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Objectives: The aim of this study was to assess Jordanian physicians' awareness about venous thromboembolism (VTE) risk among COVID-19 patients and its treatment protocol. Method(s): This was a cross-sectional-based survey that was conducted in Jordan in 2020. During the study period, a convenience sample of physicians working in various Jordanian hospitals were invited to participate in this study. Physicians' knowledge was evaluated and physicians gained one point for each correct answer. Then, a knowledge score out of 23 was calculated for each. Key Findings: In this study, 102 physicians were recruited. Results from this study showed that most of the physicians realize that all COVID-19 patients need VTE risk assessment (n = 69, 67.6%). Regarding VTE prophylaxis, the majority of physicians (n = 91, 89.2%) agreed that low molecular weight heparin (LMWH) is the best prophylactic option for mild-moderate COVID-19 patients with high VTE risk. Regarding severe/critically ill COVID-19 patients, 75.5% of physicians (n = 77) recognized that LMWH is the correct prophylactic option in this case, while 80.4% of them (n = 82) knew that mechanical prevention is the preferred prophylactic option for severe/critically ill COVID-19 patients with high bleeding risk. Moreover, 77.5% of physicians (n = 79) knew that LMWH is the treatment of choice for COVID-19 patients diagnosed with VTE. Finally, linear regression analysis showed that consultants had an overall higher knowledge score about VTE prevention and treatment in COVID-19 patients compared with residents (P = 0.009). Conclusion(s): All physicians knew about VTE risk factors for COVID-19 patients. However, consultants showed better awareness of VTE prophylaxis and treatment compared with residents. We recommend educational workshops be conducted to enhance physicians' knowledge and awareness about VTE thromboprophylaxis and management in COVID-19 patients.Copyright © 2022 The Author(s). Published by Oxford University Press on behalf of the Royal Pharmaceutical Society. All rights reserved.
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Aim To analyze the differences in clinical characteristics and outcomes of coronavirus disease 2019 (COVID-19) critically ill patients with or without vascular calcification. Methods COVID-19 critically ill patients admitted to the intensive care unit of Tongji Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology in February 2020 were analyzed retrospectively. According to the chest CT findings, the patients were divided into vascular calcification group and non-vascular calcification group. The vascular calcification group was further divided into aortic calcification group, coronary calcification group and simultaneous calcification group (both aorta and coronary artery calcification). The clinical characteristics and outcomes of patients were compared in different groups. Results Compared with the non-vascular calcification group, the patients in the vascular calcification group were older and had a higher proportion of hypertension and coronary heart disease, which showed higher levels of leukocyte count, neutro-phil count, C-reactive protein, globulin, lactate dehydrogenase, international normalized ratio, D-dimer, creatinine, crea-tine kinase-MB, high-sensitivity cardiac troponin, myohemoglobin and N-terminal pro-B-type natriuretic peptide, lower levels of lymphocyte count, platelet count, albumin, estimated glomerular filtration rate, and higher risk of death. Compared with aortic calcification group, the outcomes of coronary calcification group and simultaneous calcification group were worse. Conclusion Vascular calcification, especially coronary artery calcification, may be a risk factor for poor prognosis in COVID-19 critically ill patients. © 2022, Editorial Office of Chinese Journal of Arteriosclerosis. All rights reserved.
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Introduction: Perinatal admissions to Critical Care are increasing due to rising maternal age, obesity, and comorbid disease.1 The MBRRACE Report 2021 stated that of 191 maternal deaths in 2017-2019, only 17% had good care.2 Since the COVID-19 pandemic, there was a subjective increase in perinatal admissions to Mid Yorkshire Hospitals Critical Care. Objective(s): To investigate whether MYH Critical Care maternal admissions have increased, if there has been a change in admission trends and to evaluate the care of critically ill pregnant and postpartum women compared to FICM standards.3 Methods: Retrospective audit of notes of all pregnant and up to 6 weeks postpartum women admitted to critical care between 24/02/2019 and 05/09/2021. Data collected included gestation, duration of admission, organ support, days reviewed by obstetrics and mortality outcomes. Result(s): * There was 1 maternal death and 3 fetal deaths during the study period * 50% of the admissions were antenatal and 50% were postnatal * During the COVID-19 pandemic we have seen a 47% increased rate of admissions from 1 per 29 critical care bed days to 1 per 19 critical care bed days * 50% of patients were supported with ventilation and CPAP during admission, 13% with CPAP only. Prior to the COVID pandemic, no maternal admission required CPAP on our Critical Care unit during the data collection period * 63% of patients were reviewed by obstetrics at least one during their admission, but obstetric review was documented on only 37 of 112 patient days * There is no critical care SOP for perimortem Caesarean section * There is no specialist neonatal resuscitation equipment available on ICU * There is no named ICM consultant responsible for Maternal Critical Care * There is no SOP for support of maternal contact with baby * There is no critical care/obstetric services MDT follow-up Conclusion(s): This study shows that Critical Care admissions have increased, and that care does not follow all the FICM recommendations. Considering this, the following recommendations have been made: * Introduce an SOP and simulation training for peri-mortem section * Introduce neonatal resuscitation equipment box * Nomination of a named ICM Consultant lead for Maternal Critical Care to ensure quality of care and act as liaison * Train critical care staff in supporting contact between a mother and baby, with support from midwifery services * Introduction of Obstetric and Critical Care MDT follow-up.
