Clinical characteristics and risk factors of patients with COVID-19 developing barotrauma

Background: At our hospital, people with COVID-19 (coronavirus disease 2019) had a high rate of pulmonary barotrauma. Therefore, the current study looked at barotrauma in COVID-19 patients getting invasive and non-invasive positive pressure ventilation to assess its prevalence, clinical results, and features. Methodology: Our retrospective cohort study comprised of adult COVID-19 pneumonia patients who visited our tertiary care hospital between April 2020 and September 2021 and developed barotrauma. Result(s): Sixty-eight patients were included in this study. Subcutaneous emphysema was the most frequent type of barotrauma, reported at 67.6%;pneumomediastinum, reported at 61.8%;pneumothorax, reported at 47.1%. The most frequent device associated with barotrauma was CPAP (51.5%). Among the 68 patients, 27.9% were discharged without supplemental oxygen, while 4.4% were discharged on oxygen. 76.5% of the patients expired because of COVID pneumonia and its complications. In addition, 38.2% of the patients required invasive mechanical breathing, and 77.9% of the patients were admitted to the ICU. Conclusion(s): Barotrauma in COVID-19 can pose a serious risk factor leading to mortality. Also, using CPAP was linked to a higher risk of barotrauma.Copyright © 2021 Muslim OT et al.

ECMO for the immunocompromised pediatric patient: Our experience

Objectives: To present a series of immunosuppressed patients (oncohematological disease, congenital immunosuppression, hematopoietic stem cell (HSCT), and solid organ transplant) assisted on ECMO. Method(s): Descriptive, retrospective study (2011-2020) of a cohort of 9 immunosuppressed patients, supported on ECMO. Medical records were reviewed and demographic, clinical, and analytical variables were collected. Result(s): In our series of 9 patients, 5 were male, the median age was 8 years [RIC 3-11 years]. Considering the underlying disease, 6 were oncologic, 1 liver transplant and 2 with congenital immunodeficiency after HSCT. 4 were under active chemotherapy (median 6 days after the last cycle [RIC 5-188]). 6 were admitted due to acute respiratory failure, 3 due to hemodynamic instability (3/9), (one septic shock). The median PEEP was 12 [RIC 9-15] and FiO2 100% (81-100%). 78% (6) required vasoactive drugs (median inotropic score 35 [RIC 0-75]. 40%. 5 had severe neutropenia and/or plateletopenia in the 24 hours prior to ECMO, and alterations in acid-base balance (median pH 7. 1 [RIC 6.9-7.15]. 5 were on multiorgan failure. TPrimary ECMO transport was performed in 4 patients (44%). Cannulation was peripheral in 80% (57% cervical, 43% femoral) and central in 20%;70% VA-ECMO. Median time of assistance was 15 days [RIC 3.5-31.5] in cardiac ECMO (4), and 29 days [RIC 13.5-42] and in pulmonary ECMO (n=5). The median total time of admission was 45 days [RIC 27-59]. 9 had an infection, 2 COVID after HSCT, and 8 bleeding complications, but only one required surgical revision. Renal replacement therapy was used in 5 (median 9 days [RIC 5-34.5]). Other therapies used were polymyxin hemadsorption(2), intratracheal surfactant(2), plasma exchange(1), infusion of mesenchymal cells(1) and specific memory T lymphocytes(2). 4 patients died, 5 survived decannulation, 2 died later, with an overall survival rate to hospital discharge of 33% (3/9). Conclusion(s): Despite having a worse prognosis, ECMO can increase survival in immunosuppressed patients, in situations that are challenging and require a multidisciplinary approach.

Demonstration of Remote Control of Critical Care Ventilators and the Integrated Clinical Environment

