Medical intensivist directed VV ECMO cannulation for the facilitation of tracheostomy in a patient with severe tracheal stenosis: A case report

Objectives: We present a case report of medical intensivist driven ECMO program using ECMO as a pre-procedural tool to maintain oxygenation in a patient with critical tracheal stenosis during tracheostomy placement. Method(s): VV ECMO is primarily used to support patients when mechanical ventilation is unable to provide adequate gas exchange. Alternatively, it has been used pre-procedurally when intubation is required in anticipation of a difficult airway. Described here is the first intensivist preformed awake VV ECMO cannulation to facilitate tracheostomy in a patient with severe tracheal stenosis. Result(s): The patient is a 41-year-old female with the relevant background of COVID19 pneumonia status post tracheostomy and subsequently decannulated after prolonged intubation and ICU stay. As a result, the patient developed symptomatic tracheal stenosis and presented two years after her ICU stay for scheduled bronchoscopy and balloon dilation. However, the patient developed worsening stridor and shortness of breath requiring heliox and BPAP. After multidisciplinary discussion between the critical care team ENT teams, the decision was made to cannulate for VV ECMO as a pre-procedural maneuver to allow for oxygenation during open tracheostomy in the OR. Dexmedetomidine and local anesthesia were used for the procedure with the patient sitting at 30 degrees on non-invasive ventilation and heliox. The patient was cannulated with a 21F right internal jugular return cannula and 25F right common femoral drainage cannula by medical intensivists in the intensive care unit using ultrasound guidance. The patient went for operative tracheostomy the next day and was subsequently decannulated from ECMO the following day without complication. She was discharged home on trach collar. Conclusion(s): Intensivist performed ECMO cannulation has been shown to be safe and effective. We anticipate the indications and use will continue to expand. This case is an example that intensivist driven preprocedural ECMO is a viable extension of that practice.

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

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

Specifically designed family communication booklet to help staff to communicate effectively with Intensive Care Unit patients' next of kin

Introduction: Families of patients admitted to the Intensive Care Unit (ICU) experience significant emotional distress.1 Visiting restrictions mandated during the COVID-19 pandemic presented new barriers to family communication, including a shift from regular bedside nursing updates and in-person family meetings to scheduled, clinician-led telephone calls and video calls.2 This resulted in loss of non-verbal clues and feedback during family discussions, difficulties establishing rapport with families and risked inconsistent messages and moral injury to staff.3 Objectives: We aimed to design a system where all ICU family discussions were documented in one place in a standardised format, thereby clarifying information given to families to date and helping staff give families a consistent message. In addition, we aimed to provide practical advice for the staff making family update telephone calls and strategies for managing difficult telephone conversations. Method(s): We designed and implemented an ICU family communication booklet: this was colour-coded blue;separate to other ICU documentation within the patient notes;and included communication aids and schematics to help staff optimise and structure a telephone update. Using Quality Improvement methodology, we completed four Plan-Do-Study-Act (PDSA) cycles and gathered qualitative and quantitative feedback: this occurred prior to the project and at one,12,18 and 21 months post introduction. We implemented suggested changes at each stage. We designed staff surveys with questions in a 5-point Likert scale format plus opportunity for free comments. Twenty-one months post implementation, we designed and delivered an MDT awareness campaign using the 'tea-trolley training' method,4 departmental induction sessions for new ICU doctors and nurses and a 'Message of the Week' initiative. An updated version of the booklet was introduced in February 2022 (Figure 1). Result(s): Staff survey results are shown in Table 1. Forty-six staff participated in tea trolley training, feedback form return rate 100%. Following feedback, the family communication booklet was updated to include the following: a prompt to set up a password;a new communication checklist at the front, including documentation of next of kin contact details, a prompt to confirm details for video calls, confirm primary contact and whether the next of kin would like updates during the night;consent (if the patient is awake) for video calls while sedated;information regarding patient property;prompt to give families our designated ICU email address to allow relatives to send in photographs to display next to patients' beds;prompts to encourage MDT documentation and patient diary entry. Conclusion(s): During unprecedented visiting restrictions in the COVID-19 pandemic, we implemented an ICU family communication booklet which has been so successful that we plan to use it indefinitely. We plan to further develop this tool by encouraging MDT involvement, seek further staff feedback in six months' time, incorporate this structure into our electronic patient information system when introduced and collect feedback from patients and their next of kin at our ICU follow up clinic. This communication booklet would potentially be reproducible and transferable to other ICUs and could be used as part of a national ICU family communication initiative.