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Coronavirus disease 2019 (COVID-19) is a fatal pandemic viral disease caused by the severe acute respiratory syndrome corona virus type-2 (SARS-CoV-2). The aim of this study is to observe the associations of IL-6, SARS-COV-2 viral load (RNAemia), IL- 6 gene polymorphism and lymphocytes and monocytes in peripheral blood with disease severity in COVID-19 patients. This study was carried out from March 2021 to January 2022. RT-PCR positive 84 COVID-19 patients and 28 healthy subjects were enrolled. Blood was collected to detect SARS-COV-2 viral RNA (RNAemia) by rRT-PCR, serum IL-6 level by chemiluminescence method, SNPs of IL-6 by SSP-PCR, immunophenotyping of lymphocytes and monocyte by flow cytometry. Serum IL-6 level (pg/ml) was considerably high among critical patients (102.02 +/- 149.7) compared to severe (67.20 +/- 129.5) and moderate patients (47.04 +/- 106.5) and healthy controls (3.5 +/- 1.8). Serum SARS-CoV-2 nucleic acid positive cases detected mostly in critical patients (39.28%) and was correlated with extremely high IL-6 level and high mortality (R =.912, P < 0.001). Correlation between IL-6 and monocyte was statistically significant with disease severity (severe group, p < 0.001, and 0.867*** and critical group p < 0.001 and 0.887***). In healthy controls, moderate, severe and critically ill COVID-19 patients, IL-6 174G/C (rs 1800795) GG genotype was 82.14%, 89.20%, 67.85% and 53.57% respectively. CC and GC genotype had strong association with severity of COVID-19 when compared with GG genotype. Significant statistical difference found in genotypes between critical and moderate groups (p < 0.001, OR-10.316, CI-3.22-23.86), where CC genotype was associated with COVID-19 severity and mortality. The absolute count of T cell, B cell, NK cell, CD4+ T cells and CD8+ T cells were significantly decreased in critical group compared to healthy, moderate and severe group (P < 0.001). Exhaustion marker CD94/NKG2A was increased on NK cells and CD8+ cytotoxic T cell among critical and severe group. Absolute count of monocyte was significantly increased in critical group (P < 0.001). Serum IL-6, IL-6 174 G/C gene and SARS-CoV-2 RNAaemia can be used in clinical practice for risk assessment;T cell subsets and monocyte as biomarkers for monitoring COVID-19 severity. Monoclonal antibody targeting IL-6 receptor and NKG2A for therapeutics may prevent disease progression and decrease morbidity and mortality.Copyright © 2023 Elsevier Inc.
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Background: Coronavirus in 2019 was recognized as one of the leading causes of death worldwide. According to reports, the mortality rate in people who need mechanical ventilation varies from 50 to 97 percent. The aim of this study was to evaluate the outcome of Covid-19 disease based on different characteristics in patients and mechanically ventilated variables. Method(s): This descriptive-analytical study was conducted on 160 patients with a definite diagnosis of Covid-19 who were under mechanical ventilation and admitted to the intensive care unit of Alzahra Hospital in Isfahan from March 2020 to March 2021. Data was collected by checklist. The checklist included demographic information, including age, gender, as well as information such as underlying diseases, disease outcome, length of hospitalization, etc. After collecting the data, they were analyzed in SPSS software version 22 and at a significance level of less than 0.05. Result(s): In this study, the overall mortality rate among mechanically ventilated patients was 62.5%. The mean age of patients was 69.99+/-17.87 years and the mean duration of hospitalization in surviving patients was 15.47+/-11.73 days and for deceased ones was 55.21+/-69.14 days. The mean age of the deceased group (65.71+/-16.59) was significantly higher than the surviving group 53+/-21.17 was (P=0.0001). The length of hospital stay in the deceased group was significantly longer than the surviving group (P=0.005). As a result, ventilator mode and inotropic agent intake during treatment increased the chance of mortality in patients under mechanical ventilation (P=0.001). There was a significant relationship between underlying diseases of hypertension, kidney disease and autoimmune disease with mortality in patients (P<0.05). Conclusion(s): Various factors including the length of stay in the hospital, comorbidities such as hypertension, renal disease and autoimmunity may affect the outcome of critically ill ICU patients under mechanical ventilation. Patients who require long-term invasive ventilation and the use of inotropic drugs to maintain their cardiovascular status while hospitalized in the ICU are at higher risk for mortality.Copyright © 2022 Shetabi et al. Published by Tehran University of Medical Sciences.