Introduction: The COVID-19 pandemic posed numerous challenges to patient care, including extensive PPE use, patient care in isolation rooms, inadequate numbers of intensivists particularly in rural communities, use of unfamiliar ventilators that would be partially remedied by the ability to remotely control lung ventilation. The goals of the project were to study the intended use, risk management, usability, cybersecurity for remote control of ventilators and demonstrate the use of a single interface for several different ventilators. Method(s): Clinical scenarios were developed including remote control of the ventilator from an antechamber of an isolation room, nursing station within the same ICU, and remote control from across the country. A risk analysis and was performed and a risk management plan established using the AAMI Consensus Report--Emergency Use Guidance for Remote Control of Medical Devices. A cybersecurity plan is in progress. Testing was done at the MDPNP laboratory. We worked with Nihon Kohden OrangeMed NKV-550, Santa Ana, CA, and Thornhill Medical MOVES SLC, Toronto, Canada. Both companies modified their devices to allow remote control by and application operating on DocBox's Apiary platform. Apiary is a commercially available ICE solution, DocBox Inc, Waltham, MA. An expert panel was created to provide guidance on the design of a single common, simple to use graphical user interface (GUI) for both ventilators. Manufacturers' ventilation modes were mapped to ISO 19223 vocabulary, data was logged using ISO/IEEE 11073-10101 terminology using AAMI 2700-2-1, Medical Devices and Medical Systems - Essential safety and performance requirements for equipment comprising the patient-centric integrated clinical environment (ICE): Part 2-1: Requirements for forensic data logging. Result(s): We demonstrated that both ventilators can be controlled and monitored using common user interface within an institution and across the country. Pressure and flow waveforms were available for the NKV-550 ventilator, and usual ventilator measurements were displayed in near-real time. The interface allowed changing FiO2, ventilation mode, respiratory rate, tidal volume, inspiratory pressure, and alarm settings. At times, increased network latency negatively affected the transmission of waveforms. Conclusion(s): We were able to demonstrate remote control of 2 ventilators with a common user interface. Further work needs to be done on cybersecurity, effects of network perturbations, safety of ventilator remote control, usability implications of having a common UI for different devices needs to be investigated.

Invasive Mechanical Ventilation in COVID-19

Patients with severe COVID-19 pneumonia present with severe hypoxemic respiratory failure, typically meet the clinical criteria for acute respiratory distress syndrome (ARDS) and often require invasive mechanical ventilation. While peculiar pathophysiological aspects deserve discussion to better tailor the mechanical ventilation settings in these patients, most recommendations on the ventilatory management of these patients are derived from studies in patients with ARDS from causes other than COVID-19. Protective ventilation is recommended in most COVID-19 patients, tidal volume should be kept around 6 mL per kg of predicted body weight, positive end-expiratory pressure (PEEP) should be titrated individually considering that in many patients with COVID-19 improvement of oxygenation at higher PEEP is often accompanied by worsening of respiratory system compliance. Therefore, attention should be paid in limiting plateau and driving pressures to avoid excessive strain potentially resulting in ventilator-induced lung injury. Prone positioning has been used extensively in COVID-19 patients, but its impact on mortality is uncertain. Inhaled nitric oxide, extracorporeal CO2 removal (ECCO2R), and extracorporeal membrane oxygenation (ECMO) should be considered in selected patients as rescue measures. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

Case Report of a Transfusion-Associated Circulatory Overload Leading to Cardiac Arrest in a COVID-19 Positive Patient

Although case reports have been made regarding adverse transfusion reactions, few have been made regarding blood transfusions leading to cardiac arrest. Today, we present a case of a COVID-19 positive Bahraini male, triple vaccinated, transfused with packed red blood cell (pRBC) after finding out he has low haemoglobin levels (64 g/dl) after routine laboratory investigations. During the blood transfusion, he developed hypertension, tachycardia and tachypnoea. The patient went into cardiac arrest within a few minutes of this presentation. Return of spontaneous circulation was achieved, and the patient was managed as transfusion-associated circulatory overload (TACO) with a good overall outcome.Copyright © 2023, Bahrain Medical Bulletin. All rights reserved.

Clinical characteristics and outcome of older patients with severe COVID-19: a retrospective observational study

Introduction: The objective of the study was to assess the relevant laboratory and clinical factors that may affect the prognosis of patients with severe COVID-19 in older population. Very few studies have specifically investigated the age-specific factors that affect the outcome of the patient in elderly patients [1,2]. Method(s): The study population was adults (>= 60 years) with severe COVID-19 admitted to the intensive care unit of a tertiary care hospital between March 2021 and June 2021. Binomial logistic regression analysis was used to analyze all variables as potential predictors for the death of older patients. Result(s): In total, 113 older patients with severe COVID-19, with a median age of 68 years (interquartile range (IQR) 63-74), mortality rate was 61.9%. At admission, the median PO2/FiO2 ratio of the patients was 100 (IQR 90-150) and 33.6% were on mechanical ventilation. Binomial logistic regression showed that total leucocyte counts (TLC), platelet counts (PC), lactate dehydrogenase (LDH), D-dimer, and interleukin- 6 levels were all significantly associated with death. Patients with poor outcomes had significantly lower PO2/ FiO2 ratios at admission, higher TLC, lower PC, higher serum creatinine, and higher LDH as compared to survivals. Patients with poor outcomes had a significantly higher percentage of chronic kidney disease patients (20% vs 4%), and patients who didn't receive remdesivir (27% vs 2.3%). Conclusion(s): Increased TLC, LDH, D-Dimer, IL-6, and decreased PC are associated with poor outcomes. The use of remdesivir may increase the chance of survival in older patients.

