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Introduction: The COVID-19 pandemic has required clinical teams to function with an unprecedented amount of uncertainty, balancing complex risks and benefits in a highly fluid environment. This is especially the case when considering the delivery of a pregnant woman critically unwell with COVID-19. This is one maternal critical care team's reflections on establishing best practice and a shared mental model when undertaking a Caesarean section in critically unwell patients with COVID-19. Objective(s): We describe our experience of balancing the risks and streamlining the process of this high-risk intervention. Method(s): We used our standard clinical governance forums across four specialties (Obstetrics, Intensive care, Anaesthetics and Neonatology) to identify key challenges and learning points. We developed a working group to combine our learning and develop a shared mental model across the involved teams. Result(s): 1. The decision to deliver must be multidisciplinary involving Obstetrics, Intensive care, Anaesthetics, Neonatology and the patient according to their capacity to participate. The existing structure of twice daily ITU ward rounds could be leveraged as a 'pause' moment to consider the need for imminent delivery and review the risk-benefit balance of continued enhanced pharmacological thromboprophylaxis. 2. We identified a range of scenarios that our teams might be exposed to: 3. Perimortem Caesarean section 4. Critically unwell - unsafe to move to theatre 5. Critically unwell - safe to move to theatre 6. Recreating an obstetric theatre in the ICU Advantages Avoids moving a critically unstable patient, although our experience is increasing moving patients for ECMO. Some forms of maximal non-invasive therapy such as High Flow Nasal Oxygen may require interruption to move to theatre with resultant risk of harm or be difficult to continue in transport mode through a bulky ICU ventilator e.g. CPAP Disadvantages Significant logistics and coordination burden: multiple items of specialist equipment needing to be brought to the ICU. Human factors burden: performing a caesarean section in an unfamiliar environment is a significant increase in cognitive load for participating teams. Environmental factors: ICU side rooms may offer limited space vs the need to control the space if performed on an open unit. Delivering a Neonate into a COVID bubble. Conclusion(s): Developing a shared mental model across the key teams involved in delivering an emergency caesarean section in this cohort of critically unwell patients has enabled our group to own a common understanding of the key decisions and risks involved. We recommend a patient centred MDT decision making model, with a structure for regular reassessment by senior members of the teams involved. In most circumstances the human factors and logistical burden of recreating an operating theatre in the ICU outweighs the risk of transport to theatre. Pre-defined checklists and action cards mitigate the cognitive and logistical burden when multiple teams do perform an operative delivery in ICU. Action cards highlight key aspects of routine obstetric care to be replicated in the ICU environment.
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Climate change may strongly modify the habitat conditions for many woody plant species. Some species could disappear from their natural habitats and become endangered, while others could adapt well to the changed environmental conditions and continue to survive successfully or even proliferate more easily. A similar process can occur within the artificial urban environment as the hitherto popularly planted urban trees may suffer from the extremities of the urban climate. However, among the planted taxa, there are species that spread spontaneously and appear as weeds in extensively managed gardens. In our study, we evaluated the native and non-native species involved in spontaneous spreading in the institutional garden of Buda Arboretum (Budapest) during the COVID-19 period in 2020–2021 when entry was prohibited, and maintenance went on in a restricted, minimal level. We investigated the correlation between spontaneously settling and planted individuals, and then performed multivariate analyses for native and non-native spreading plants for spatial and quantitative data. During our studies, we observed the spontaneous spreading of 114 woody species, of which 38 are native and 76 are non-native. Taking the total number of individuals into account, we found that, in addition to the 2653 woody species planted, a further 7087 spontaneously emerged weeds developed, which creates an additional task in the maintenance. © 2023 by the authors.