Coronavirus in patient with positive PCR test in cerebrospinal fluid led to generalized tonic-clonic seizure without brain lesion: a case report

SARS-CoV-2 which first was observed in Wuhan region, China in December 2019 is affected many organs, such as central nervous system. We describe a case of a 57-year-old male patient, in hospital with the loss of consciousness, in the form of lack of verbal and visual communication. He got a seizure attack for about 3 minutes in the form of generalized tonic-clonic seizure (GTS) and admitted to the neurological department and was intubated. Since, the patient was not aware, awake, did not obey, corneal reflexes test was positive and his pupils were isochoric and reactive therefore, the primary diagnosis was cerebrovascular accident (CVA). On the second day after admission, although the brain computed tomography (CT) did not show brain lesion, but chest X-ray (CXR) revealed lung involvement. In addition, on third day the RT-PCR test for coronavirus RNA in and the cerebrospinal fluid and nasopharyngeal swap done and the result was positive for both of them. Therefore, treatment for the covid-19 was started. Result(s): Since, the treatment for the covid-19 was started with Atazanavir, Clindamycin and ceftriaxone, ten days after hospitalization, the lung involvement and general condition of patient got better and after two weeks he was released from the hospital. Conclusion(s): GTS should be considered as a neurological outcome of COVID-19 and medications against the coronavirus, such as Atazanavir, Clindamycin and ceftriaxone can recover the neurological deficits in these patients.Copyright© 2020, TMU Press.

Clinical features and acute management in adults

COVID-19 is a multisystem disease that requires holistic management. Most patients will experience mild symptoms including cough, fever and mild dyspnoea. A small proportion of patients will have severe manifestations including respiratory failure, ARDS and multiorgan failure. Extrapulmonary features are common and include gastrointestinal, thromboembolic, neurological, cardiac, renal, endocrine and dermatological manifestations. The care of COVID-19 patients requires close attention to these features. This includes respiratory support (such as supplemental oxygen, NIV and awake proning);fluid, electrolyte and nutrition management;prevention, detection and treatment of thrombotic events;management of diabetic complications;review of medications;appropriate use of antibiotics;and evidence-based use of therapeutic agents such as corticosteroids, antivirals such as remdesivir and other emerging therapies such as immunomodulating agents. Early planning for treatment escalation and decision making around the appropriateness of cardiopulmonary resuscitation are crucial as deterioration can be rapid. Prolonged symptoms occur in a minority of patients and longitudinal follow-up is required.Copyright © ERS 2021.

Non-invasive ventilation in >= 70 year old COVID-19 patients in a level two unit: retrospective cohort analysis, comparison with COVIP substudy and defense of a multifaceted work of breathing control driven strategy

