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1.
Crit Care Explor ; 2(6): e0139, 2020 Jun.
Article in English | MEDLINE | ID: covidwho-1795099

ABSTRACT

OBJECTIVES: The severe acute respiratory syndrome coronavirus 2 pandemic has stretched ICU resources in an unprecedented fashion and outstripped personal protective equipment supplies. The combination of a novel disease, resource limitations, and risks to medical personnel health have created new barriers to implementing the ICU Liberation ("A" for Assessment, Prevention, and Manage pain; "B" for Both Spontaneous Awakening Trials and Spontaneous Breathing Trials; "C" for Choice of Analgesia and Sedation; "D" for Delirium Assess, Prevent, and Manage; "E" for Early Mobility and Exercise; and "F" for Family Engagement and Empowerment [ABCDEF]) Bundle, a proven ICU care approach that reduces delirium, shortens mechanical ventilation duration, prevents post-ICU syndrome, and reduces healthcare costs. This narrative review acknowledges barriers and offers strategies to optimize Bundle performance in coronavirus disease 2019 patients requiring mechanical ventilation. DATA SOURCES STUDY SELECTION AND DATA EXTRACTION: The most relevant literature, media reports, and author experiences were assessed for inclusion in this narrative review including PubMed, national newspapers, and critical care/pharmacology textbooks. DATA SYNTHESIS: Uncertainty regarding coronavirus disease 2019 clinical course, shifts in attitude, and changes in routine behavior have hindered Bundle use. A domino effect results from: 1) changes to critical care hierarchy, priorities, and ICU team composition; 2) significant personal protective equipment shortages cause; 3) reduced/restricted physical bedside presence favoring; 4) increased depth of sedation and use of neuromuscular blockade; 5) which exacerbate drug shortages; and 6) which require prolonged use of limited ventilator resources. Other identified barriers include manageable knowledge deficits among non-ICU clinicians unfamiliar with the Bundle or among PICU specialists deploying pediatric-based Bundle approaches who are unfamiliar with adult medicine. Both groups have been enlisted to augment the adult ICU work force to meet demand. Strategies were identified to facilitate Bundle performance to liberate patients from the ICU. CONCLUSIONS: We acknowledge current challenges that interfere with comprehensive management of critically ill patients during the coronavirus disease 2019 pandemic. Rapid response to new circumstances precisely requires established safety mechanisms and protocols like the ABCDEF Bundle to increase ICU and ventilator capacity and help survivors maximize recovery from coronavirus disease 2019 as early as possible.

2.
Cureus ; 13(4): e14663, 2021 Apr 24.
Article in English | MEDLINE | ID: covidwho-1236944

ABSTRACT

The novel coronavirus disease 2019 (COVID-19) has placed a burden on critical care facilities worldwide. Patients who remain critically unwell with COVID-19 require prolonged periods of ventilation, and the burden of both the resources during a pandemic and the slow respiratory wean must be managed. Percutaneous tracheostomies are commonplace in long-term intensive care patients, yet little is known about their role in COVID-19, particularly how operator safety is maintained during the procedure. Here, we describe an approach designed to minimize cross-infection of the operators undertaking percutaneous tracheostomies within this subset of patients. Focus should be on non-technical skills, prolonged periods of pre-oxygenation, and minimal ventilation during the procedure to minimize the risk of aerosolization generated from an open breathing system. Our modified technique demonstrates successful early experiences with no operators testing positive for COVID-19 or developing symptoms following any performed procedure.

3.
BMJ Open ; 11(5): e048124, 2021 05 18.
Article in English | MEDLINE | ID: covidwho-1234303

ABSTRACT

OBJECTIVE: To understand National Health Service (NHS) staff experiences of working in critical care during the first wave of the COVID-19 pandemic in the UK. DESIGN: Qualitative study using semistructured telephone interviews and rapid analysis, interpreted using Baehr's sociological lens of 'communities of fate'. PARTICIPANTS: Forty NHS staff working in critical care, including 21 nurses, 10 doctors and advanced critical care practitioners, 4 allied health professionals, 3 operating department practitioners and 2 ward clerks. Participants were interviewed between August and October 2020; we purposefully sought the experiences of trained and experienced critical care staff and those who were redeployed. SETTING: Four hospitals in the UK. RESULTS: COVID-19 presented staff with a situation of extreme stress, duress and social emergency, leading to a shared set of experiences which we have characterised as a community of fate. This involved not only fear and dread of working in critical care, but also a collective sense of duty and vocation. Caring for patients and families involved changes to usual ways of working, revolving around: reorganisation of space and personnel, personal protective equipment, lack of evidence for treating COVID-19, inability for families to be physically present, and the trauma of witnessing extreme patient acuity and death on a large scale. The stress and isolation of working in critical care during COVID-19 was mitigated by strong teamwork, camaraderie, pride and fulfilment. CONCLUSION: COVID-19 has changed working practices in critical care and profoundly affected staff physically, mentally and emotionally. Attention needs to be paid to the social and organisational conditions in which individuals work, addressing both practical resourcing and the interpersonal dynamics of critical care provision.