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Case history: We present the case of a 31-year-old Hispanic male with history of recurrent bronchiectasis, invasive aspergillosis, and severe persistent asthma, who is now status post lung transplant for end-stage lung disease. He initially presented at 7 years of age with diarrhea, failure to thrive, and nearly absent immunoglobulin levels (IgG < 33 mg/dL, IgA < 7 mg/dL, IgM = 11 mg/dL, IgE = 4 IU/dL) necessitating IVIG treatment. Small intestinal biopsy showed villous atrophy consistent with autoimmune enteropathy. Sweat chloride was reported as indeterminate (44 me/dL). Initial WBC, platelet, and T- and NK-cell counts were within normal range, and B-cell count and percentage were borderline low. Most recently, he was found to have increased immature B-cell count (CD21low), decreased memory B-cells, and poor pneumococcal vaccine antibody response. Patient has been hospitalized numerous times with increasingly severe bronchiectasis, pneumonitis, and COVID-19 infections twice despite vaccination, leading to respiratory failure and lung transplantation. Family history is negative for immune deficiency and lung diseases. Discussion(s): Of these 3 VUSs (see the table), the one in IRF2BP2 has the most pathogenic potential due to its autosomal dominant inheritance, its location in a conserved domain (Ring), and previous case reports of pathogenic variants at the same or adjacent alleles 1-3. Baxter et al reported a de novo truncating mutation in IRF2BP2 at codon 536 (c.1606CinsTTT), which is similar to our patient's mutation. This patient was noted to have an IPEX-like presentation, with chronic diarrhea, hypogammaglobulinemia, and recurrent infections. Variant Functional Prediction Score for our variant predicts a potentially high damage effect. There are 2 other case reports of heterozygous mutations in loci adjacent to this allele;one (c.1652G>A)2 with a similar clinical phenotype to our patient and the other (C.625-665 del)3 with primarily inflammatory features and few infections. Impact: This case highlights a variant in IRF2BP2 associated with severe hypogammaglobulinemia, recurrent pulmonary infections, and autoimmune enteropathy. [Table presented]Copyright © 2023 Elsevier Inc.
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Introduction: COVID pneumonia can lead to pneumomediastinum or pneumothorax during non-invasive or invasive mechanical ventilation. This affects the prognosis. Methodology: During the study period, 121 patients with SARS-CoV-2 infections and invasive or non-invasive ventilation therapy were recorded in our hospital. All patients with a pneumothorax or pneumomediastinum were analyzed in more detail. Result(s): Pneumothorax and pneumomediastinum occurred in 12 patients and resulted in 7 deaths. Discussion(s): The incidence of pneumothorax with COVID infection ranges from 0.56 to 1%, reaching 3.5% in our own studies and 4.2% under invasive mechanical ventilation. The incidence of pneumomediastinum was 10% and 9.2% in our own patients. Overall mortality was 58.3% and similar to that reported in the literature, up to 60%.Copyright © 2023 Dustri-Verlag Dr. K. Feistle.
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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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Objective. To study risk factors, clinical and radiological features and effectiveness of the treatment of invasive aspergillosis (IA) in adult patients with COVID-19 (COVID-IA) in intensive care units (ICU). Materials and methods. A total of 60 patients with COVID-IA treated in ICU (median age 62 years, male - 58%) were included in this multicenter prospective study. The comparison group included 34 patients with COVID-IA outside the ICU (median age 62 years, male - 68%). ECMM/ISHAM 2020 criteria were used for diagnosis of CAPA, and EORTC/MSGERC 2020 criteria were used for evaluation of the treatment efficacy. A case-control study (one patient of the main group per two patients of the control group) was conducted to study risk factors for the development and features of CAPA. The control group included 120 adult COVID-19 patients without IA in the ICU, similar in demographic characteristics and background conditions. The median age of patients in the control group was 63 years, male - 67%. Results. 64% of patients with COVID-IA stayed in the ICU. Risk factors for the COVID-IA development in the ICU: chronic obstructive pulmonary disease (OR = 3.538 [1.104-11.337], p = 0.02), and prolonged (> 10 days) lymphopenia (OR = 8.770 [4.177-18.415], p = 0.00001). The main location of COVID-IA in the ICU was lungs (98%). Typical clinical signs were fever (97%), cough (92%), severe respiratory failure (72%), ARDS (64%) and haemoptysis (23%). Typical CT features were areas of consolidation (97%), hydrothorax (63%), and foci of destruction (53%). The effective methods of laboratory diagnosis of COVID-IA were test for galactomannan in BAL (62%), culture (33%) and microscopy (22%) of BAL. The main causative agents of COVID-IA are A. fumigatus (61%), A. niger (26%) and A. flavus (4%). The overall 12-week survival rate of patients with COVID-IA in the ICU was 42%, negative predictive factors were severe respiratory failure (27.5% vs 81%, p = 0.003), ARDS (14% vs 69%, p = 0.001), mechanical ventilation (25% vs 60%, p = 0.01), and foci of destruction in the lung tissue on CT scan (23% vs 59%, p = 0.01). Conclusions. IA affects predominantly ICU patients with COVID-19 who have concomitant medical conditions, such as diabetes mellitus, hematological malignancies, cancer, and COPD. Risk factors for COVID-IA in ICU patients are prolonged lymphopenia and COPD. The majority of patients with COVID-IA have their lungs affected, but clinical signs of IA are non-specific (fever, cough, progressive respiratory failure). The overall 12-week survival in ICU patients with COVID-IA is low. Prognostic factors of poor outcome in adult ICU patients are severe respiratory failure, ARDS, mechanical ventilation as well as CT signs of lung tissue destruction.Copyright © 2022, Interregional Association for Clinical Microbiology and Antimicrobial Chemotherapy. All rights reserved.