Introduction: The debate about optimal management of patients with COVID-19 ARDS remains, including medical treatment, ventilatory strategies, awake proning and others. COVIP is a multicentric observational study with over 3000 patients under NIV. A substudy by Polok and al. evaluated patients (PTS) >= 70 years old. At our intermediate care unit (IU) we used a strategy of high dose corticosteroid started when the work of breathing (WOB) increased, prolonged awake prone positioning (> 12 h) and high CPAP ventilatory strategy. We describe our cohort of >= 70 years old NIV PTS and compare it to COVIP substudy results. Method(s): Descriptive retrospective study. Data were collected from electronic medical records of 95 COVID-19 PTS aged 70 years old or above under NIV at the IU between September/20 and March/21. Categorical data are presented as frequency (percentage) and were compared using chi2-test. Continuous variables were compared using Mann-Whitney U test. Cohort results were compared with those from Polok et al. COVIP substudy (COVIPss). Result(s): 95 of PTS were submitted to NIV. Median age was 76 years and 49.5% were male, versus 75.7 and 71.4% in COVIPss. Median admission SOFA score was 4 and CFS was 3 with 14% considered frail (CFS > 5). In COVIPss median SOFA was 5 and 17% of PTS were frail. The preferred mode was CPAP with median maximum pressure of 13. Mean PaO2/fiO2 ratio after start of NIV was 125, 30% < 100. NIV failure occurred in 46.3% versus 74,7% in COVIPss. Our intra-unit mortality was 31.6%. 14 PTS (14.7%) were submitted to invasive mechanical ventilation and 57% of those died. In COVIPss mortality at 30d was 52.9% in NIV and 47.7 in IMV groups. Conclusion(s): We argue that NIV is a valid option for COVID ARDS management if supported by a multifaceted strategy such as ours, using prone and CPAP for WOB control. We agree with COVIPss authors as NIV trial should be short and intubation promptly if WOB not controlled. Comparison with COVIP substudy NIV failure and mortality results, support our belief.

Asymmetric Cerebral Perfusion in Comatose Extracorporeal Membrane Oxygenation Patients

Asymmetric cerebral perfusion can occur when extracorporeal membrane oxygenation (ECMO) flow competes with native cardiac circulation. It is unclear whether this phenomenon associates with brain injury. Diffuse correlation spectroscopy (DCS) provides continuous, laser-based, non-invasive, bedside monitoring of relative cerebral blood flow (rCBF). This study measured rCBF in ECMO patients via DCS to determine whether comatose patients experience asymmetric cerebral perfusion. Adults receiving ECMO for any indication were prospectively recruited from 12/2019-3/2021. Patients with prior neurologic injury, scalp/facial lacerations, and SARS-CoV-2 infection were excluded. DCS monitoring was performed daily during ECMO support with sensors placed on bilateral foreheads. Mean arterial pressure (MAP) was continuously recorded from the bedside monitor. The Glasgow Coma Scale (GCS) was assessed by clinical staff multiple times daily with sedation pauses, if possible, per standard of care. rCBF was calculated by comparing continuous cerebral blood flow (CBF) measurements to the daily median CBF, then averaged at each MAP value. Daily rCBF asymmetry was calculated by summing the absolute difference of rCBF between the two hemispheres at each MAP value, normalized for the total MAP range experienced by the patient that day. Twelve subjects were enrolled in this study (ages 21-78, 6 with cardiac arrest, 4 with acute heart failure, 2 with ARDS) and grouped by maximum GCS motor (GCS-M) score during ECMO, with 3 "comatose" subjects (GCS-M <= 4), and 9 "awake" subjects (GCS-M > 4). DCS was performed over 66 sessions with a mean duration of 131.83 +/- 1.13 minutes. Comatose subjects exhibited more rCBF asymmetry than awake subjects (0.28 +/- 0.06 mmHg-1 vs. 0.10 +/- 0.001 mmHg-1, p=0.045). No difference in asymmetry was noted between patients with or without cardiac arrest. We found that comatose ECMO subjects exhibited higher inter-hemispheric rCBF asymmetry over a range of blood pressures than awake subjects. Though our comatose sample is small, further validation of this finding and its causes, such as cerebrovascular dysregulation, is warranted.

The CRISIS Approach When Autonomy and Beneficence Are in Conflict (CS358)