Subject(s)
COVID-19 , Critical Care , Humans , Pandemics , Qualitative Research , SARS-CoV-2 , State Medicine , United Kingdom
4.
J Rehabil Med Clin Commun ; 3: 1000044, 2020.
Article in English | MEDLINE | ID: covidwho-1197496

ABSTRACT

Platypnea-orthodeoxia syndrome, characterized by dyspnoea and arterial desaturation while upright, is a rare complication of acute respiratory distress syndrome. We report here 2 patients with COVID-19 pneumonia, who were diagnosed with platypnea-orthodeoxia syndrome during commencement of rehabilitation, 18 and 9 days respectively after admission to the intensive care unit. Both patients presented with normocapnic hypoxaemia. One patient required mechanical ventilation with supplemental oxygen during intensive care, while the other required high-flow nasal oxygen therapy. The manifestations of platypnea-orthodeoxia syndrome were most prominent during physiotherapy, when verticalization was attempted, and hindered further mobilization out of bed, including ambulation. This report describes the clinical manifestations of platypnea-orthodeoxia syndrome and the rehabilitative strategies carried out for these 2 patients. The platypnea-orthodeoxia syndrome in these patients resolved after 65 and 22 days respectively from the day of detection. This report highlights this potentially under-recognized phenomenon, which may be unmasked during rehabilitation of patients with COVID-19 pneumonia. Good functional outcomes were achieved with a combination of verticalization training with supplemental oxygen support, respiratory techniques training and progressive endurance and resistance training, whilst awaiting resolution of the platypneaorthodeoxia syndrome.

5.
Can J Infect Dis Med Microbiol ; 2021: 6656092, 2021.
Article in English | MEDLINE | ID: covidwho-1189959

ABSTRACT

BACKGROUND: Timely detection of the progression of the highly contagious coronavirus disease (COVID-19) is of utmost importance for management and intervention for patients in intensive care (ICU). AIM: This study aims to better understand this new infection and report the changes in the various laboratory tests identified in critically ill patients and associated with poor prognosis among COVID-19 patients admitted to the ICU. METHODS: This was a retrospective study that included 160 confirmed SARS-CoV-2-positive patients. RESULTS: Elevated serum ferritin, D-dimer, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and nonconjugated bilirubin levels were present in 139 (96%), 131 (96%), 107 (68%), 52 (34%), and 89 (70%) patients, respectively. Renal parameters were abnormal in a significant number of cases with elevated creatinine and blood urea nitrogen in 93 (62%) and 102 (68%) cases, respectively. Hematological profiles revealed lower red blood cell count, hemoglobin, eosinophils, basophils, monocytes, and lymphocytes in 90 (57%), 103 (65%), 89 (62%), 105 (73%), 35 (24%), and 119 (83%) cases, respectively. The neutrophil count was found to increase in 71.3% of the cases. There was significantly higher mortality (83%) among patients older than 60 years (p=0.001) and in female patients (75%) (p=0.012). Patients with lung diseases had a poor outcome compared to patients with other comorbidities (p=0.002). There was a significant association between elevated D-dimer levels and increased mortality (p=0.003). Elevated levels of AST, creatinine, blood urea nitrogen, and bilirubin were significantly associated with unfavorable outcomes. CONCLUSION: Different parameters can be used to predict disease prognosis, especially the risk of poor prognosis. Accurate diagnosis and monitoring of disease progression from the early stages will help in reducing mortality and unfavorable outcomes.