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Objectives: Reporting a case of a COVID-19 vaccinated patient admitted to our intensive care unit with severe acute respiratory failure due to SARSCoV2 - Omicron variant, rapidly deteriorating requiring intubation, prone ventilation, and ECMO support. Method(s): A 62 years old Caucasian male was admitted in ICU for rapidly deranging respiratory failure and fever which occurred over the previous 24h. The patient received two doses of SARS-CoV2 vaccine (Oxford, AstraZeneca), the last one over five months before onset of symptoms. The patient was admitted to the intensive care unit (ICU) with tachypnea, low peripheral saturation (80%), elevated serum creatinine (2.4 mg/dl), and mild obesity (BMI 34,6). Pressure support ventilation trial (2 hours) failed carryng out to orotracheal intubation and protective ventilation. Worsening of respiratory exchanges (5 th day from the admission) required a rescue prone ventilation cycle, in the meantime an indication was given to the placement of veno-venous ECMO. The cannulation site was femoro-femoral and the configuration used was Vivc25- Va21, according to the current ELSO nomenclature;ECMO flow was progressively increased until a peripheral saturation of 95% was obtained. Result(s): The patient passed out after 2 month of extracorporeal support with no sign of recovery of pulmonary and renal function. Conclusion(s): Unlike evidences showing a lower symptomatic engagement of the Omicron variant SARSCoV2 positive patients, we have witnessed a rapid and massive pulmonary involvement. The short time that passed from the onset of symptoms and the rapid decay of respiratory function required rapid escalation of the intensity of care up to extracorporeal support. The patient showed previous pathologies that can lead to suspicion of a loss of immune coverage given by the vaccine, in addition to the long time elapsed since the last dose. (Figure Presented).
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The novel coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2).Mortality attributable to COVID-19 remains considerably high, with case fatality rates as high as 8-11%. Early medical intervention in patients who are seriously and critically ill with COVID-19 reduces fatal outcomes. Thus, there is an urgent need to identify biomarkers that could help clinicians determine which patients with SARS-CoV-2 infection are at a higher risk of developing the most adverse outcomes, which include intensive care unit (ICU) admission, invasive ventilation, and death. In COVID-19 patients experiencing the most severe form of the disease, tests of liver function are frequently abnormal and liver enzymes are found to be elevated. For this reason, we examine the most promising liver biomarkers for COVID-19 prognosis in an effort to help clinicians predict the risk of ARDS, ICU admission, and death at hospital admission. In patients meeting hospitalization criteria for COVID-19, serum albumin < 36 g/L is an independent risk factor for ICU admission, with an AUC of 0.989, whereas lactate dehydrogenase (LDH) values > 365 U/L accurately predict death with an AUC of 0.943.The clinical scores COVID-GRAM and SOFA that include measures of liver function such as albumin, LDH, and total bilirubin are also good predictors of pneumonia development, ICU admission, and death, with AUC values ranging from 0.88 to 0.978.Thus, serum albumin and LDH, together with clinical risk scores such as COVID-GRAM and SOFA, are the most accurate biomarkers in the prognosis of COVID-19.Copyright © 2021 Sociedad Medica del Hospital General de Mexico. Published by Permanyer.
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Background: Several pro- and anti-inflammatory cytokines involved in COVID-19 and it is reasonable to speculate that their removal from blood might limit organ damage. Hemoperfusion with CytoSorb is a technique developed to adsorb molecules in the middle molecular weight range (up to 55 kDa). Studies in vitro and in vivo have shown that HP is highly effective in clearing blood from a number of cytokines. Method(s): We report a case series of 9 consecutive COVID-patients admitted to our COVID Intensive Care Unit (ICU). Five of them were treated with HP using CytoSorb (T), due to the heavy emergency overload it was impossible to deliver blood purification in the other 4 patients (C), who were also considered as potential candidates by the attending medical team. All patients had pneumonia and respiratory failure requiring continuous positive airway pressure. Different antibacterial prophylaxes, antiviral, and anti-inflammatory therapies including steroids were delivered. Result(s): Our results show a better clinical course of T compared to control patients (C), in fact all T except 1 survived, and only 2 of them were intubated, while all C required intubation and died. CRP decreased in both groups, but to a greater extent after HP. Lymphocytopenia worsened in control patient but not in treated patient after HP. Procalcitonin increased in 2 of the not treated patients. In all survived patients (n = 4) HP reduced pro-inflammatory cytokines, as IL-6, TNF-alpha, and IL-8. Notably, a striking effect was observed on IL-6 levels that at the end of the second session were decreased by a 40% than before the first treatment. Serum levels of IL-8 and TNF-alpha were lowered within normal range. In all patients the treatment was safe and there were no complications. Conclusion(s): Our study suggests a potential efficacy of HP in an early phase of viral infection not only for improving survival in the treated patients but also by the remodeling treatment-associated cytokine levels.
