25.3 and 35.1 kg/m2.Mean Sequential Organ Failure Assessment and Respiratory ECMO Survival Prediction scores were higher in the non-COV group, while the Lung Injury Scores were similar. Non-COV and COV groups had similar hospital and length of stay (60 vs 54 days;53 vs 50 days) and were cannulated for similar duration (24, 26 days). PT evaluations occurred soon after admission for both groups (4, 5 days). Non-COV and COV groups received a median of 2.5 and 2.6 sessions/week, and 45-and 40-minutes/session, respectively. Sixty-seven percent of non-COV sessions and 86% of COV sessions were done with >=1 femoral cannulas in situ. The COV group was supported on significantly higher pump flow (4.3 vs 3.6 L/min), pump speed (3200 vs 2675 rpm), and sweep settings (6 vs 4 L/min), however, blender fraction of inspired oxygen was the same (100%). Sessions in the COV group more often had simultaneous sedative infusions (20% vs 4%), abnormal blood gases (91% vs 71%), and hypertension or desaturation. Sessions in the non-COV group more often had simultaneous continuous renal replacement therapy (26% vs 1%), mechanical ventilation (68% vs 38%), and severe anemia (49% vs 37%). Vasoactive infusions presence and lactate levels were similar in both groups. Thirty-five percent and 50% of sessions were in-bed exercises in the non-COV and COV groups. Sitting at edge of bed or passive transfers to chair, standing or marching, and ambulation were achieved in 20%, 24%, and 21% of non-COV sessions;and in 27%, 16%, and 7% of COV sessions. The non-COV group had a mean first ICU Mobility Scale score (IMS) of 2.23, and a mean improvement by 0.31 points. The COV group had a mean first IMS of 1.13, and a mean improvement by 1.29 points. Safety events were categorized as minor or major according to whether interventions were required. The safety event rate in the non-COV and COV sessions were 5% (4 minor, 3 major) and 4% (5 minor, 1 major). CONCLUSION(S): This investigation describes patients on ECMO with and without COVID, with detail on medical condition, mobility, and adverse events. While ECMO settings were higher during COV sessions, other measures did not indicate a clear disparity in disease severity or fragility. The COV group started with lower mobility but made larger gains while on ECMO. CLINICAL RELEVANCE: PT provided to patients with and without COV and on ECMO can result in safe and effective mobility outcomes.
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Background: In the COVID-19 pandemic, children with COVID-19 infection have mild symptoms. However, some children may develop a hyperinflammatory response called multisystem inflammatory syndrome in children (MIS-C) after the COVID-19 infection. The main pathophysiology of this syndrome is mainly dysregulated inflammatory response lead to multi-organ dysfunction especially cardiovascular system. Despite early treatment with IVIG and corticosteroid, some children with MIS-C are still refractory disease and progressive symptoms. Additional from biologic agent, we try to find the treatment options as adjunctive treatment for rapid removing the inflammatory mediators. Blood purification by hemoadsorption may be a good choice for improve this clinical symptoms. Method(s): Five critically ill children with severe MIS-C who received initiated treatment with IVIG and corticosteroid, all children were received an extracorporeal blood purification by using HA330 disposable hemoperfusion cartridge (HA330;Jafron, Zhuhai City, China) combined with a continuous renal replacement therapy (CRRT) machine. Hemoadsorption (HA) will be performed for a maximum of 4 hours, and the second session will be started approximately 12-24 hours after the end of the first session. We observed the reduction of the PELOD-2 and PRISM-3 score compared between baseline and 72 hours after HA treatment. The reduction of VIS and inflammatory markers such as IL-6, procalcitonin (PCT), high sensitivity C-reactive protein (hs-CRP), lactate levels at 72 hours will be recorded. Result(s): This small case series, a total of 5 children who diagnosed with MIS-C were compared the severity score before and after HA treatment. The average PELOD-2 score decreased significantly from 9.0 (IQR;7.0-10.0) at baseline to 2.0 (IQR;0-7.0) at 72 hours (p = 0.04). The median PRISM-3 score also decreased significantly from 15.0 (IQR;15.0-18.0) at baseline to 2.0 (IQR;0-8.0) at 72 hours (p = 0.04). The median VIS decreased from 20.0 (IQR;20.0-52.0) at baseline to 7.0 (IQR;3.0-7.0) at 72 hours but no statistically significant in reduction. Similar to VIS, there were no statistically difference in other inflammatory markers such as IL-6, PCT, hs- CRP and lactate levels at 72 hours. Conclusion(s): MIS-C is rare and may have a serious complications especially cardiovascular dysfunction. Early initiated treatment with IVIG and corticosteroid may have a favorable outcome. In the severe MIS-C and refractory disease, using HA330 may be a good option and safe for adjunctive treatment with IVIG and corticosteroid for rapid improvement in organ dysfunction and mortality score in context of rapid reduction of the inflammatory cytokines.