6.
Lancet Respir Med ; 9(4): 360-372, 2021 04.
Article in English | MEDLINE | ID: covidwho-1045088

ABSTRACT

BACKGROUND: Mechanical ventilation in intensive care for 48 h or longer is associated with the acute respiratory distress syndrome (ARDS), which might be present at the time ventilatory support is instituted or develop afterwards, predominantly during the first 5 days. Survivors of prolonged mechanical ventilation and ARDS are at risk of considerably impaired physical function that can persist for years. An early pathogenic mechanism of lung injury in mechanically ventilated, critically ill patients is inflammation-induced pulmonary fibrin deposition, leading to thrombosis of the microvasculature and hyaline membrane formation in the air sacs. The main aim of this study was to determine if nebulised heparin, which targets fibrin deposition, would limit lung injury and thereby accelerate recovery of physical function in patients with or at risk of ARDS. METHODS: The Can Heparin Administration Reduce Lung Injury (CHARLI) study was an investigator-initiated, multicentre, double-blind, randomised phase 3 trial across nine hospitals in Australia. Adult intensive care patients on invasive ventilation, with impaired oxygenation defined by a PaO2/FiO2 ratio of less than 300, and with the expectation of invasive ventilation beyond the next calendar day were recruited. Key exclusion criteria were heparin allergy, pulmonary bleeding, and platelet count less than 50 X 109/L. Patients were randomly assigned 1:1, with stratification by site and using blocks of variable size and random seed, via a web-based system, to either unfractionated heparin sodium 25 000 IU in 5 mL or identical placebo (sodium chloride 0·9% 5 mL), administered using a vibrating mesh membrane nebuliser every 6 h to day 10 while invasively ventilated. Patients, clinicians, and investigators were masked to treatment allocation. The primary outcome was the Short Form 36 Health Survey Physical Function Score (out of 100) of survivors at day 60. Prespecified secondary outcomes, which are exploratory, included development of ARDS to day 5 among at-risk patients, deterioration of the Murray Lung Injury Score (MLIS) to day 5, mortality at day 60, residence of survivors at day 60, and serious adverse events. Analyses followed the intention-to-treat principle. There was no imputation of missing data. The trial is registered with the Australian and New Zealand Clinical Trials Register, number ACTRN12612000418875 . FINDINGS: Between Sept 4, 2012, and Aug 23, 2018, 256 patients were randomised. Final follow-up was on Feb 25, 2019. We excluded three patients who revoked consent and one ineligible participant who received no intervention. Of 252 patients included in data analysis, the mean age was 58 years (SD 15), 157 (62%) were men, and 118 (47%) had ARDS. 128 (51%) patients were assigned to the heparin group and 124 (49%) to the placebo group, all of whom received their assigned intervention. Survivors in the heparin group (n=97) had similar SF-36 Physical Function Scores at day 60 compared to the placebo group (n=94; mean 53·6 [SD 31·6] vs 48·7 [35·7]; difference 4·9 [95% CI -4·8 to 14·5]; p=0·32). Compared with the placebo group, the heparin group had fewer cases of ARDS develop to day 5 among the at-risk patients (nine [15%] of 62 patients vs 21 [30%] of 71 patients; hazard ratio 0·46 [95% CI 0·22 to 0·98]; p=0·0431), less deterioration of the MLIS to day 5 (difference -0·14 [-0·26 to -0·02]; p=0·0215), similar day 60 mortality (23 [18%] of 127 patients vs 18 [15%] of 123 patients; odds ratio [OR] 1·29 [95% CI 0·66 to 2·53]; p=0·46), and more day 60 survivors at home (86 [87%] of 99 patients vs 73 [73%] of 100 patients; OR 2·45 [1·18 to 5·08]; p=0·0165). A similar number of serious adverse events occurred in each group (seven [5%] of 128 patients in the heparin group vs three [2%] of 124 patients in the placebo group; OR 2·33 [0·59 to 9·24]; p=0·23), which were a transient increase in airway pressure during nebulisation (n=3 in the heparin group), major non-pulmonary bleeding (n=2 in each group), haemoptysis (n=1 in the heparin group), tracheotomy site bleeding (n=1 in the heparin group), and hypoxaemia during nebulisation (n=1 in the placebo group). INTERPRETATION: In patients with or at risk of ARDS, nebulised heparin did not improve self-reported performance of daily physical activities, but was well tolerated and exploratory outcomes suggest less progression of lung injury and earlier return home. Further research is justified to establish if nebulised heparin accelerates recovery in those who have or are at risk of ARDS. FUNDING: Rowe Family Foundation, TR and RB Ditchfield Medical Research Endowment Fund, Patricia Madigan Charitable Trust, and The J and R McGauran Trust Fund.