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The respiratory pump that provides pulmonary ventilation includes the respiratory center, peripheral nervous system, chest and respiratory muscles. The aim of this study was to evaluate the activity of the respiratory center and the respiratory muscles strength after COVID-19 (COronaVIrus Disease 2019). Methods. The observational retrospective cross-sectional study included 74 post-COVID-19 patients (56 (76%) men, median age - 48 years). Spirometry, body plethysmography, measurement of lung diffusing capacity (DLCO), maximal inspiratory and expiratory pressures (MIP and MEP), and airway occlusion pressure after 0.1 sec (P0.1) were performed. In addition, dyspnea was assessed in 31 patients using the mMRC scale and muscle strength was assessed in 27 of those patients using MRC Weakness scale. Results. The median time from the COVID-19 onset to pulmonary function tests (PFTs) was 120 days. The total sample was divided into 2 subgroups: 1 - P0.1 <= 0.15 kPa (norm), 2 - > 0.15 kPa. The lung volumes, airway resistance, MIP, and MEP were within normal values in most patients, whereas DLCO was reduced in 59% of cases in both the total sample and the subgroups. Mild dyspnea and a slight decrease in muscle strength were also detected. Statistically significant differences between the subgroups were found in the lung volumes (lower) and airway resistance (higher) in subgroup 2. Correlation analysis revealed moderate negative correlations between P0.1 and ventilation parameters. Conclusion. Measurement of P0.1 is a simple and non-invasive method for assessing pulmonary function. In our study, an increase in P0.1 was detected in 45% of post-COVID-19 cases, possibly due to impaired pulmonary mechanics despite the preserved pulmonary ventilation as well as normal MIP and MEP values.Copyright © Savushkina O.I. et al., 2023.
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Background: Mucormycosis is a serious life-threatening fungal infection that recently made severe sudden and devastating surge during the second wave of the COVID-19 epidemic with a mortality rate of up to 50%. Although the causality link between COVID-19 and rhino-orbito-cerebral mucormycosis (ROCM) remains unclear, many factors including poor diabetes control, high doses of steroids, viral-induced lymphopenia, and cytokine storm have been attributed to ROCM in patients with COVID-19. Orienting to risk factors and early recognition of this potentially fatal opportunistic infection is the key to optimal management and improved outcomes. In these contexts, we conducted a prospective study for 33 patients admitted to our tertiary hospital to determine the risk factors for ROCM in patients with COVID-19 and the cumulative mortality rates. Result(s): This study found a statistically significant relation between the fate of death in COVID-MUCOR patients who had presented fever, ophthalmoplegia, facial skin necrosis, and visual loss with those who received dose of steroid to control their respiratory symptoms P < 0.001. Death from COVID-MUCOR was statistically significant related to the prolonged interval from the onset of the symptoms to start of treatment and intervention. Also, it was found that there was a significant decrease in duration between COVID-19 infection and the start of mucormycosis (days) with incidence of DKA on admission. Nineteen (57.6%) of the patients had uncontrolled diabetes mellitus (hemoglobin A1C (HbA1c) of > 7.0%). Conclusion(s): Mucormycosis epidemic was precipitated by a unique confluence of risk factors: diabetes mellitus, widespread use of steroids, and perhaps SARS-CoV-2 infection itself. Restricting steroid use in patients with severe COVID-19 requiring oxygen therapy, and screening for and optimally controlling hyperglycemia, can prevent COVID-MUCOR in a large majority.Copyright © 2023, The Author(s).