Outcomes: 1. Utilizing CRISIS approach, participants can employ a unique strategy to holistically support patients with poor coping in an acute life-threatening situation. 2. Utilizing the CRISIS approach, participants will apply an ethical tool to mitigate the incongruence that sometimes happens between two ethical principles-autonomy versus beneficence. Autonomy is not always in harmony with beneficence. We present a patient with decisional capacity hospitalized with acute reversible neuromuscular paralysis who refused treatment despite expected recovery. Her decision created moral distress for the clinicians. An improvised palliative strategy resolved the above dilemma. Case presentation: 68-year-old female admitted with new-onset unsteady gait, diplopia, and speech impairment on waking up. She was healthy until 3 weeks before admission, when she developed upper extremity numbness progressing to both legs after a COVID-19 infection. She had bulbar and axial muscle weakness and right oculomotor nerve palsy with ptosis. Positive ice pack and pyridostigmine test indicated myasthenia gravis (MG). During hospitalization, she required mechanical ventilation secondary to acute respiratory failure from progressive paralysis. Serum-negative MG diagnosed, given the response to IVIG and pyridostigmine. The patient, amid acute crisis, refused therapies and wanted to transition to DNR-comfort care despite understanding the reversibility of her illness. Her family members supported comfort care option. Neurology was conflicted with the patient's choice because MG was treatable. Palliative care, ethics, and neuropsychology consulted to establish decision-making capacity, goals-of-care, and holistic support. Intervention(s): Palliative team utilized the CRISIS approach to address the impasse between the patient and the clinicians: 1. Continue care, collaborate with the teams 2. Respond empathetically 3. Integrate patient's autonomy 4. Support holistically 5. Improvise a care plan 6. Sustain quality of life We validated patient's autonomy. We recommended allowing time for the patient/family to process her illness. We continued holistic support and symptom management and created an improvised multidisciplinary plan to help her cope with the acute illness. The above approach enabled her to opt for therapies instead of comfort care only, and she gradually recovered. Respecting patients' autonomy and incorporating beneficence via our intervention led to positive outcomes. The CRISIS approach could help other clinicians in the situation when conflict arises between autonomy and beneficence.Copyright © 2023

COVID-19 and the autonomic nervous system

Background: COVID-19 infection has been shown to have an adverse impact on the cardiovascular system. Cardiac injury, as indicated by elevated cardiac troponin and NT-proBNP levels have been confirmed in COVID-19 cases. There is still ambivalent data on the effect of left ventricular function. Cases of left ventricular impairment, persistent hypotension, acute myopericarditis, myocarditis, arrhythmia and heart failure have been reported in the short term, but there is a significant lacuna when it comes to medium and long-term follow-up of subjects previously infected with COVID-19. Purpose(s): To assess any residual myocardial and autonomic injury in subjects previously infected with COVID-19 at a median follow-up of 5 months. Method(s): A case-control study was performed. Cases were randomly selected subjects who were previously diagnosed with COVID-19 infection following nasopharyngeal swabbing. Controls were subjects who had not been found to be infected with COVID-19 following swabbing and were negative for COVID-19 IgG antibodies. All participants were submitted a standardised questionnaire regarding past medical history. Blood investigations were taken including NT-proBNP and troponin I levels. In addition, all participants underwent 24-hour ambulatory blood pressure monitoring (ABPM) and 24-hour ECG monitoring. The latter was used to assess both for underlying arrhythmias as well as heart rate variability (HRV), a measure of autonomic regulation of the heart. All data was analysed using SPSS version 23.0. Result(s): The study comprised 259 subjects, whereby cases included 174 participants while 75 subjects were age- and gender-matched controls. The study cohort was relatively young with a mean age of 46.1+/-13.8 years. The median follow-up was of approximately 5 months (median 173.5 days, IQR 129-193.25 days). There was no statistically significant difference between cases and controls with regards cardiovascular risk factors and underlying medical conditions. Likewise, there was no difference in blood investigations, including troponin I and NT-proBNP levels at 5-months followup. No difference was noted between the two groups in both awake and asleep blood pressure (BP) readings, as well as dipping BP status. No significant arrhythmias were noted in both groups on 24-hour ECG monitoring. However, when assessing for heart rate variability, it was shown that subjects who had been previously infected with COVID-19 exhibited lower root-mean square differences of successive R-R intervals (RMSSD), p=0.028. This indicates poor vagus nerve-mediated autonomic control of the heart. Conclusion(s): Subjects previously infected with COVID-19 exhibited lower HRV as exhibited by low RMSSD as compared to controls. Reduced HRV is a known biomarker for mortality and sudden death in cardiac disease. The possible long-term implications of reduced HRV in subjects previously infected with COVID-19 merits further investigation.