Subject(s)
Critical Care/methods , Heparin/administration & dosage , Respiration, Artificial/adverse effects , Respiratory Distress Syndrome/epidemiology , Activities of Daily Living , Administration, Inhalation , Adult , Aged , Australia/epidemiology , Double-Blind Method , Female , Hemoptysis/chemically induced , Hemoptysis/epidemiology , Heparin/adverse effects , Hospital Mortality , Humans , Hypoxia/chemically induced , Hypoxia/epidemiology , Incidence , Male , Middle Aged , Nebulizers and Vaporizers , Placebos/administration & dosage , Placebos/adverse effects , Respiratory Distress Syndrome/diagnosis , Respiratory Distress Syndrome/etiology , Respiratory Distress Syndrome/prevention & control , Self Report/statistics & numerical data , Severity of Illness Index , Survivors/statistics & numerical data , Time Factors , Treatment Outcome
7.
Indian J Crit Care Med ; 24(11): 1114-1124, 2020 Nov.
Article in English | MEDLINE | ID: covidwho-1116795

ABSTRACT

Understanding the concepts of disinfection, sterilization, cleaning and asepsis is of prime importance to prevent transmission of infection to patients and to protect healthcare workers (HCWs). Proper disinfection of surfaces after cleaning, an important consideration at all times, has assumed special significance during the current pandemic. The global shortage of disposable equipment such as personal protective equipment (PPE), specifically N95 masks and surgical 3 ply masks, and other items makes the HCWs vulnerable to transmission of infection while caring for these patients. Therefore, resterilization of such items has assumed equal importance. Cleaning, the first step in the process of sterilization, is of vital importance to reduce bioburden. The type of disinfection required depends on the nature of the equipment and its intended use. For example, critical items need high-level decontamination. In this narrative review, we elaborate on the methods of decontamination and sterilization. Many chemicals can be used for both sterilization and disinfection, and the difference lies in the concentration of the chemical and exposure time. We have also summarized strategies which can be used for resterilization of single-use items, in view of the shortages caused by the current pandemic. HOW TO CITE THIS ARTICLE: Kothekar AT, Kulkarni AP. Basic Principles of Disinfection and Sterilization in Intensive Care and Anesthesia and Their Applications during COVID-19 Pandemic. Indian J Crit Care Med 2020;24(11):1114-1124.

8.
Am J Occup Ther ; 75(2): 7502170010p1-7502170010p5, 2021.
Article in English | MEDLINE | ID: covidwho-1115510

ABSTRACT

The coronavirus disease 2019 (COVID-19) pandemic reshaped the health care landscape, leading to the reassignment of essential health care workers to critical areas and widespread furloughs of providers deemed nonessential, including occupational therapy practitioners. Although multidisciplinary critical care teams often include occupational therapy practitioners, efforts to define, measure, and disseminate occupational therapy's unique contributions to critical care outcomes have been overlooked. This editorial provides recommendations to improve the occupational therapy profession's readiness to meet society's current and future pandemic needs. We propose a three-pronged strategy to strengthen occupational therapy clinical practice, education, and advocacy to illuminate the distinct value of occupational therapy in critical care.


Subject(s)
COVID-19 , Occupational Therapy , Critical Care , Humans , SARS-CoV-2
9.
Kidney Int Rep ; 6(2): 265-271, 2021 Feb.
Article in English | MEDLINE | ID: covidwho-1056576

ABSTRACT

INTRODUCTION: During the coronavirus disease 2019 (COVID-19) pandemic in 2020, high rates of acute kidney injury (AKI) in critically unwell patients are being reported, leading to an increased demand for renal replacement therapy (RRT). Providing RRT for this large number of patients is proving challenging, and so alternatives to continuous renal replacement therapies (CRRT) in the intensive care unit (ICU) are needed. Peritoneal dialysis (PD) can be initiated immediately after percutaneous insertion of the catheter, but there are concerns about impact on ventilation and RRT efficacy. We sought to describe our recent experience with percutaneous catheter insertion and peritoneal dialysis in patients in the ICU with COVID-19 infection. METHOD: Patients were selected according to local protocol, and catheters were inserted percutaneously by experienced operators using a Seldinger technique. Sequential Organ Failure Assessment (SOFA) score and ventilation requirements were recorded at the time of insertion and 24 hours later. Procedural complications, proportion of RRT provided by PD, renal recovery, and RRT parameters (serum potassium and maximum base excess) during PD were assessed. RESULTS: Percutaneous PD catheters were successfully inserted in 37 of 44 patients (84.1%) after a median of 13.5 days (interquartile range [IQR] = 10.0, 20.3 days) in the ICU. No adverse events were reported; SOFA scores and ventilation requirements were comparable before and after insertion; and adequate RRT parameters were achieved. The median proportion of RRT provided by PD following catheter insertion was 94.6% (IQR = 75.0, 100%). CONCLUSION: Peritoneal dialysis provides a safe and effective alternative to CRRT in selected patients with AKI and COVID-19 infection requiring ventilation on intensive care.