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.

Comparison of the efficacy of tocilizumab and itolizumab for the treatment of severe COVID-19: a retrospective cohort study

Introduction: Itolizumab, a CD6 inhibitor has been found to be effective in COVID-19 in some studies [1] but there is no randomised controlled trial at present to prove its effectiveness. Method(s): The study population was adults (> 18 years) with severe COVID-19 pneumonia admitted in the ICU who received either tocilizumab or itolizumab in their course of stay in ICU. The primary outcome of the study was a clinical improvement (CI). The secondary outcomes were time for clinical improvement, improvement in PO2/ FiO2 ratio, best PO2/ FiO2 ratio, need for mechanical ventilation (MV) after administration of study drugs, time to discharge and survival days. Result(s): 126 patients were included in the study;92 received tocilizumab, and 34 received itolizumab. CI was seen in 46.7% and 61.7% of the patients in the tocilizumab and itolizumab groups, respectively and was statistically non-significant. The time to CI was also non-significant between the tocilizumab and itolizumab groups (median 12 vs 11 days). The number of days required to achieve the improvement of 100 in the PO2/ FiO2 ratio was significantly less with itolizumab as compared to tocilizumab. (6 vs 8 days, p value = 0.028). The best PO2/ FiO2 ratio achieved was also significantly better with itolizumab as compared to tocilizumab (315 vs 250, p value = 0.043). The incidence of serious adverse events due to the study drugs was significantly higher with itolizumab as compared to tocilizumab (14.7 vs 3.26%). The estimated median time for CI was 12 days and 11 days in the tocilizumab and itolizumab groups, respectively and was non-significant (log-rank p value = 0.262) (Fig. 1). Conclusion(s): The clinical improvement and survival rates with itolizumab are similar to tocilizumab. Better oxygenation can be achieved with itolizumab and can be a substitute for tocilizumab in managing severe COVID-19 infection.

Prolonged prone position in COVID-19-associated ARDS: a prospective study

Introduction: Ventilation in prone-position (PP) improves survival in moderate-to-severe ARDS. However, optimal duration of the intervention to gain maximum benefit is unknown. We sought to examine the efficacy and safety of a prolonged PP protocol in COVID-19-associated ARDS. Method(s): This was a prospective observational study. We included consecutive intubated and mechanically ventilated patients with ARDS and positive PCR for SARS-CoV-2 who underwent at least one session of PP from March 2021 to August 2021. PP was undertaken if P/F < 150 with FiO2 > 0.6 and PEEP > 10cmH2O. Oxygenation parameters and respiratory mechanics were recorded before PP, at the end of PP session and 4 h after supine repositioning. Patients with PP longer than 24 h (prolonged group) were compared to patients who were proned for less than 24 h (control group). The duration of PP was at the discretion of the treating intensivist. Result(s): We recorded 56 patients (62.7% male). Five patients were excluded because PP was terminated in less than 4 h. Mean age of the 51 studied patients was 61.4 years. Patients in the prolonged group had significantly higher BMI than controls. Baseline oxygenation and respiratory mechanics were similar between groups. PP duration was 39.8 versus 20.5 h (p < 0.001). Increase of P/F was higher in the prolonged PP group during proning (103.8 +/- 70.8 vs 66 +/- 53.9, p < 0.05) and after supination (76.3 +/- 64.6 vs 48.6 +/- 34.9, p = 0.058). No change in respiratory mechanics was observed in either group. 28-day survival was 75% in the prolonged PP group and 69.5% in the control group (p = 0.665). Duration of mechanical ventilation, number of PP cycles and rate of complications were similar between groups. Conclusion(s): In patients with ARDS due to COVID-19 prolonged PP resulted in better oxygenation, but had no impact on outcome. However, it is both feasible and safe and can be an alternative in conditions of increased work load as was the case during the recent pandemic.