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Background: Tocilizumab, an interleukin-6 (IL-6) antagonist, is being evaluated for the management of covid-19 pneumonia. The objective of this study was to assess the effectiveness of Tocilizumab in severe covid-19 pneumonia. Method(s): This was a retrospective, observational, single centre study performed in 121 patients diagnosed with severe covid-19 pneumonia. 83 patients received standard of care treatment whereas 38 patients received tocilizumab along with standard of care. Tocilizumab was administered intravenously at 8mg/kg (upto a maximum of 800mg). The second dose of Tocilizumab was given 12 to 24 hours apart. The primary outcome measure was ICU related and hospital related mortality. The secondary outcome measures were change in clinical status of patients measured by WHO (World Health Organisation) 7 category ordinary scale, changes in interleukin-6 (IL-6) levels, secondary infections and duration of ICU stay. Result(s): Tocilizumab was administered between 3-27 days after the patient reported symptoms ( a median of 10.9 days ) and between the 1st to 3rd day of ICU admission (median of 2.1 days) . In Tocilizumab group, 16(42.1%) of 38 patients died in ICU whereas in standard of care group, 27(32.53%) of 83 patients died. The difference in clinical status assessed using WHO (World Health Organisation) 7 category ordinary scale at 28 days between Tocilizumab group and standard of care group was not statistically significant (odds ratio 1.35, 95% confidence interval 0.61 to 2.97, p = 0.44). Conclusion(s): Tocilizumab plus standard care was not superior to standard care alone in reducing mortality and improving clinical outcomes at day 28.Copyright © RJPT All right reserved.
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Introduction: Background: Intensive Care Learning in the North East is a group of intensive care doctors in the North East of England, passionate about education in ICM.1 The SARS-CoV-2 pandemic has necessitated social distancing and disrupted traditional in-person courses. However, this has borne opportunities for virtual courses delivered to a national audience.2 Course content: We describe the second iteration of an eight-part online and interactive lecture series entitled 'Critical Concepts: An Introduction to Intensive Care'. The lectures focus on the A-E management of the critically ill patient, with additional sessions on 'Return of Spontaneous Circulation', and 'Applications and Careers in ICM.' The lectures were delivered fortnightly via Zoom,3 and consist of a 45-minute lecture followed by a 45-minute break-out room to discuss interactive cases with a facilitator and four participants. The lectures were available for two weeks on YouTube4 via private link, to enable participants to catch-up if not able to attend. Objective(s): We wished to examine the effectiveness and quality of our lecture series through a pre-course and a post-course questionnaire. We designed the questionnaire to elicit qualitative and quantitative feedback from the participants. Method(s): We invited the 60 course participants to fill in a pre- and post-course questionnaire, and received 28 and 51 responses respectively. Result(s): Participant demographics: 25% of delegates were in FY1, 75% were in FY2. 50% had no prior experience of working in an ICU, 21.4% had worked in an ICU during FY, 28.6% had undertaken a Taster Week in ICU. Quantitative results: * 'How would you rate your current apprehension regarding redeployment to ICU?' (1 - very apprehensive;5 - not apprehensive), the mean self-rating prior to the course was 2.54, and following completion of the course was 3.51. * 'How would you rate your understanding of what happens in an ICU?' (1 - very poor understanding;5 - very good understanding), the mean self-rating prior to the course was 2.75, and following completion of the course was 4.00. * 'How confident do you feel in discussing escalation of care with critical care staff?' (1 - not confident at all;5 - very confident), the mean self-rating prior to the course was 3.00, and following completion of the course was 4.04. YouTube catch-up The mean number of weeks that participants were able to attend in real-time was 4. 4 participants were able to attend all weeks, 78.8% of participants missing at least 1 week were able to catch-up on all weeks using YouTube, 21.2% were able to catch-up on some weeks, and no participants did not use this facility. Conclusion(s): We have demonstrated that our online teaching course has improved understanding of the care delivered on ICU, and reduced apprehension surrounding working in ICU and discussing patients with colleagues. We have demonstrated that YouTube is a free and well utilised method to enable to enable participants to catch-up on lecture content they were unable to attend in real-time. We believe that courses such as this will remain as Covid-19 restrictions are lifted.