Amount and distribution of parenchymal abnormalities at CT-scan do not predict awake prone position outcome in Covid-19

Background: Even if definitive evidence is still missing, prone position in non-intubated hypoxemic patients with Covid-19 is largely used. The aim of the present study was to investigate whether the amount and distribution of lung abnormalities evaluated by CT-scan can predict the improvement of oxygenation when Covid-19 patients undergoing non-invasive ventilation (NIV) are turned prone. Method(s): Retrospective monocentric study of severe Covid-19 patients who underwent NIV and prone position, evaluated with a basal chest CT-scan. Result(s): Forty-five severe Covid-19 patients were considered. On average 50% of the overall lung volume was involved by pneumonia at CT-scan, with ground glass, and consolidation accounting for 44, and 4%, respectively. The parenchymal abnormalities were predominantly posterior, as demonstrated by a posterior/anterior ratio of ground glass and consolidation of 1.5, and 4.4, respectively. PaO2/FiO2, whose basal value under NIV in supine position was 140 [IQR 108;169] improved on average by 67% (+98) during prone position. Once supine position was resumed, improvement in oxygenation was maintained in 28 patients (62% of the overall population, categorized as "responders"). We did not find significant difference between responders and non-responders in terms of the amount and distribution of parenchymal abnormalities. No correlation emerged between the distribution of parenchymal abnormalies and changes in oxygenation in supine position before and after prone position (R2 = 0.009, p= 0.526). Conclusion(s): the amount and distribution of lung abnormalities evaluated by CT-scan do not predict the response to awake prone position in patients with severe Covid-19 pneumonia undergoing non-invasive ventilation.

Persistent asthma-like symptoms in COVID-19 patients 3 and 12 months after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)infection

Background: Post-acute COVID-19 syndrome is recognised as a complex systematic disease. There is limited information on asthma-like symptoms following acute COVID-19. Objective(s): We estimated prevalence and persistence of asthma-like symptoms at 3 and 12 months after acute COVID-19 as compared to a control population. Method(s): Community-based COVID-19 patients from the first pandemic wave in Bergen, Norway, were included in a longitudinal clinical study. At 3- and 12-months, 158 and 89 patients, respectively, also participated in an additional sub-study, which was harmonised with clinical follow-up of the community-based RHINESSA population (control) with 235 participants. The European Community Respiratory Heath Survey structured questionnaire on general characteristics, asthma and respiratory symptoms, was administered to both groups. The prevalence of respiratory symptoms in acute COVID-19 patients at two time points post infection was estimated, using logistic regression adjusted for sex, age and smoking. Result(s): In the COVID-19 patients, symptoms in the last 3 days were more common after 12 than after 3 months: wheeze 11.2% vs 3.2%, waking up with shortness of breath (SOB) 5.6% vs 0.6%, and night cough 10.1% vs 3.2%. A year after the infection, COVID-19 cases reported more asthma-like symptoms than the control population: waking up with SOB (odds ratio [OR], 95% confidence interval [CI]: 2.50, 1.10-5.68);wheeze in the last 3 days (OR, 95%CI: 5.00, 1.10-22.8);and waking up with cough in the last 3 days (OR, 95%CI: 1.80, 0.60-5.37). Conclusion(s): Our findings indicated that asthma-like symptoms persisted one year after acute COVID-19.

Lung Transplantation in Patients with Irreversible Lung Injury Due to SARS-CoV-2: A Single-Center Experience