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The COVID-19 pandemic has caused a severe global problem of ventilator shortage. Placing multiple patients on a single ventilator (ventilator sharing) or dual patient ventilation has been proposed and conducted to increase the cure efficiency for ventilated patients. However, the ventilator-sharing method needs to use the same ventilator settings for all the patients, which cannot meet the ventilation needs of different patients. Therefore, a novel multivent system for non-invasive ventilation has been proposed in this study. The close loop system consists of the proportional valve and the flow-pressure sensor can regulate the airway pressure and flow for each patient. Multiple ventilation circuits can be combined in parallel to meet patients’ventilation demands simultaneously. Meanwhile, the mathematical model of the multivent system is established and validated through experiments. The experiments for different inspired positive airway pressure (IPAP), expired positive airway pressure (EPAP), inspiratory expiratory ratio (I:E), and breath per minute (BPM) have been conducted and analyzed to test the performance of the multivent system. The results show that the multivent system can realize the biphasic positive airway pressure (BIPAP) ventilation mode in non-invasive ventilation without interfering among the three ventilation circuits, no matter the change of IPAP, EPAP, I:E, and BPM. However, pressure fluctuation exists during the ventilation process because of the exhaust valve effect, especially in EPAP control. The control accuracy and stability need to be improved. Nevertheless, the novel designed multivent system can theoretically solve the problem of ventilator shortage during the COVID-19 pandemic and may bring innovation to the current mechanical ventilation system. Author
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Objectives: In patients with severe respiratory failure, invasive ventilation may deteriorate the pneumomediastinum and hypoxia. This study aimed to compare the mortality and the complications of the patients with coronavirus disease 2019 (COVID-19) related severe ARDS treated with invasive ventilation or veno-venous ECMO (VV-ECMO) to avoid intubation. We hypothesized that VV-ECMO support without prior intubation is a feasible alternative strategy to invasive ventilation. Method(s): This retrospective study evaluated patients with COVID-19 related severe respiratory failure and radiological evidence of pneumomediastinum. The primary outcome was intensive care unit (ICU) survival at 90 days. Result(s): Out of 347 patients with COVID-19 disease treated in our unit, 22 patients developed spontaneous pneumomediastinum associated with deterioration of respiratory function. In 13 patients (59%), invasive ventilation was chosen as initial respiratory support;in 9 patients (41%), VV-ECMO was chosen as initial respiratory support. The median age of the patients in the invasive ventilation group was 62 years (IQR: 49-69) compared to 53 years (IQR: 46-62) in ECMO group (P=0.31). No statistically significant difference in SAPS II score between the groups was observed (39.7 (IQR: 33.2-45.3) vs. 28.9 (IQR:28.4-34.6), P=0.06). No elevated fluid balance within the first 4 days was observed in the ECMO group compared to the invasive ventilation group (162 mL (IQR: -366-2000) vs. 3905 mL (IQR: 2068-6192), P=0.07). VV-ECMO as the initial strategy for supporting patients with severe respiratory failure and pneumomediastinum, was associated with lower 90 days mortality (HR: 0.33 95%-CI: 0.11-0.97, P= 0.04) compared to patients treated with invasive ventilation (Figure). Conclusion(s): VV-ECMO can be an alternative strategy to invasive ventilation for treating patients with severe respiratory failure and spontaneous pneumomediastinum. (Figure Presented).