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Background & Aim: Adoptive T cell immunotherapy holds great promise for the treatment of viral complications. Our group has been developing and trialling virus-specific T cell therapies for more than 20 years. Recently, we have generated a repository of multi-virus-specific T cells for our clinical trials. Unfortunately, for many patients with viral complications, there is no suitable trial through which to access these therapies. In Australia, the Therapeutic Goods Administration has a Special Access Scheme (SAS) to enable provision of unapproved therapies for compassionate use. Our research group is now a leading Australian provider of "off-the-shelf" and custom-grown allogeneic virus-specific T cells to hospitals for patients with no other treatment options. Methods, Results & Conclusion(s): We have generated a repository of multi-virus-specific T cells from 20 healthy donors, with up to 150 doses of T cells per donor generated from a single blood sample. Each product batch is thoroughly characterised in terms of viral antigen specificity, HLA restriction and alloreactivity. These T cells target a combination of Epstein-Barr virus, cytomegalovirus, BK polyomavirus, John Cunningham virus and adenovirus epitopes. We have also generated a repository of SARS-CoV-2-specific T cells and occasionally grow custom patient-specific batches of T cells from nominated donors, on request. Since 2008, we have provided virus-specific T cells to 15 hospitals across Australia, and the volume of supply requests has significantly increased in recent years, as clinicians have gained interest in adoptive immunotherapy. In 2022, we provided T cells for 26 patients via the SAS. The majority were experiencing post-transplant complications, including cytomegalovirus disease, BK virus-associated haemorrhagic cystitis and post-transplant lymphoproliferative disorder. Through our clinical trials, we have developed rigorous processes for T cell therapy manufacture and characterisation, in addition to a computer-based selection algorithm, which we apply to SAS cases. As these cases are not part of a clinical trial, concomitant therapy varies, and monitoring is not uniform. However, we have received reports of clinical benefit from adoptive T cell therapy. These include cases of reduction in viral load, improvement in symptoms, and complete resolution of infection. We believe that these promising T cell therapies should be available to hospitals through a nationally funded centre for cellular therapies for critically ill patients.Copyright © 2023 International Society for Cell & Gene Therapy
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Introduction: Northern Ireland (NI) has 5.5 ICU beds/100 000 population,1 amongst the lowest in Western Europe.2 Alongside ICU bed expansion the Covid-19 response required delivery of advanced Respiratory support (Continuous Positive Airway Pressure (CPAP) and High Flow Nasal Oxygen (HFNO)) outside ICU. ICNARC provides robust data for patients within ICU but this is unavailable for those receiving 'critical care' elsewhere. Objective(s): To evaluate delivery of CPAP/HFNO outside of ICU to Covid-19 patients - focusing on demographics and outcomes including ICU admission and mortality. Method(s): Ward-CPAP for acute hypoxaemic respiratory failure (AHRF) was not previously utilised.3 It was introduced for Covid-19 to Medical wards. Data was analysed using the NI Electronic Care Record, ward electronic note system (EDAMS) and ICU system (ICCA, Koninklijke Philips N.V.). Data was compared between Wave 1 (01/03/2020 - 12/12/2020) and Wave 2 (13/12/2020 - 01/04/2021). Result(s): 215 patients received CPAP/HFNO/Invasive Mechanical Ventilation (IMV) for Covid-19: 103 in Wave 1 and 112 in Wave 2. 75 Covid-19 patients were admitted to the ICU itself (comprising 44 of the study cohort, 11 direct from ED and 20 transferred from other Trusts). Table 1 shows demographics. Fewer patients were female as seen elsewhere,4 there were more young patients in Wave 2. The majority of patients would likely have been ICU candidates pre-pandemic,3 but a subset of 25% were deemed for a ward ceiling-of-care on admission by a Consultant and the proportion of elderly patients was higher than described by ICNARC.4 Comorbidities and obesity were common. Outcomes are shown in Table 2 and Figures 1-3. Close co-operation with ICU saw 61% of patients with a documented ICU review. Overall 20% of patients were admitted to ICU, and 15% received IMV. Mortality was 37%, but 22% if patients with an admission ward ceiling-of-care decision were excluded. Mortality correlated with frailty and age (fig 2&3). Outcomes were generally better in Wave 2. Conclusion(s): This Evaluation documents the huge contribution to the critical care Covid-19 response made by our Medical teams, not captured by ICNARC. Most patients avoided ICU admission and IMV and outcomes were likely at least comparable which undoubtedly freed up vital ICU beds. We thank the teams involved and believe it is vital to evaluate the outcome of all critically ill Covid-19 patients irrespective of their location.
