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2.
J Med Virol ; 93(9): 5458-5473, 2021 Sep.
Article in English | MEDLINE | ID: covidwho-1272201

ABSTRACT

Kawasaki-like disease (KLD) and multisystem inflammatory syndrome in children (MIS-C) are considered as challenges for pediatric patients under the age of 18 infected with coronavirus disease 2019 (COVID-19). A systematic search was performed on July 2, 2020, and updated on December 1, 2020, to identify studies on KLD/MIS-C associated with COVID-19. The databases of Scopus, PubMed, Web of Science, Embase, and Scholar were searched. The hospitalized children with a presentation of Kawasaki disease (KD), KLD, MIS-C, or inflammatory shock syndromes were included. A total number of 133 children in 45 studies were reviewed. A total of 74 (55.6%) cases had been admitted to pediatric intensive care units (PICUs). Also, 49 (36.8%) patients had required respiratory support, of whom 31 (23.3%) cases had required mechanical ventilation/intubation, 18 (13.5%) cases had required other oxygen therapies. In total, 79 (59.4%) cases had been discharged from hospitals, 3 (2.2%) had been readmitted, 9 (6.7%) had been hospitalized at the time of the study, and 9 (6.7%) patients had expired due to the severe heart failure, shock, brain infarction. Similar outcomes had not been reported in other patients. Approximately two-thirds of the children with KLD associated with COVID-19 had been admitted to PICUs, around one-fourth of them had required mechanical ventilation/intubation, and even some of them had been required readmissions. Therefore, physicians are strongly recommended to monitor children that present with the characteristics of KD during the pandemic as they can be the dominant manifestations in children with COVID-19.


Subject(s)
Brain Infarction/complications , COVID-19/complications , Heart Failure/complications , Mucocutaneous Lymph Node Syndrome/complications , SARS-CoV-2/pathogenicity , Shock/complications , Systemic Inflammatory Response Syndrome/complications , Adolescent , Brain Infarction/diagnostic imaging , Brain Infarction/mortality , Brain Infarction/virology , COVID-19/diagnostic imaging , COVID-19/mortality , COVID-19/virology , Child , Child, Preschool , Female , Heart Failure/diagnostic imaging , Heart Failure/mortality , Heart Failure/virology , Humans , Infant , Infant, Newborn , Intensive Care Units, Pediatric , Male , Mucocutaneous Lymph Node Syndrome/diagnostic imaging , Mucocutaneous Lymph Node Syndrome/mortality , Mucocutaneous Lymph Node Syndrome/virology , Patient Readmission/statistics & numerical data , Respiration, Artificial , SARS-CoV-2/physiology , Shock/diagnostic imaging , Shock/mortality , Shock/virology , Survival Analysis , Systemic Inflammatory Response Syndrome/diagnostic imaging , Systemic Inflammatory Response Syndrome/mortality , Systemic Inflammatory Response Syndrome/virology
3.
Ann Intern Med ; 174(5): 613-621, 2021 05.
Article in English | MEDLINE | ID: covidwho-1239133

ABSTRACT

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic continues to surge in the United States and globally. OBJECTIVE: To describe the epidemiology of COVID-19-related critical illness, including trends in outcomes and care delivery. DESIGN: Single-health system, multihospital retrospective cohort study. SETTING: 5 hospitals within the University of Pennsylvania Health System. PATIENTS: Adults with COVID-19-related critical illness who were admitted to an intensive care unit (ICU) with acute respiratory failure or shock during the initial surge of the pandemic. MEASUREMENTS: The primary exposure for outcomes and care delivery trend analyses was longitudinal time during the pandemic. The primary outcome was all-cause 28-day in-hospital mortality. Secondary outcomes were all-cause death at any time, receipt of mechanical ventilation (MV), and readmissions. RESULTS: Among 468 patients with COVID-19-related critical illness, 319 (68.2%) were treated with MV and 121 (25.9%) with vasopressors. Outcomes were notable for an all-cause 28-day in-hospital mortality rate of 29.9%, a median ICU stay of 8 days (interquartile range [IQR], 3 to 17 days), a median hospital stay of 13 days (IQR, 7 to 25 days), and an all-cause 30-day readmission rate (among nonhospice survivors) of 10.8%. Mortality decreased over time, from 43.5% (95% CI, 31.3% to 53.8%) to 19.2% (CI, 11.6% to 26.7%) between the first and last 15-day periods in the core adjusted model, whereas patient acuity and other factors did not change. LIMITATIONS: Single-health system study; use of, or highly dynamic trends in, other clinical interventions were not evaluated, nor were complications. CONCLUSION: Among patients with COVID-19-related critical illness admitted to ICUs of a learning health system in the United States, mortality seemed to decrease over time despite stable patient characteristics. Further studies are necessary to confirm this result and to investigate causal mechanisms. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.