Background: Lung transplantation (LTx) has been demonstrated to be a feasible therapy in patients with irreversible lung injury due to SARS-CoV-2. Aim of this retrospective study was to present our experience with LTx in SARS-CoV-2 patients. Method(s): Records of the 136 patients who underwent LTx between January 2021 and August 2022 at our institution were retrospectively reviewed. LTx was performed in SARS-CoV-2 patients who showed radiological evidence of irreversible lung failure, after failed attempts of weaning off mechanical ventilation (MV) and ECMO;showed single-organ dysfunction;were SARS-CoV-2 negative, preferably <65 years old and awake under MV and ECMO support. Graft survival was compared between COVID-19 LTx patients and contemporary patients transplanted for other indications. Median follow-up amounted to 7.6 (5.2-14.5) months. Result(s): Among the 79 patients with SARS-CoV-2 lung failure referred for LTx, 9 (11%) patients were listed, 8 of them being transplanted between January 2021 and August 2022. One patient died while on the waiting list. All were on MV and ECMO support (awake in 6 cases) for a median ECMO support time of 75 (38.5-152.8) days. Four (50%) patients were male and median age was 52 (37-57) years. All patients underwent bilateral LTx on ECMO support that was weaned off in all patients at the end of Tx. After LTx, 2 (25%) patients showed a primary graft dysfunction (PGD) score grade 3 at 72 hours and required reinstitution of veno-venous (n = 1) and veno-arterial (n = 1) ECMO support that was successfully weaned after 7 and 6 days, respectively. One patient (12.5%) required rethoracotomy for bleeding, and two (25%) patients required new hemodialysis treatment, with recovery of renal function in all patients. Median MV time amounted to 8 days (1-30), median intensive care unit stay to 19 (13-26) days, and median hospital stay to 91 (62-103) days. No patient died in-hospital. At 1-year follow-up, graft survival was 100% in SARS-CoV-2 LTx patients and 95% for patients (n = 128) transplanted for other indications (p = 0.539). Conclusion(s): Lung transplantation in highly selected SARS-CoV-2 patients yielded excellent posttransplant results. Graft survival was comparable between patients transplanted for SARS-COV-2 pneumonia and patients transplanted for other indications. A multidisciplinary approach is of paramount importance to successfully bridge these patients to transplantation and to guarantee a complete patient functional recovery after transplantation.

Differences in the diurnal variation of salivary stress biomarkers during the coronavirus (COVID-19) pandemic between telecommuters and office workers

OBJECTIVES: It is necessary to objectively assess the stress state of workers, from the standpoint of holistic palliative care, in order to determine how the rapid change in work styles in the "live with coronavirus era"-in which people will coexist and live with the coronavirus (COVID-19)-will affect their physical and mental health. The aim of this study is to assess the impact of rapid changes in work patterns during the COVID-19 pandemic on the neuroendocrine stress response of workers. DESIGN AND METHODS: A total of sixteen subjects, 9 telecommuters (2 males, 7 females;age, 37.1+/-2.6 years) and 7 office workers (3 males, 4 females;age, 37.3+/-3.0 years) who provided their informed consent were enrolled in this prospective observational study. Saliva was collected four times a day (after waking, noon, evening, and before bedtime) and three times a week (Monday, Wednesday, and Friday) during May and June 2020. The saliva samples were stored at -20degreeC until measurement. Saliva components were analyzed by ELISA for cortisol, melatonin, s-IgA, and oxytocin. RESULT(S): The diurnal variation of salivary components between telecommuting and office work groups was investigated. Cortisol showed diurnal variation with higher secretion during waking hours and lower secretion toward nighttime in both groups, and no modulation was observed. In the office work group Melatonin showed diurnal variation, with increased secretion at night. In contrast, the telecommuting group showed modulation, with higher secretion at waking and lower secretion at night. s-IgA showed diurnal variation with a high level at waking and a low level thereafter in both groups, and no modulation was observed. The telecommuting group showed higher oxytocin levels in comparison to the office work group. CONCLUSION(S): These results suggest that the absence of commuting in the telecommuting group reduces anxiety due to infection, and that the diurnal variation of melatonin may be due to the alteration of circadian rhythm caused by being at home all day.