ZINC ADJUVANT TREATMENT IN SARS-CoV-2: A RANDOMIZED CLINICAL TRIAL

Background: The immune system is highly susceptible to changes of zinc levels and this might imply a different response against infection. Prior evidence suggests some benefit on viral infection prognosis after zinc supplementation. We aim to study the efficacy of zinc supplementation in SARS-CoV-2 infection outcomes. Method(s): This is an unicenter prospective, randomized cliinical trial where unvaccinated individuals with moderate SARS-CoV-2 infection without endorgan failure were randomized to standard of care+oral zinc for 15 days (three times per day a tablet of 83mg of Zn acetate equals to 75 mg of Zn element) (zSoC) (n =37) or standard of care alone (SoC) (n = 34). The primary combined outcome was death due to SARS-CoV-2 or intensive care unit (ICU) admission. Secondary outcomes included length of hospital stay (LoS) and time to clinical stability (defined as: oxygen saturation >94% [FiO2 21%], normalized level of consciousness [baseline], HR < 100rpm, systolic BP >90mm Hg,Temperature < 37.2degreeC). Wilcoxon-Mann-Whitney test generalized Odds ratio (ORs) and 95% confidence intervals (CIs) for differences in outcomes between SoC and zSoC. A logistic regression model was fitted adjusted by age, sex, severity and comorbidity to compare the primary outcome between SoC and zSoC. Result(s): Seventy-one participants were recruited. No significant differences in terms of age, gender and comorbidities nor in SoC were found between groups (Table 1). 14-day Mortality was 2.90 % (2 participants) in the SoC group and none in zSoC. ICU admission rates were, respectively, 8 (23%) and 1 (2.7%) (OR: .098;95% CI .013-.766). The principal combined outcome occurred in 8 participants (23%) in SoC and in 2 (5.4%) in zSoC (OR: 0.18;95% CI .03-.946). In a logistic regression model adjusting by age, sex, comorbidity and severity the OR for the combined outcome in those in zSoC was 0.091 (95% CI: 0.007-0.913;p=0.045). LoS was shorter in zSoC (6.9 days (SD 6.1) vs 12.7 (SD 11.6);p=0.013) respectively. Time to clinical stability was significantly shorter in zSoC (5 days (SD 6.1)) compared to SoC (11.9(SD 9.1));p=0.005. No significant differences in changes in inflammatory markers were found among groups. No severe adverse events were observed during the study. Conclusion(s): Daily zinc supplementation with 240 mg of zinc acetate for 14 days during the acute phase of SARS-CoV-2 infection resulted in lower rates of severity (less death and ICU admission) and faster clinical recovery along with shorter hospital stay.

Ventilator avoidance among critically ill COVID-19 patients with acute respiratory distress syndrome

Introduction: Misinformation citing mechanical ventilation, not the virus, as causing death in COVID-19 patients with respiratory failure has led to ventilator avoidance (initial refusal of intubation) during the pandemic. Method(s): Prospective observational cohort study (March 2020- June 2021) evaluating the incidence and significance of initial refusal of intubation in patients with critical COVID-19 defined as ARDS requiring > 55% sustained FiO2 on high flow nasal canula (HFNC), non-invasive positive-pressure ventilation (NIPPV) or requiring intubation. Outcomes included in-hospital mortality and 1-year modified Rankin Scale (mRS) score. Logistic regression was used to estimate the age and Charlson Comorbidity Index adjusted odds ratio (OR) of in-hospital death. The Wilcoxon rank-sum test was used to evaluate differences in the mRs. Result(s): The cohort was predominantly non-Latino white (76%), male (65%), unvaccinated (99.4%), mean age of 66, and good pre- COVID-19 functional status (median mRs score of 0). Overall, 315 patients were critically ill due to COVID-19 with an in-hospital mortality of 41.9% (132/315;95% CI 36-47%). In patients in whom intubation was recommended 39% initially refused (40/102;95% CI 30-49%). Utilization of HFNC (90%) and NIPPV (72%) were similar between groups, however actual use of mechanical ventilation differed (98.4% in those that did not initially refuse compared to 20% in those that initially refused (p = 0.001)). In-hospital mortality was 79.3% (49/62) in those who initially did not refuse intubation compared to 77.5% (31/40) in those who refused (adjusted OR 1.3;95% CI 0.5-.5). The distribution of 1-year mRS was not significantly different between groups (p = 1.0) (Fig. 1). Conclusion(s): Among critically ill patients with COVID-19 associated ARDS, ventilator avoidance was common however, it was not associated with increased in-hospital mortality or a difference in 1-year functional outcome.

42nd International Symposium on Intensive Care and Emergency Medicine

The proceedings contain 369 papers. The topics discussed include: effective FiO2 delivered by a new frugal CPAP system with low oxygen needs: from bench to clinical observations;effect of non invasive respiratory support on interstitial lung disease with acute respiratory failure: a systematic review and meta analysis;causes of mortality of severe COVID 19 patients receiving high flow oxygen therapy;patient ventilator interaction during noninvasive ventilation with helmet: a comparison between pressure support ventilation and the new neural pressure support (NPS) software;tidal volume measurement during non invasive respiratory support by helmet continuous flow CPAP is feasible and accurate in a bench model;delayed intubation with high flow nasal cannula in COVID: a comparison between a first and second pandemic wave;outcomes following application of high flow nasal cannula and non invasive ventilation during the second COVID 19 wave in Singapore;ventilator avoidance among critically ill COVID 19 patients with acute respiratory distress syndrome;and mortality rate, intensive care unit length of stay and time to orotracheal intubation of COVID 19 patients under different non invasive ventilatory therapies: retrospective cohort study.