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Background: Sepsis is a life-threatening condition that needs immediate diagnosis and treatment to maximize the chances of survival. Bacterial superinfection is a severe and frequent complication among COVID-19 patients and its diagnosis is challenging. Previous reports suggested that Pancreatic Stone Protein (PSP) may be a predictive biomarker for sepsis in critically ill patients. We report a case series of three COVID- 19 patients admitted to our intensive care unit (ICU) with risk of sepsis. Method(s): We daily monitored PSP, procalcitonin (PCT), and C-reactive protein (CRP) levels in three COVID- 19 patients admitted to our ICU. Microbiological sampling and antibiotic treatment were performed according to the ward organization and in case of clinical suspects for infection. Positive cultures and antibiotic treatment were retrieved from clinical charts and patients were followed from ICU admission up to a maximum of 20 days. Result(s): Patient 1 (male, 55 years-old, overweight, no other comorbidity) was admitted to the ICU in treatment with Ceftriaxone then interrupted on day 7. On day 2 he was intubated and piperacillin/tazobactam was started on day 12 for suspected hospital acquired pneumonia. PSP levels markedly increased on day 10 with no significant changes in CRP and PCT levels. On day 13 a positive bronchospirate for Klebsiella pneumoniae was found. Similarly, patient 2 (male, 70 years-old, mild emphysema and diabetes) was admitted to ICU without antibiotic and with a PSP level of 287 ng/ml. His conditions rapidly worsened in severe septic shock requiring intubation. CRP markedly raised 48-72 hours after PSP with only mild increase of PCT. Patient 3 (male, 78 years-old, no comorbidities) was admitted to ICU with high levels of PSP and piperacillin/tazobactam therapy was started. After 48-72 hours CRP levels increased with no significant changes of PCT. A positive bronchospirate for Ps. aeruginosa was collected on day 3. Conclusion(s): Our findings suggest a potential role of PSP as early biomarker of sepsis in critically ill COVID-19 patients. Daily PSP monitoring may anticipate an appropriate treatment of COVID-19 patients with a septic complication in comparison with the actual laboratory markers. Further studies are needed to confirm our hypothesis.
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Objectives: There is a paucity of data on echocardiographic findings in patients with COVID-19 supported with Venovenous Extracorporeal Membrane Oxygenation (VV ECMO). This study aimed to compare baseline echocardiographic characteristics of mechanically ventilated patients for acute respiratory distress syndrome (ARDS) due to COVID-19 infection with and without VV ECMO support and to describe the incidence of new echocardiographic abnormalities in these patients. Method(s): Single-center, retrospective cohort study of patients admitted from March 2020 to June 2021 with COVID-19 infection, that required mechanical ventilation, and had an available echocardiogram within 72 hours of admission. Follow-up echocardiograms during ICU stay were reviewed. Result(s): A total of 242 patients were included in the study. One-hundred and forty-five (60%) patients were supported with VV ECMO. Median (IQR) PaO2/ FiO2 was 76 (65-95) and 98 (85-140) in the VV ECMO and non-ECMO patients, respectively (P = < 0.001). On the admission echocardiograms, the prevalence of left ventricular (LV) systolic dysfunction (10% vs 15%, P= 0.31) and right ventricular (RV) systolic dysfunction (38% vs. 27%, P = 0.27) was not significantly different in the ECMO and non-ECMO groups. However, there was a higher proportion of acute cor pulmonale (41% vs. 26 %, P = 0.02) in the ECMO group. During their ICU stay, echocardiographic RV systolic function worsened in 44 (36%) patients in the ECMO group compared with six (10%) patients in the non-ECMO group (P< 0.001). The overall odds ratio for death for patients with worsening RV systolic function was 1.8 (95% confidence interval 0.95-3.37). Conclusion(s): Echocardiographic findings suggested that the presence of RV systolic dysfunction in COVIDECMO patients was comparable to the non-ECMO group on admission. However, a higher percentage of patients on ECMO developed worsening RV systolic function during follow-up.
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Reaching a proper diagnosis for critically ill patients is like collecting pieces of puzzle and bed side lung ultrasound (LUS) becomes a crucial piece complementary to clinical and laboratory pieces. It is a bed side, real time tool for diagnosis of patients in ICU who are critical to be transferred to radiology unit especially in Covid-19 pandemic with risk of infection transmission. The aim was to evaluate the accuracy of lung ultrasound in assessment of critically ill patients admitted to Respiratory Intensive Care Unit (RICU), moreover to assess its diagnostic performance in different pulmonary diseases as compared to the gold standard approach accordingly. This observational prospective (cross sectional) study with a total 183 patients who met the inclusion criteria,were selected from patients admitted at the RICU;Chest Department, Zagazig University Hospitals, during the period from September 2019 to September 2021. LUS examination was performed to diagnose the different pulmonary diseases causing RF. All cases were examined by LUS on admission. From a total 183 patients, 111 patients 60.7% were males and 72 patients 39.3% were females, with a mean age of 56+/-12.77 years, 130 patients were breathing spontaneously received conservative management with O2 therapy, 32 patients needed NIV while 21 patients needed IMV with ETT. Exacerbated COPD was the most common disease finally diagnosed followed by bacterial pneumonia, exacerbated ILD, post Covid-19 fibrosis and pulmonary embolism in32, 29,27, 19 and 11 patients respectively with corresponding diagnostic accuracy of LUS 97.3%, AUC=0.943, 93.9% (AUC=0.922), 96.7%(AUC=0.920), 97.8%, AUC=0.895, and 97.8% respectively, while Covid-19 pneumonia was the final diagnosis in 8 patients with LUS diagnostic accuracy of 97.8% (AUC=0.869) with no statistical significant difference p-value=0.818 with bacterial pneumonia in distribution of US profiles. A profile was the commonest detected US profile among the studied patients followed by B profile, C profile, A/B profile and A' profile in 37.2%, 24.6%, 15.8% 4.9%, and 3.8% of cases respectively. Bed side LUS has a reliable, valuable diagnostic performance when integrated with clinical and laboratory data for the diagnosis of most pulmonary diseases in RICU.Copyright © 2023, Colegio de Farmaceuticos de la Provincia de Buenos Aires. All rights reserved.