ABSTRACT
Background: Lung-protective ventilation (LPV) with low tidal volumes (TV), aimed to reduce ventilator-induced lung injury, is one of the cornerstones in the treatment of acute respiratory distress syndrome (ARDS), including that secondary to Coronavirus disease 2019 (COVID-19). To allow LPV, and avoid the risk of progressive hypercapnia and respiratory acidosis, a wide range of extracorporeal CO2 removal (ECCO2R) techniques have been developed. These treatments may be performed alone or in combination with other organ support therapies. Here, we report our experience with a pregnant woman with multiorgan failure (MOF), occurring as a sequela of COVID-19, who was successfully treated with ECCO2R coupled with continuous renal replacement therapy (CRRT). Case Presentation: A 34-year-old pregnant patient at the 16th gestational week affected by COVID-19 was admitted for dyspnea, rapidly complicated by MOF. Because of concomitant hypercapnia and acute kidney injury the patient was treated with an ECCO2R membrane inserted in series after a hemofilter in a common CRRT platform. ECCO2R was provided using a polymethyl pentene, hollow fiber, gas-exchanger membrane of 1.35 m2. ECCO2R+CRRT was set in continuous venovenous hemodialysis (CVVHD) mode with blood flow of 300 mL/min and a sweep gas blood flow of 5 l/min. Systemic anticoagulation was obtained by continuous administration of unfractionated heparin (UFH), with a target activated partial thromboplastin time (aPTT) of 70-80 seconds. (In table 1, ventilatory and hemodynamic parameters collected during ECCO2R+CRRT treatment are reassumed). The combined treatment was effective in reducing hypercapnia, allowing the maintenance of LPV. Moreover, it was associated with the hemodynamic stability of both mother and fetus and it was well-tolerated. Anyway, the treatment was complicated by minor bleeding episodes mainly linked to the anticoagulation required to maintain the patency of the extracorporeal circuit. After ECCO2R+CRRT termination, the patient progressively recovered pulmonary and kidney function, so that it was possible to withdraw any support therapy. Moreover, she underwent a preterm spontaneous vaginal delivery of an alive baby. Conclusion(s): Our case supports the use of ECCO2R+CRRT as a suitable approach in complex patients, including those with severe COVID-19, being aware of the potential complications linked to this treatment.
ABSTRACT
Background: Acute kidney injury (AKI) is a common complication of COVID-19 ARDS and is associated with greater risk of mortality (1)). In addition to the direct tubular injury mediated by the virus, indirect mechanisms play a role in AKI development. Positive pressure ventilation, by increasing intrathoracic pressure, leads to a decreased venous return to the heart and to a reduced cardiac output (2). In addition, elevated central venous pressure (CVP) may result in elevated tubular hydrostatic pressure in the encapsulated kidney, which reduces glomerular filtration rate and oxygen delivery (3). We hypothesized that elevated intrathoracic pressure, determined by positive pressure ventilation is associated with an increased risk of AKI. The aim of the study is to assess the association between hemodynamics and ventilatory parameters set during mechanical ventilation and AKI in patients with COVID-19 ARDS. Method(s): This is single center retrospective observational study performed at Papa Giovanni XXIII Hospital Bergamo (Italy). Consecutive patients were enrolled with a diagnosis of COVID-19 and ARDS managed with invasive mechanical ventilation. If patients developed AKI (defined according to KDIGO definition) within 14 days of ICU stay were included in "AKI group", otherwise were classified in "non-AKI group". Demographic characteristics, lab tests and hemodynamic [mean arterial pressure (MAP) and central venous pressure (CVP), fluid balance] and ventilatory parameters [positive end-expiratory pressure (PEEP), plateau pressure (PPlat)] were compared between group using Mann Whitney test. Data are presented as median and 95% CI. Only data registered until the day of the AKI occurrence, in patients in AKI group, or until the day corresponding to the median days between ICU admission and the AKI occurrence calculated before for patients in non-AKI group, were considered for the statistical analysis. Result(s): Among the 140 patients included in the analysis, AKI occurred in 70 (48%) patients and 27 (19%) required continuous renal replacement therapy (CRRT). Table 1 shows comparison between the two groups. Patients in AKI group were older, had higher prevalence of obesity, hypertension and diabetes, had lower MAP and received a greater amount of fluid and furosemide compared to patients in non-AKI group (p<0.05). Only a trend toward a greater CVP was observed in patients with AKI, without reaching a significant difference. Both PEEP and Pplat were set higher in patients with AKI, while the severity of lung disease, measured by PaO2/FiO2 were not different between the two groups. Conclusion(s): In our cohort, higher pressure ventilation was associated with an increased risk of AKI.