Prognostic value of brain natriuretic peptide in COVID-19 with or without acute heart failure

Background: Although Brain Natriuretic Peptide (BNP) provides strong prognostic information of an unfavorable outcome in patients with acute heart failure (AHF), there is little information of its relevance as a biomarker for outcomes in COVID-19 and its complications Purpose: To evaluate the association of increased BNP levels with complications and in-hospital mortality in a cohort of hospitalized COVID-19 patients. Method(s): The study included COVID-19 patients with data on BNP levels included in the ISACS COVID-19 registry. The population was categorized according to the presence of peak BNP levels >=100 pg/mL during hospitalization. Primary outcomes included in-hospital mortality, AHF or acute respiratory failure (ARF, defined as PiO2/FiO2<300 mmHg or need for mechanical ventilation). Calculations were conducted using age and sex-adjusted multivariable logistic regression analyses. Results were also stratified according to presence or absence of cardiovascular disease (CVD) history. Differences between subgroups were verified for statistical significance using test for interaction. Result(s): Of the 1152 patients included in the study, 615 (53.4%) had elevated BNP levels. These subjects were older (69.9+/-13.8 vs 59.1+/-16.8, p-value<0.001), had higher rates of cardiovascular risk factors (82.9% vs 57.7%, p-value<0.001) and presented more frequently with a prior history of CVD (either ischemic heart disease, cerebrovascular disease, venous thromboembolism, atrial fibrillation or a history of revascularization) (50.1% vs 27.5%, p-value<0.001). No sex differences were observed. When considering outcomes, BNP levels >=100 pg/mL were associated with increased rates of in-hospital mortality (32.9% vs 4.9%, p-value<0.001), even after adjustment for demographic characteristics (OR: 7.35;95% CI: 4.75-11.40;p-value<0.001). High BNP levels were also strongly associated with an increased risk of AHF (OR 19.9;95% CI 8.6-45.9;pvalue< 0.001), a correlation that persisted both in patients with and without a prior CVD history (p for interaction=0.29). Of note, patients with elevated BNP also had a higher likelihood of developing ARF (OR 2.7;95% CI 2.1- 3.6;p-value<0.001), even in absence of AHF (OR 3.00;95% CI 2.20-4.1;p-value<0.001). Conclusion(s): In COVID-19, blood BNP level not only appears to be predictor of in-hospital mortality and AHF but was also independently associated with an increased risk of ARF. This finding supports the routine use of BNP in all patients admitted to hospital for COVID-19, regardless of a prior history of CVD.

COVID-19 and acute heart failure among patients with cancer

Background: Patients with cancer represent a uniquely vulnerable population not only with higher susceptibility to COVID-19 but also at increased risk for death. However, detailed information on causes of death and the contribution of pre-existing health conditions to death yet is missing. Purpose(s): This study focuses on the implications of COVID-19 in the cardiovascular health of patients with cancer by assessing the relation between cancer and de novo acute heart failure (AHF) with in-hospital mortality. Method(s): The initial population consisted of 3968 patients included in the ISACS COVID-19 registry between March 2020 and February 2022. Of these, 546 patients with chronic HF were excluded, leaving a final population of 3422. Patients were divided in two groups according to the presence or absence of a cancer diagnosis at the time of hospitalization for COVID- 19. Primary outcomes were incidence of in-hospital mortality or AHF during hospitalization. Association between cancer and outcomes was estimated using multivariable logistic regression analyses. Subsidiary analysis was conducted to evaluate differences between patients with prior vs active cancer. Result(s): Of the 3422 patients included in the study, 468 patients had cancer (8.2% active, 5.5% past cancer). Cancer patients were older (68.9+/-13.4 vs 63.3+/-15.6, p-value <0.001) and more likely to be female (50.4% vs 39.1%, p-value <0.001). They presented more frequently with a history of chronic obstructive pulmonary disease (12.3% vs 7.6%, p-value = 0.001). When considering outcomes, cancer patients had a significantly higher incidence of in-hospital mortality (27.7% vs 19.2%;p-value <0.001). This despite the presence of a numerically higher mean PiO2/FiO2 (281+/-108.8 vs 267.05+/-122.5, p-value = 0.11) on admission and a lower rate of X-ray findings of interstitial pneumonia (60% vs 70.5%, p-value <0.001) than their non-oncological counterparts, as well as similar use of mechanical ventilation (30.6% vs 35.0%, p value=0.14). The association between cancer and death persisted when adjusting for demographic, laboratory findings and in-hospital treatment (OR: 1.46;95% CI: 1.11-1.94;p value=0.01). Cancer patients also had higher rates of AHF (9.6% vs 4.7%, p-value <0.001) during hospitalization. This association was independent from presence of cardiovascular risk factors or comorbidities (OR: 1.61;95% CI: 1.07-2.43;p value=0.02). When restricting the analysis to the cancer population, AHF appeared to be significantly associated with death (OR: 2.41;95% CI 1.18- 4.95;p-value = 0.01), but this correlation persisted only in patients affected by active cancer in age and sex adjusted analyses (OR: 4.27;95% CI: 1.51-12.07;p value=0.01 vs 1.20;95% CI: 0.38-3.76;p-value = 0.75). Conclusion(s): The incidence of AHF in cancer patients with COVID-19 is high. Patients with active cancer are also at high risk for mortality. This has implications for cardiac monitoring and chemotherapy administration during COVID-19.