Distribution of sequelae in post-covid patients according to previous need of respiratory support

Introduction: "Long COVID" is defined by the persistence of symptoms after 4-12 weeks from COVID-19 disease. Data comparing different clinical phenotypes according to COVID-19 severity are still scanty. Aims and objectives: We aimed to identify different clinical phenotypes of post-COVID syndrome according to the level of respiratory support used. Method(s): We enrolled 309 patients who previously suffered from COVID-19 disease. All patients performed routine blood tests, arterial blood gas analysis, 6 minute walking test and body plethysmography. Then, we assigned each patient to a "severity group" according to the respiratory support needed during COVID-19 disease. Severity group 0: no respiratory support needed Severity group 1: oxygen only Severity group 2: positive airway pressure (CPAP or NIV) Severity group 3: Invasive Mechanical Ventilation (IMV) Results: Patients belonging to Group 0 experienced less fatigue (p=0.004) and mood disorders (p=0.007) compared to the other groups. Group 0 and 3 reported less frequently insomnia (p<0.0001). Hospitalized patients developed sleep and mood disorders during hospitalization due to several factors (fear, acoustic/visual triggers ect.). Patients who underwent IMV, instead, were completely sedated for the entire course of the acute phase of the disease, not being exposed to these triggers. Among blood markers, only Galectin-3 (p=0.004) and IL6 (p=0.004) had significant lower serum concentrations in patients belonging to Group 0, confirming their lower inflammatory status Conclusion(s): Awake hospitalization seems to deeply affect post-COVID sequelae in several patients.

Comparing the effect of strict versus routine awake prone positioning among patients hospitalized with COVID-19

Background: In patients with moderate to severe coronavirus disease 2019 (COVID-19), awake prone positioning improves oxygenation and clinical outcome. Despite prone positioning incorporated in the protocol, it's not followed in true letter and spirit. Aims and objectives: The objective of this study was to compare the effect of strict versus routine awake proning among patients hospitalized with Covid-19. Method(s): PCR positive COVID-19 patients admitted to the Khyber Teaching Hospital Peshawar's isolation unit were randomly allocated to 2 groups, Group A prone positioning (PP) was ensured for at least 12 hours by helping proning during rounds by the respiratory therapists and nurses. Further, prone positioning was ensured by the use of telemedicine, whereas Group B just followed the standard care in which awake proning was emphasized on a routine basis without doing any intervention. Their biochemical and clinical parameters, outcomes related to oxygen requirement, intubation, and mortality were followed weekly for two weeks or till discharge. Result(s): Out of the 58 patients, 29 patients with PP had a better outcome in terms of oxygenation (p<0.01), respiratory rate (P<0.05), and inflammatory markers such as serum ferritin (p<0.02) and C reactive protein (p<0.03). Additionally, ventilatory support (18% VS 42%, p<0.05) and mortality rate 21.4% Vs 64.3%) were significantly lower in the PP group. Conclusion(s): Strict compliance of awake prone positioning improved oxygenation in COVID-19 patients, resulting in a clinically better outcome.

ERS International Congress 2022 Abstracts

The proceedings contain 3270 papers. The topics discussed include: the impact of age and gender on mortality from COVID-19 at A UK hospital;vaccinated COVID-19 patients admitted in a Tunisian ICU: clinical features and outcome;pneumothorax - a life-threatening complication in patients with cystic fibrosis;impact of combined non-invasive support strategies use during acute respiratory failure due to COVID-19;early mobilization of mechanically ventilated patients in the intensive care units: results of a Saudi-wide national survey;awake prone positioning in acute hypoxemic respiratory failure from COVID-19: a randomized clinical trial;amount and distribution of parenchymal abnormalities at CT-scan do not predict awake prone position outcome in COVID-19;impact of dexamethasone on pathogen profile of COVID-19 patients requiring intensive care: a multicenter retrospective study;higher crystalloids volumes predict adverse outcomes in emergency department patients with blunt thoracic trauma;and STUMBL score for emergency department safe discharge of patients with minor blunt thoracic trauma.