Subject(s)
COVID-19/mortality , COVID-19/therapy , Critical Illness/mortality , Critical Illness/therapy , Pneumonia, Viral/mortality , Pneumonia, Viral/therapy , Shock/mortality , Shock/therapy , APACHE , Academic Medical Centers , Aged , Female , Hospital Mortality , Humans , Intensive Care Units , Length of Stay/statistics & numerical data , Male , Middle Aged , Pandemics , Patient Readmission/statistics & numerical data , Pennsylvania/epidemiology , Pneumonia, Viral/virology , Respiration, Artificial/statistics & numerical data , Retrospective Studies , SARS-CoV-2 , Shock/virology , Survival Rate
4.
Crit Pathw Cardiol ; 20(2): 100-102, 2021 06 01.
Article in English | MEDLINE | ID: covidwho-1234149

ABSTRACT

PURPOSE: To understand the hemodynamic effect of angiotensin II as a vasopressor in patients with shock secondary to COVID-19 infection. METHODS: A retrospective analysis was performed on all patients at a single center with COVID-19 infection and shock who were treated with angiotensin II. The hemodynamic response to angiotensin II was estimated by recording the mean arterial pressure, norepinephrine equivalent dose (NED) and urine output. RESULTS: Ten patients with COVID-19 related shock were treated with angiotensin II. Over the initial 6 hours, the average the NED decreased by 30.4% (from 64.6 to 44 µg/min) without a significant change in the mean arterial pressure (0.7% decrease). Six patients experienced at least a 25% reduction in NED by 6 hours, and 2 experienced at least a 50% reduction. CONCLUSIONS: On average, the hemodynamic response to angiotensin II in COVID-19 related shock was favorable. Two patients had a marked rapid improvement. Given the relationship of SARS-CoV-2 with the renin-angiotensin-aldosterone system, further evaluation of angiotensin II for the treatment of COVID-19 related shock is warranted.


Subject(s)
Angiotensin II/therapeutic use , COVID-19/complications , Shock/drug therapy , Vasoconstrictor Agents/therapeutic use , Aged , Arterial Pressure , COVID-19/physiopathology , COVID-19/therapy , Female , Humans , Male , Middle Aged , Retrospective Studies , Shock/physiopathology , Shock/virology
5.
J Trauma Acute Care Surg ; 90(5): 880-890, 2021 05 01.
Article in English | MEDLINE | ID: covidwho-1199599

ABSTRACT

BACKGROUND: We sought to describe characteristics, multisystem outcomes, and predictors of mortality of the critically ill COVID-19 patients in the largest hospital in Massachusetts. METHODS: This is a prospective cohort study. All patients admitted to the intensive care unit (ICU) with reverse-transcriptase-polymerase chain reaction-confirmed severe acute respiratory syndrome coronavirus 2 infection between March 14, 2020, and April 28, 2020, were included; hospital and multisystem outcomes were evaluated. Data were collected from electronic records. Acute respiratory distress syndrome (ARDS) was defined as PaO2/FiO2 ratio of ≤300 during admission and bilateral radiographic pulmonary opacities. Multivariable logistic regression analyses adjusting for available confounders were performed to identify predictors of mortality. RESULTS: A total of 235 patients were included. The median (interquartile range [IQR]) Sequential Organ Failure Assessment score was 5 (3-8), and the median (IQR) PaO2/FiO2 was 208 (146-300) with 86.4% of patients meeting criteria for ARDS. The median (IQR) follow-up was 92 (86-99) days, and the median ICU length of stay was 16 (8-25) days; 62.1% of patients were proned, 49.8% required neuromuscular blockade, and 3.4% required extracorporeal membrane oxygenation. The most common complications were shock (88.9%), acute kidney injury (AKI) (69.8%), secondary bacterial pneumonia (70.6%), and pressure ulcers (51.1%). As of July 8, 2020, 175 patients (74.5%) were discharged alive (61.7% to skilled nursing or rehabilitation facility), 58 (24.7%) died in the hospital, and only 2 patients were still hospitalized, but out of the ICU. Age (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.04-1.12), higher median Sequential Organ Failure Assessment score at ICU admission (OR, 1.24; 95% CI, 1.06-1.43), elevated creatine kinase of ≥1,000 U/L at hospital admission (OR, 6.64; 95% CI, 1.51-29.17), and severe ARDS (OR, 5.24; 95% CI, 1.18-23.29) independently predicted hospital mortality.Comorbidities, steroids, and hydroxychloroquine treatment did not predict mortality. CONCLUSION: We present here the outcomes of critically ill patients with COVID-19. Age, acuity of disease, and severe ARDS predicted mortality rather than comorbidities. LEVEL OF EVIDENCE: Prognostic, level III.