Potential Predictors for Disease Severity in Hospitalised COVID-19 Patients

Background and Objectives Several studies have shown that SARS-CoV-2 can induce a cytokine release storm which is a major cause of disease severity and death. Therefore, cytokine levels in the serum may predict disease severity and survival in patients with COVID-19. Methods We included 88 COVID-19 patients who were hospitalised at the Division of Pulmonology of the Vienna General Hospital between January and May 2021 in this observational trial. Blood samples for serum peptide measurements were drawn at the time closest to hospitalisation, at day 5, 9 and 13( +/- 1). We correlated the type of ventilation (nasal oxygen therapy, high flow nasal canula, non-invasive ventilation or mechanical ventilation), occurrence of consolidations on chest X-ray or if available HRCT and the level of care (general ward, IMCU or ICU) with serum peptide values. We assessed the concentration of cytokines (IL-1a, IL-1b, IL-1RA, IL-6, L-7, L-10, IFN- gamma and TNF-alpha), chemokines (CCL-3, CCL-4 and CCL-7) and growth factors (G-CSF, GM-CSF and VEGF). Results Patients were 68 years of age (median) and stayed in hospital between 5-171 days. The peak inspiratory pressure in patients receiving non-invasive ventilation or mechanical ventilation was significantly associated with IL-1RA, G-CSF and IFN-gamma and the fraction of inspired oxygen in patients receiving highflow nasal canula oxygen therapy was significantly associated with IL-6, IL-7, IFN-gamma, and CCL-7. Results are shown in Table 1. No investigated cytokine correlated with the type of ventilation, occurrence of consolidations on imaging and in-hospital mortality. Conclusions In conclusion, concentrations of IL-1RA, G-CSF, IL-6, IL-7, IFN-gamma, and CCL-7 were associated with more severe disease progression in hospitalised COVID-19 patients.

High flow nasal oxygen (HFNO) in the treatment of COVID-19 infection of adult patients from - An emergency perspective: A systematic review and meta-analysis

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by SARS-CoV-2, which was first discovered in Wuhan, China. The disease has grown into a global pandemic causing mild to moderate symptoms in most people. The disease can also exhibit serious illnesses, especially for patients with other chronic diseases such as cardiovascular diseases, diabetes, chronic respiratory disease, or cancer. In such cases of severe illness, high flow nasal oxygen (HFNO) has been used to provide oxygenation to COVID-19 patients. However, the efficiency of HFNO remains uncertain, prompting the conduction of this systematic review to evaluate the effectiveness of the therapy. A thorough search for relevant and original articles was carried out on five electronic databases, including ScienceDirect, PubMed, Cochrane Library, Embase, and Google Scholar. No time limitation was placed during the search as it included all the articles related to COVID-19 from 2019 to 2022. The search strategy utilized in this systematic review yielded 504 articles, of which only 10 met the eligibility criteria and were included. Our meta-analysis reveals that HFNO success rate was higher than HFNO failure rates (0.52 (95% CI;0.47, 0.56) and 0.48 (95% CI;0.44, 0.53), respectively), however, the difference was statistically insignificant. HFNO was associated with a significant decrease in mortality and intubation rates (0.28 (95% CI;0.19, 0.39) and 0.28 (95% CI;0.18, 0.41), respectively). Our statistical analysis has shown that significantly lower ROX index (5.07 +/- 1.66, p = 0.028) and PaO2/FiO2 (100 +/- 27.51, p = 0.031) are associated with HFNO failure, while a significantly lower respiratory rate (RR) (23.17 +/- 4.167, p = 0.006) is associated with HFNO success. No statistically significant difference was observed in SpO2/FiO2 ratio between the HFNO success and failure groups (154.23 +/- 42.74 vs. 124.025 +/- 28.50, p = 0.62, respectively). Based on the results from our meta-analysis, the success or failure of HFNO in treating COVID-19 adult patients remains uncertain. However, HFNO has been shown to be an effective treatment in reducing mortality and intubation rates. Therefore, HFNO can be recommended for COVID-19 patients but with close monitoring and should be carried out by experienced healthcare workers.Copyright © 2023 The Authors