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Background: The pandemic of COVID-19 since its beginning has created havoc all-round the globe. The role of oxygen therapy remains constant. Various modalities have been studied for oxygen delivery to hypoxic patients but high flow nasal oxygen (HFNO) has lately gained importance in terms of non-invasive oxygen delivery, easy administration and great improvement in patient's recovery. We conducted this retrospective analysis with the primary objective of looking for the proportion of patients who were successfully weaned off of HFNO or non-invasive ventilation (NIV) and the secondary aim was to look for duration of hospital stay and its effect on clinical recovery based on laboratory parameters. Methods: All patients, positive for COVID-19 infection by real-time reverse transcriptase polymerase chain reaction (RTPCR) were admitted to covid ICU or ward with oxygen requirement and were treated with either NIV or HFNO were enrolled for the study. Patients were grouped under H group (HFNO) or N group (NIV). Daily ABG readings, chest x-ray, respiratory rate, hemodynamic parameters and urine output were noted on 12 hourly intervals. Any changes in above parameters along with need for intubation were assessed. Results: Patients from both the groups showed significant improvement in their oxygen saturation by the fifth day of their treatment. Fourteen patients from the NIV group and 10 from the HFNO group had saturation >90% by Day 5. Of those who presented with saturation of <85%, 2 out of 5 in the NIV group (40%) and 1 of the 2 patients in the HFNO group (50%) showed improvement in their oxygen saturation. The P/F was statistically comparable (p 0.928) in both groups. The levels of bio markers, and the improvement was comparable and correlated with clinical improvement as well. Conclusion: We conclude that though HFNO is accepted better than NIV, the improvement in the respiratory status of the patient was comparable with both the treatment modalities and hence we do not recommend use of HFNO, especially in a situation of gross deficit of oxygen availability as compared to the exponential rise in the demand. © 2023 Tehran University of Medical Sciences.
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Background: The second wave of the COVID-19 pandemic caused significant demand for beds capable of delivering enhanced respiratory support. NHS England recommended the use of CPAP for patients with COVID-19 respiratory failure, a treatment which can be offered outside of a critical care facility, and on a Respiratory High Care/ Support Unit (RSU). The enhancement of Portsmouth's RSU provided CPAP and NIV for patients with COVID-19 respiratory failure. With our intensive care facilities at 300% their normal capacity, this greatly alleviated bed pressures on critical care. Varied levels of deprivation exist in Portsmouth's dense population. Deprivation has an impact on overall health, however the effect of postcode on outcomes for people going onto support for COVID-19 respiratory failure, is unknown. Method(s): Retrospective cohort analysis of consecutive patients admitted to Respiratory Support Unit during the second wave of the COVID-19 pandemic, from 02/11/2020 to 31/01/2021. 227 patients were included in the study with 8 removed due to incomplete data, all of the patients received respiratory support in the form of CPAP or NIV. We collected multivariate data including biochemical markers, demographics, oxygenation status, co-morbidities and outcomes. Outcomes measured were: 1) Death in RSU, 2) Discharge from RSU or 3) Intubation and Ventilation. To measure deprivation, we linked a persons postcode to an area called an LSOA (Lower-layer Super Output Area). These are small areas of similar population size, each of which has a deprivation score (ie. top 10%, to the lowest 10% areas of deprivation in the UK). This is measured using an 'index of multiple deprivation'. An individual's outcome from the RSU was then analysed in relation to the deprivation score allocated to their postcode. Result(s): We observed a significant number of patients discharged from RSU, without needing invasive mechanical ventilation. 80/219 were discharged directly. 45/219 died in RSU, and 94 were eventually admitted to ITU. The average stay on CPAP or NIV before needing admission to ITU was 3 days. Some biochemical markers which stood out in relation to the outcomes described were as follows: average LDH, D-dimer and Troponin levels were higher in those who were admitted to intensive care. In patients who died, the PCT was significantly higher on average when compared to the other two groups. In the group who were discharged, mean lymphocyte count was >1, in the other two groups this was <1. From our observations in Portsmouth, there is a negative correlation between deprivation and lower aged individuals admitted for COVID-19 related respiratory support. Overall, we also saw disproportionate representation of those from the most deprived 50% of the UK in our respiratory support unit. Conclusion(s): CPAP and NIV can effectively be used in an RSU during a spike of COVID-19, to safely minimise demand on critical care services. Deprivation may have an impact on outcomes in patients needing respiratory support related to COVID-19. Deprivation levels may help predict risk of needing enhanced respiratory support in certain age groups. Multiple biochemical markers may be of prognostic value in COVID-19.