Awake Prone Positioning for COVID-19 Hypoxemic Respiratory Failure: A Systematic Review and MetaAnalysis of Randomized Trials

Background and Rationale: The benefits of awake prone positioning (APP) in patients with hypoxemic respiratory failure due to Coronavirus disease 2019 (COVID-19) remain uncertain. This systematic review and meta-analysis aimed to determine the efficacy and safety of APP versus usual care in non-intubated adults with COVID-19 hypoxemic respiratory failure. Method(s): We searched MEDLINE, Embase and CENTRAL for randomized trials on APP for hypoxemic respiratory failure. The primary outcome was endotracheal intubation. Secondary outcomes were mortality, ventilator-free days, intensive care unit and hospital length of stay, escalation of oxygen modality, change in oxygenation and respiratory rate, and adverse events. Random-effects meta-analysis was performed for the primary and secondary outcomes. Bayesian meta-analysis was performed for endotracheal intubation and mortality outcomes. Result(s): Seventeen trials (2931 patients) met eligibility criteria. APP, versus usual care, reduced the risk of intubation (24.2% vs 29.8%, relative risk [RR] 0.83, 95% Confidence Interval [CI] 0.73-0.94;I =0%, high certainty). APP did not significantly affect mortality or other secondary outcomes. Bayesian meta-analysis using non-informative priors found a high probability of benefit with APP for intubation (mean RR of 0.84, 95% Credible Interval [CrI] 0.72 to 0.97;posterior probability for RR <1 of 0.99) but not for mortality (mean RR of 0.94, 95% CrI 0.78 to 1.14: posterior probability for RR <1 of 0.75). Conclusion(s): APP reduces the risk of intubation versus usual care in patients with COVID-19 but did not improve mortality or other secondary outcomes.

Anesthetic management of toxic epidermal necrolysis: a report of two cases

Toxic epidermal necrolysis (TEN), is an acute, life-threatening emergent disease involving the skin and mucous membranes with serious systemic complications. It is characterized by widespread epidermal sloughing. Drugs are the most common triggers of TEN, but infection, vaccination, radiation therapy and malignant neoplasms can all induce it in susceptible patients. We report two cases in whom a hair dye and a COVID-19 vaccine (BioNTech, Pfizer) were believed to be the causative agents. These patients have to undergo repeated debridements of the necrotic tissue. In this manuscript the anesthetic management of TEN patients is discussed. Detailed preoperative evaluation, aggressive fluid and electrolyte replacement, avoidance of hypothermia during debridement, minimizing anesthetic agents and limiting traumatic procedures are key points in the management.Copyright © 2023 Faculty of Anaesthesia, Pain and Intensive Care, AFMS. All rights reserved.

Awake Prone Positioning in Acute Hypoxemic Respiratory Failure from COVID-19: A Randomized Clinical Trial

Background: The efficacy and safety of awake prone positioning (APP) in hypoxemic patients with coronavirus disease 2019 (COVID-19) is unclear. Aim(s): To evaluate the efficacy and safety of APP in non-intubated adults with COVID-19. Method(s): We performed a pragmatic, international, randomized trial at 21 centers in Canada, Saudi Arabia, Kuwait, and the United States between May 19, 2020, and May 18, 2021. Eligible patients were hospitalized adults with COVID-19 requiring >40% oxygen. Patients were randomized to APP (n=205) or usual care (n=195). The primary outcome was intubation by day 30. Secondary outcomes included mortality at 60 days, ventilation-free days at 30 days, intensive care unit (ICU) and hospital-free days at 60 days, adverse events, and serious adverse events. Result(s): Patients in the APP group proned for a median of 4.8 hours per day (IQR 1.8 to 8.0) in the first 4 days. By day 30, 70/205 patients (34.1%) in the APP group and 79/195 (40.5%) in the control group were intubated (hazard ratio [HR] 0.81;95% confidence interval [CI] 0.59 to 1.12). APP did not reduce mortality at 60 days (HR 0.93;95% CI 0.62 to 1.40) and had no effect on days alive invasively or noninvasively ventilated at 30 days, or days out of ICU or hospital at 60 days. There were no serious adverse events in either group. A prespecified subgroup analysis suggested that APP reduced intubation among patients with SpO2:FiO2 >150 (HR of 0.44, 95% CI 0.23 to 0.87) but not among patients with SpO2:FiO2 <150 (HR 1.02;95% CI 0.70 to 1.48;P-interaction= 0.03). Conclusion(s): APP did not significantly reduce intubation at 30 days or mortality at 60 days overall, but may be effective in patients with SpO2:FiO2 >150.