Analysis of High Flow Nasal Cannula Utilization During Pediatric Critical Care Transport

Objective: There are limited studies on the safety and efficacy of high flow nasal cannula (HFNC) utilization in pediatric critical care transport (CCT). This 15-month retrospective study was designed to describe HFNC utilization by our transport team and to track escalations in respiratory support within 24 hours of hospital admission including increased liter flow, non-invasive ventilation (NIV), or intubation. Method(s): This study was conducted at a large quaternary free standing children's hospital with a dedicated pediatric transport team that completes an average of 5,500 transports per year. Data was collected from January 1, 2019, to March 31, 2020. A total of 6,279 pediatric transports were completed during the study period. Inclusion criteria: >30 days and <18 years old, required HFNC >=4 L/min during transport, and admitted to our pediatric facility. Our institutions HFNC pediatric floor (Peds) criteria: <2 years of age, no comorbidities, suspected respiratory viral illness, max 2 L/kg and/or 15 L/min, <=40% FiO2. All patients used the standard HFNC equipment in our department. No new equipment was trialed during this study. We did not include SARS-COVID-19 patients given the initial variability in non-invasive respiratory support. Result(s): A total of 382 charts reviewed;358 patients met inclusion criteria. Median age 0.7 years old, with an interquartile range (IQR) of 0.3-1 year of age. Median weight 8.4 kilograms (kg), IQR 6.2-11 kg. Median transport time 80 minutes (min), IQR 69-115 min. Most of our HFNC volume was initiated by the referral (279, 78%) and we initiated the remainder (79, 22%). The majority of our HFNC patients were transported from the (ER) (184, 51%) and Peds (119, 33%) with the remainder being from urgent care (UC) (42, 12%), and Pediatric Intensive Care Unit (PICU) (13, 4%). We transported (210, 41%) back to the PICU versus (148, 41%) to Peds. Of the 279 patients that were on HFNC started by the referral, 42 (15%) had their flow weaned by the transport team. Median HFNC 10 L/min with an IQR of 6-15 L/min appreciated at drop-off regardless of HFNC status (initiated by transport, weaned by transport, or continued referral settings) (p-value 0.122). Escalations of care were tracked up to 24 hours after patient drop-off. A total of 118 patients (33%) had an escalation of care;90 (76%) required an increase in flow, 28 (24%) required NIV, and 0 (0%) required intubation within 24 hours. Escalations of care typically occurred within the first 6 hours after patient drop-off, 96 (27%), with a median HFNC 10.25 L/min, IQR 8-14 L/min (p-value range <=0.310). Conclusion(s): Our data suggests HFNC utilization in pediatric patients during CCT is a safe modality for non-invasive oxygen delivery with minimal risk of escalation requirement and no need for intubation. The number of escalations in liter flow after patient drop-off (~25% of high flow volume) was likely due to inpatient protocol to place all HFNC patients on 2 L/kg or max of 15 L/min. In the future, we plan to implement a HFNC protocol for management guidelines during CCT while conducting further research and review.Copyright © 2022

Clinical and laboratory characteristics of patients who succumbed to COVID-19: a single center experience from a resource poor setting

Introduction: The clinical and laboratory characteristics of patients who died with COVID 19 yet to be elucidated. Aims and objectives: We were aiming at identifying potential contributory factors for the mortality in COVID 19. Method(s): Patients died with COVID 19 at the intensive care unit (ICU), National Hospital, Kandy, Sri Lanka from 01.01.2021 to 31.12.2021 were retrospectively studied. Result(s): 79 deaths were analyzed. Males (44/79);median age 63 years (19, 94). Mean hospital and ICU stay were11 days (interquartile range-IQR:7,14), 7days (IQR: 2.5,9) subsequently. Median of 2 comorbidities (0,5) were present;diabetes(n=43), hypertension(n=43), ischemic heart disease(n=21), chronic kidney disease(n=10), post kidney transplant recipients(n=10), other(n=10). 14/79 had none. Mean systolic blood pressure on admission:130 mmHg (IQR: 115,148), mean SpO2/FiO2 ratio was 147(IQR 95,163), mean serum lactate level was 1.9(IQR: 1.08,2.25). The average heart rate 95(IQR: 81,108);mean respiratory rate was 28(IQR: 22, 33);mean random blood sugar was 229(IQR: 156, 289). 15/79 documented to be vaccinated (one =4/11: two=6/15: three=5/15). C-Reactive protein was available in 72/79;mean=122(IQR: 38, 182). Procalcitonin (PCT) on admission was available in 32/79;median=3.70 (0.01, 96), PCT was >1 in 16/32. 8/18 blood culture samples, 4/12urine culture samples detected bacterial pathogens. 25/46 demonstrated either PCT>1 or blood and/or urine culture positivity. Conclusion(s): Higher proportion of patients were unvaccinated, with multiple comorbidities predominantly diabetes. Hyperinflammation was common and significant proportion had bacterial co-infection.