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Objectives: Obesity is a condition prone to pose difficulties to a successful extra-corporeal membrane oxygenation (ECMO) support. Not being a contraindication, it yields significant challenges to physicians and may interfere with patient;s outcome. The number of obese patients supported by ECMO has increased during COVID-19 pandemic due to severe illness in this population. We designed a retrospective study in order to identify prognostic factors for 180-day survival in critical COVID-19 obese patients in venovenous ECMO (VV-ECMO). Method(s): Single-center retrospective cohort of critical COVID-19 adult patients in VV-ECMO, obese and overweight (according to WHO classification), admitted in a tertiary hospital;s ICU from April 1st 2020 to May 31th2022. Univariate logistic regression analysis was performed to assess 180-day mortality differences. Result(s): The analysis included 41 patients. The median [interquartile range (IQR)] age was 55 (IQR 45-60) years and 70,7% were male. Median body mass index (BMI) was 36 (IQR 31-42,5) Kg/m2 ;39% of patients had a BMI >=40 kg/m2 . The sampling had 3 (IQR 1,5-4) days of invasive ventilation prior to ECMO and 63,4% were weaned from ECMO-VV support after a median of 19 (IQR 10-34) days. The median ICU length of stay was 31,9 (IQR 17,5-44,5) days. The invasive ventilation period was 30 (IQR 19-49,5) days. The 60, 90 and 180-day mortalities were 41,5%. On the univariate logistic regression analysis we found that higher BMI was associated with higher 180-day survival (odds ratio [OR] 1,157 (1,038-1,291), p 0,009). Younger age, female patients, less invasive ventilation time prior to ECMO and fewer complications at time of ECMO cannulation were associated with higher 180-day survival [respectively, OR 0,858 (0,774- 0,953), p 0,004;OR 0,074 (0,008-0,650), p 0,019;OR 0,612 (0,401-0,933), p 0.022;OR 0.13 (0,03-0,740), p 0,022)]. Conclusion(s): In this retrospective cohort of critical COVID-19 obese adult patients supported by VVECMO, a higher BMI, younger age and female patients were associated with higher 180-day survival. A shorter invasive ventilation time prior to ECMO and fewer complications at ECMO cannulation were also associated with increased survival.
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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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Non-invasive ventilation (NIV) via a mask to maintain a constant positive airway pressure (CPAP mask) is the method of choice for the treatment of pulmonary disorders in severe COVID-19-associated pneumonia. Nowadays, there are no studies which had shown the effectiveness of the ROX-index in predicting the efficacy of NIV in patients with acute hypoxic respiratory failure (AHRF). This clinical case describes our experience of effective use of ROX-index in patients with AHRF because of coronavirus dis-ease, SARS-CoV-2-associated, who underwent non-invasive lung ventilation through CPAP mask. © 2022. The Authors.
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Background: The recognition of the relationship between thromboembolism in COVID-19 and poor clinical outcomes led to the use of anticoagulants in patients diagnosed with COVID-19. Aim(s): To determine the effects of anticoagulants in COVID-19 patients and to compare the effect of oral, subcutaneous, and combined anticoagulants on patient outcomes. Study design: Retrospective cohort study Place and duration: A private tertiary care hospital, in Lahore, from 1st April 2020 to 30 Sep 2020 Methodology: Data were collected from electronic and paper records of admitted patients with a confirmed diagnosis of COVID-19 on PCR or with a radiological diagnosis of COVID-19. A total of 179 patients were included in the study, 172 were given anticoagulation, out of these, 74 were given oral anticoagulation, 73 were given subcutaneous and 24 were given combination of oral and subcutaneous anticoagulants. Result(s): Among 172 patients on anticoagulants, 41(23.8%) expired while 131(76.2%) recovered. Among 7(100%) patients on no anticoagulation, 1(14.3%) patient expired while 6(85.7%) recovered. 19(11%) patients on anticoagulation progressed towards the need for invasive ventilation while 152(89%) patients did not need invasive ventilation. Among patients on subcutaneous anticoagulants, 27(37%) expired while 46(63%) recovered. 8(33.3%) patients on combined anticoagulants expired while 16(66.7%) recovered. 6(8.1%) patients on oral anticoagulants expired while 68(91.9%) recovered. Conclusion(s): Anticoagulation improves the outcome of COVID-19 patients and oral anticoagulation is better than subcutaneous and combined anticoagulation.Copyright © 2023 Lahore Medical And Dental College. All rights reserved.