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Objectives: To assess protein and energy intake and duration of venous-venous ECMO in critically ill patients with covid-19 Methods: We conducted a retrospective observational analysis on the intensive care units of a large tertiary private teaching Hospital. Adult patients admitted to intensive care unit (ICU) with laboratory confirmed SARS-CoV-2 (RT-PCR), cannulated on venous-venous ECMO and on exclusive enteral feeding were included. Data between march 2020 and june 2021 were collected. Weight and height data were acquired at the time of admission in ICU. Body mass index (BMI) was subsequently calculated. We obtained delivery and adequacy of nutrition data from a enteral nutrition form routinely filled out by nutritionists during hospitalization. Other data were obtained from electronic medical record. For statistical analysis of the data, we used SPSS version 13.0. Result(s): This cohort included 39 patients. 27 (69.2%) were men, mean age was 50 (+/- 12) years and 11 (28,2%) had more than 60 years. The more prevalent comorbidities were obesity in 22 (56%), hypertension in 20 (51,3%) and diabetes in 6 (15,4%) patients. The mean time on ECMO was 24.7 +/- 15.2 days. 29 patients (74%) died. Regarding nutritional support, the average protein intake was 0,9 +/- 0.4 g/kg/day and calories 13.9 +/- 5.2 cal/kg/day. No statistically significant association was observed between the nutritional intake and the duration on ECMO and clinical outcomes of patients. Conclusion(s): There was a high mortality in our cohort. Center;s inexperience may have played a role in these results, in addition to other factors. We observed a high prevalence of obesity. Neither energy nor protein intake were associated with the duration of ECMO and clinical outcomes. These results are similar to other recent observational studies where an insufficient energy and protein intake did not affected mortality or other outcomes. Our small sample and study design prevents a definitive conclusion on the subject. Thus, we propose further studies to elucidate the role of adequate nutrional strategies to improve outcomes and reabilitation of patients on ECMO.
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The COVID-19 pandemic continues to affect millions of people with increasing morbidity and mortality. Substantial variations exists in drug treatment of COVID-19. Extracorporeal membrane oxygenation (ECMO) facilitates survival of select critically ill patients with COVID-19 with about 25-45% survival rate;survivors tend to be younger and have a shorter duration from diagnosis to cannulation. The practioners found the severe complications including concomitant neurological manifestations (from headache, anosmia, ageusia to encephalopathy, stroke and others) and multisystem inflammation syndrome (MIS) predominantly in children few weeks after SARS-CoV-2 infection and characterized by persistent fever, vomiting, headache, Kawasaki - like rash and fatigue. Regarding MIS the authors did not find strong association between the complications rate and outcomes and regime of immunomodulation treatment. The neurological manifestations in pts with COVID-19 were associated with higher in-hospital mortality.Copyright © 2022 Sinergia Press. All rights reserved.
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Objectives: Analgosedation of patients with severe respiratory failure due to coronavirus disease 2019 (COVID-19) proved to be challenging. Patients supported with venovenous extracorporeal membrane oxygenation (VV ECMO) seemed to require analgosedative drugs in high doses. This study reviews analgosedation practices in patients with COVID-19 associated severe respiratory failure supported with VV ECMO. Method(s): This is a retrospective, single-center registry study including all patients with COVID-19 associated severe respiratory failure that were supported with VV ECMO at our center. All sedative and analgetic drugs administered intravenously or via inhalation to patients for at least two hours were recorded and analyzed. Result(s): Between March 2020 and January 2022, 88 patients with COVID-19 associated severe respiratory failure were supported with VV ECMO at our center. Propofol and sufentanil were used most frequently for analgosedation in this cohort. Both drugs were co-administered following treatment standards established prior to the emergence of COVID-19 at our center. Sedative and analgetic drugs were switched to alternative regimens after a median time of 3 and 12.5 days. Alternative regimens included Isofluran, alpha-2- agonists (clonidine or dextomidine) or esketamine. Alpha-2- agonists were initiated at a median time of 2 days after starting VV ECMO support. Benzodiazepines were used primarily as last resort treatment option for sedation at our center. During the four waves of the pandemic experienced at our center, we experienced an increased average number of drugs needed for analgosedation. Conclusion(s): Analgosedation in critically ill COVID-19 patients supported with ECMO is challenging. It remains unclear, whether the standard analgosedation regimen with sufentanil and propofol established at our center prior to the COVID-19 pandemic is optimal for this patient cohort. Further studies are needed to determine optimal and long term safe analgosedation regimens in critically ill patients supported by VV ECMO. Furthermore, changes experienced during the course of the pandemic need to be scrutinized in comparison to other cohorts. (Table Presented).