Automated cough detection in COVID-19 and nonCOVID-19 pneumonia using machine learning-based technology

Background: Viral and bacterial pneumonia are characterized by exaggerated inflammation, dyspnea, and cough. We investigated cough evolution in hospitalized patients with COVID-19 and non-COVID-19 pneumonia using a novel, automated cough count detector. Material(s) and Method(s): In this observational cohort study, we used an automated, machine learning-based, contact-free, near real-time, smartphone-enabled cough counter to quantify cough in 46 patients with pneumonia in a non-ICU setting. Cough frequencies were correlated to clinical and laboratory markers of pneumonia disease activity. Result(s): We observed steady declines of cough frequencies during hospital stay in both COVID-19 and non-COVID19 pneumonia. Cough frequencies were associated with the degree of oxygenation/ oxygen supplementation (ROX index, FiO2, SpO2, breathing rate) as well as markers of inflammation (ferritin, CRP, LDH, body temperature) (Figure 1). No association with markers of multi-systemic disease (ASAT, ALAT, D-dimer) was found. Conclusion(s): Mobile technology leverages cough detection and allows for unobtrusive, long-term monitoring of patients in aerosol isolation. Results from this study suggest that cough frequency represents a surrogate marker of pneumonia disease activity. Future studies are warranted to assess cough frequency as a clinically actionable digital biomarker for lower respiratory tract infections.

Clinical and Laboratory Predictors of Mortality in Severe COVID-19 Pneumonia: A Retrospective Study from India

OBJECTIVE: Wide arrays of laboratory parameters have been proposed by many studies for prognosis in COVID-19 patients. In this study, we wanted to determine if the International Severe Acute Respiratory and Emerging Infections Consortium-Coronavirus Clinical Characterization Consortium score in addition to certain clinical and laboratory parameters would help in predicting mortality. We wanted to determine if a greater severity score on chest x-ray at presentation translated to poor patient outcomes using the COVID-19 chest radiography score. MATERIAL AND METHODS: This retrospective study was conducted at SDS TRC and Rajiv Gandhi Institute of chest diseases, Bangalore from March 2021 to June 2021. This study included 202 real-time-polymerase chain reaction-positive COVID-19 patients aged above 18 years admitted to the intensive care unit of our hospital. Demographic characteristics and baseline hematological and inflammatory markers (serum C-reactive protein, lactate dehydrogenase, troponin-I, ferritin, and d-dimer) were collected. Radiological severity on a chest x-ray was assessed using the validated COVID-19 chest radiography score. The International Severe Acute Respiratory and Emerging Infections Consortium-Coronavirus Clinical Characterization Consortium score was assigned to each patient within 24 hours of intensive care unit admission. Outcome studied was in-hospital mortality. RESULT(S): The overall mortality was 54.9% (111 cases). Age more than 50 years, >4 days of symptoms, peripheral oxygen saturation/ fraction of inspired oxygen ratio less than 200, elevated serum lactate dehydrogenase >398.5 IU/L, and hypoalbuminemia (<2.95 g/dL) were detected as independent predictors of mortality. A significant correlation of risk stratification with mortality (P = .057) was seen with International Severe Acute Respiratory and Emerging Infections Consortium-Coronavirus Clinical Characterization Consortium score. There was no significant correlation between the COVID-19 chest radiography score and mortality. CONCLUSION(S): Age >50 years, peripheral oxygen saturation/fraction of inspired oxygen ratio <200, mean symptom duration of >4 days, elevated serum lactate dehydrogenase, and hypoalbuminemia are independent predictors of mortality in severe COVID-19 pneumonia. International Severe Acute Respiratory and Emerging Infections Consortium-Coronavirus Clinical Characterization Consortium score was different in the survivors and deceased.Copyright © Author(s).