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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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The clinical and epidemiological features of acute kidney injury in severe and extremely severe pneumonia associated with coronavirus disease-2019 (COVID-19) are considered. An observational prospective study was conducted with the inclusion of 117 patients, including 75 men and 42 women, suffering from severe and extremely severe pneumonia associated with COVID-19, who were treated in the intensive care unit of the 1586th Military Clinical Hospital in 2020–2022. Acute kidney injury was diagnosed in 21 (17.9%) patients (stage 1 in 10, stage 2 in 4, and stage 3 in 7 patients), kidney dysfunction was recorded in 22 (8.8%) patients (serum creatinine was higher than normal, but does not reach the diagnostic criteria of Kidney Disease Improving Global Outcomes). Four patients underwent renal replacement therapy. The probability of kidney damage increases with age (the average age of the patients with acute kidney damage is 65 (58;71) years, and those without acute kidney damage was 47.5 (41;55) years;p = 0.0001). Compared with patients without acute kidney injury, patients with acute kidney injury scored higher on the scales NEW (p = 0.000975), SMRT-CO (p = 0.011555), and Sequential Organ Failure Assessment (p = 0.000042). Among those suffering from acute kidney injury, significantly more pronounced manifestations of systemic inflammation were determined (leukocytes, p = 0.047324;platelets, p = 0.001230;ferritin, p = 0.048614;and D-dimer, p = 0.004496). In the general cohort, the mortality rate was 22.2%, whereas a significant intergroup difference in mortality was observed, i.e., 52.4% in patients with acute kidney injury and 15.62% in those without acute kidney injury (Chi-squared criterion, 13.468;p < 0.001). Invasive artificial lung ventilation was performed in 19.66% of the patients, and a significant intergroup difference was identified, with 66.7% in patients with acute kidney injury and 9.38% in patients without acute kidney injury (Chi-squared criterion, 35.810;p < 0.001). The durations of treatment in the intensive care unit in patients with and without acute kidney injury were 9 (7;14) and 6 (4;10) days, respectively. After the treatment, all patients with acute kidney injury had fully recovered kidney function upon discharge. In general, acute kidney injury occurs in almost every fifth patient with severe and extremely severe pneumonia associated with COVID-19, aggravates the condition of patients, and increases mortality. The alertness of doctors regarding acute kidney injury and early diagnosis and timely nephroprotective treatment may reduce the possibility of adverse disease outcomes. All rights reserved © Eco-Vector, 2022.
ABSTRACT
The SARS-coronavirus 2 disease initially reported in December 2019 in China (COVID-19) represents a major challenge for intensive care medicine, due to the high number of ICU admission and the prolonged stay for many patients. Up to 5% of COVID-19 infected patients develop severe acute hypoxemic respiratory failure requiring invasive mechanical ventilation as supportive treatment. Apart from early antiviral and anti-inflammatory treatment, the management of COVID-19 patients is mainly applying protective mechanical ventilation, to support the injured lungs. However recently acquired data and clinical experience suggest that COVID-19-related ARDS presents some specificities that will be summarized in the present article.Copyright © 2020 Editions Medecine et Hygiene. All rights reserved.
ABSTRACT
Acute respiratory failure (ARF) is the leading cause of death in hospitalized patients with severe forms of COVID-19. At the beginning of COVID-19 pandemic the starting respiratory protocol suggested early use of intubation and artificial lung ventilation (ALV) in patients with severe pneumonia complicated by ARF. However, after the analysis of the published studies it was noted that the pathophysiology of the development of ARF in COVID-19 had features that determine the atypical clinical pattern - "silent hypoxemia". This leads to the late onset of respiratory support (RS) and, as a result, to the lower effectiveness of non-invasive RS methods. This article discusses the creation of an algorithm for the early use of various non-invasive RS methods in patients with COVID-19 complicated by ARF, that will decrease the frequency of hospitalization to the Intensive care units, tracheal intubation and ALV, reduce the duration of treatment and improve prognosis.Copyright © 2023 IRBIS LLC. All Rights Reserved.