ABSTRACT
Purpose: To evaluate the effectiveness and safety of a pharmacist-managed protocol for transitioning critically ill patients from intravenous (iv) to subcutaneous insulin compared with a provider-managed process. Method(s): This single-center, retrospective, observational study included patients admitted to the medical or surgical/trauma intensive care unit who received a continuous infusion of iv insulin from January 2019 to April 2021. Patients were excluded if they were less than 18 years of age, pregnant, incarcerated, or received iv insulin for the diagnosis of diabetic ketoacidosis, hyperglycemic hyperosmolar state, calcium channel blocker or beta blocker overdose, or hypertriglyceridemia. The primary outcome was the percentage of blood glucose (BG) concentrations within the target range of 70-150 mg/dL from 0 to 48 h following transition to subcutaneous insulin. Secondary outcomes included percentage of BG concentrations within goal range following transition at 0-12 h and 12-24 h, incidence of hypo- and hyperglycemia, and percentage of patients requiring dose adjustments after initial transition. Result(s): A total of 110 unique patients were included with 70 patients in the provider-managed group and 40 patients in the pharmacist-managed group. On average, pharmacists transitioned patients to 63% basal insulin based on their 24-h total day dose of insulin. The pharmacist-managed group achieved glycemic control in 53% of transitions at 12 h, 40% at 24 h, and 47% from 0 to 48 h, while the provider group achieved glycemic control in 25% of transitions at 12 h, 12% at 24 h, and 18% from 0 to 48 h (p < 0.001 for all time points). As for safety end points, the pharmacist-managed group demonstrated lower rates of hypoglycemia (p = 0.001), severe hypoglycemia (p = 0.332), hyperglycemia (p < 0.001), and severe hyperglycemia (p < 0.001) compared with the provider-managed group. Conclusion(s): Pharmacists can effectively and safely transition critically ill patients from iv to subcutaneous insulin utilizing a standardized protocol.Copyright © 2023 Pharmacotherapy Publications, Inc.
ABSTRACT
Introduction: Acute kidney injury (AKI) is a complication of SARS-CoV-2 disease, associated with worse clinical outcomes. Renal replacement therapy (RRT) in combination with sequential extracorporeal blood purification therapies (EBPT) might support renal function, attenuate systemic inflammation, and prevent or mitigate multiple organ dysfunctions. Method(s): We retrospectively analyzed 20 patients admitted in ICU for ARDS and who developed moderate-to-severe AKI requiring RRT. Cytokine hemadsorption with Cytosorb was performed in association with CRRT. The main indication for this treatment was the worsening of hemodynamic and respiratory conditions and suspicion of cytokine storm. The protocol consisted in the use of 3-4 cartridges in total;among these, the first 2 were changed after 12 hours of treatment to maximize cytokine removal, while the others after 24 hours. We examined comorbidities, clinical and laboratory characteristics and the impact of treatment in terms of mortality rate and changes in data before and after treatment. Result(s): Nineteen patients (95%) had an AKI at any time during their ICU stay. Of these, 5 patients (25%) had AKI stage II and 14 patients (70%) had AKI stage III. All patients included in this subgroup were mechanical ventilated and required vasopressor's use. Mean prescribed CRRT dose was 31.2 +/- 11.7 ml/kg/h. The median time to strating RRT after ICU admission was 7 days (IQR 3.5-15 days) and the median duration was 7 days (IQR 2.5-12.5 days). Mean SOFA score at the time of RRT start was extremely high (14.5 +/- 2.8). Mortality rate was important (18 patients, 90%) in our cohort. Comparing clinical and laboratory data before and after treatment, a significant improvement of inflammatory markers was reported, with the reduction of C-reactive protein (CRP, 143 [62.1- 328.5] vs 83.5 [66.7-153.5] mg/L);however, no significant changes in IL-6, WBC and PCT values were observed. A slight increase of PaO2/FiO2 were described, although not statistically significant (PaO2/FiO2 ratio 144 [82.7-174.2] vs 183 [132-355.5] mmHg). Conclusion(s): Our experience supports the need of an adequate timing for the use of Cytosorb in critically ill patients with Covid-19. Although a discrete efficacy in improving inflammatory cascade, the late use of EBPT, when organ dysfunction was already ongoing, didn't impact survival.