Subject(s)
COVID-19/complications , COVID-19/mortality , Hospital Mortality , Patient Acuity , Acute Kidney Injury/virology , Adult , Age Factors , Aged , Aged, 80 and over , Antimalarials/therapeutic use , Boston/epidemiology , COVID-19/physiopathology , COVID-19/therapy , Comorbidity , Creatine Kinase/blood , Critical Care , Critical Illness , Extracorporeal Membrane Oxygenation , Female , Gastrointestinal Diseases/virology , Humans , Hydroxychloroquine/therapeutic use , Length of Stay , Male , Middle Aged , Neuromuscular Blockade , Organ Dysfunction Scores , Pneumonia, Bacterial/virology , Pressure Ulcer/etiology , Prone Position , Prospective Studies , Respiratory Distress Syndrome/physiopathology , Respiratory Distress Syndrome/virology , Risk Factors , SARS-CoV-2 , Shock/virology , Steroids/therapeutic use , Survival Rate , Thromboembolism/virology , Treatment Outcome
6.
J Intensive Care Med ; 36(4): 392-403, 2021 Apr.
Article in English | MEDLINE | ID: covidwho-910321

ABSTRACT

BACKGROUND: Multisystem inflammatory syndrome associated with SARS-CoV-2 infection can lead to myocardial injury and shock in children, likely the result of a severe inflammatory state, and can mimic Kawasaki disease. OBJECTIVE: To describe the characteristics of shock and myocardial injury in children with confirmed or suspeted COVID-19 during the SARS-CoV-2 pandemic in Spain, including clinical presentation, laboratory and imaging findings, treatment, disease course, and outcome. An extensive literature review is provided. METHODS: Retrospective case series including all children (age 1 month-18 years) admitted to a pediatric intensive care unit in Madrid, Spain, between March 15 and April 30, 2020 with suspected or confirmed SARS-CoV-2 infection and shock. RESULTS: Twelve previously healthy patients with shock, age 5 to 14 years, were included. All required volume resuscitation and 75% required vasoactive/inotropic support. Distributive shock was present on admission in 67% (n = 8), and 4 patients (33%) showed features of cardiogenic shock. Myocardial injury was diagnosed in 67% (n = 8) and ventricular dysfunction in 33% (n = 4). The most common symptoms on presentation were fever (100%), anorexia (100%), diarrhea (75%), and vomiting (75%). Five patients showed signs of Kawasaki disease but none met the criteria for the classic form. Laboratory findings revealed lymphopenia (83%), thrombocytopenia (83%), and increased inflammatory markers (100%). Respiratory status was not significantly impacted. Chest X-ray showed bilateral alveolar infiltrates in 7 (58%) and bilateral pneumonia in 3 (25%). COVID-19 was confirmed in 11 cases (92%). All received empirical therapy against COVID-19, thromboprophylaxis and immunomodulation. Median stay in the PICU and inpatient ward was 4.5 and 10 days, respectively. No patients died. CONCLUSION: Multisystem inflammatory syndrome in children with COVID-19 can mimic Kawasaki disease and lead to a combination of distributive and cardiogenic shock, probably secondary to a hyperinflammatory state that remains to be precisely defined. Treatment strategies include hemodynamic support, empirical therapies against COVID-19, thromboprophylaxis, and immunomodulation.


Subject(s)
COVID-19/complications , Heart Injuries/virology , SARS-CoV-2 , Shock/virology , Systemic Inflammatory Response Syndrome/complications , Adolescent , Child , Child, Preschool , Female , Humans , Infant , Infant, Newborn , Intensive Care Units, Pediatric , Male , Mucocutaneous Lymph Node Syndrome/virology , Retrospective Studies , Spain , Ventricular Dysfunction/virology
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