10.
Aust Crit Care ; 34(2): 176-181, 2021 Mar.
Article in English | MEDLINE | ID: covidwho-1046574

ABSTRACT

BACKGROUND: Acute respiratory distress syndrome (ARDS) is a relatively common condition of varied aetiology associated with high morbidity and mortality. A range of therapies have been proven to be useful for patients with ARDS, including ventilatory and nonventilatory strategies. Prone positioning is one of the nonventilatory strategies and has been proven to be safe and is associated with significant mortality benefit in patients with moderate to severe ARDS. It is now included in several international guidelines as the standard of care for these cases. OBJECTIVES: The aim of the study was to develop, implement, and evaluate a prone positioning program in two nonmetropolitan, nontertiary intensive care units in South East Queensland. METHODS: A Plan-Do-Study-Act quality improvement model was used to implement changes in clinical practice in relation to prone positioning of patients. RESULTS: A description of the methods used to promote a complex change strategy is provided in this article. CONCLUSIONS: In this article, we demonstrate the feasibility of introducing a nonventilatory intervention of prone positioning in the management of patients with moderate to severe ARDS in regional intensive care in South East Queensland. This implementation strategy could be replicated and adopted in other similar intensive care units that do not have the ability to provide tertiary services such as extracorporeal life support.


Subject(s)
COVID-19/therapy , Pneumonia, Viral/therapy , Prone Position , Respiratory Distress Syndrome/therapy , Adult , Aged , COVID-19/epidemiology , Female , Humans , Intensive Care Units , Male , Middle Aged , Patient Selection , Pneumonia, Viral/epidemiology , Pneumonia, Viral/virology , Queensland/epidemiology , SARS-CoV-2
11.
Wien Klin Wochenschr ; 132(13-14): 400-402, 2020 Jul.
Article in English | MEDLINE | ID: covidwho-996398

ABSTRACT

Mankind has to prepare for a pandemic with respect to medical and practical aspects, but also with respect to ethical issues. There are various ethical guidelines for managing infectious disease outbreaks, but they do not apply to the specific aspects of the COVID-19 pandemic, since they were formulated after the different kinds of outbreaks of avian influenza and Ebola. Today we are confronted with completely new issues endangering our fundamental human rights. As COVID-19 is spreading all over the world, we are in a desperate situation to find treatment solutions; however, despite the urgency, scientific rules have to be applied as bad science is unethical since it might be harmful for patients. Fake news and alternative facts might not be easily recognized and are also threatening scientific values. Pandemics might be leading to a meltdown of the health system if no measures are being taken constraining fundamental human rights. Tracking of persons is violating human rights as well if not accepted on a voluntary basis. A failure to have safeguards for times of crisis leads to a scarcity of medicinal products and goods resulting in a nationalistic approach and ignorance of international solidarity. And last but not least selective measures and triage in intensive care have to be taught to young physicians and nursing staff in medical schools in order to be prepared in times of an infectious disease outbreak and scarcity of resources.


Subject(s)
Civil Defense , Coronavirus Infections , Human Rights , Pandemics/ethics , Pneumonia, Viral , Betacoronavirus , COVID-19 , Civil Defense/ethics , Coronavirus Infections/epidemiology , Humans , Mass Media , Pneumonia, Viral/epidemiology , Resource Allocation/ethics , SARS-CoV-2 , Truth Disclosure
12.
Clin Endosc ; 53(6): 746-749, 2020 Nov.
Article in English | MEDLINE | ID: covidwho-1000537

ABSTRACT

The novel coronavirus disease (COVID-19) quickly spread to all continents. However, data regarding all the signs and symptoms of COVID-19 are insufficient. Patients with COVID-19 might present higher susceptibility to fungal coinfections. Mucormycosis is a rare and often life-threatening fungal disease characterized by vascular invasion by hyphae, resulting in thrombosis and necrosis. This is the first case report of mucormycosis in a COVID-19 patient. An 86-year-old male patient was admitted to the emergency room with acute diarrhea, cough, dyspnea, and fever from 5 days prior. Blood tests revealed a hemoglobin level of 14.3 mg/dL. Five days following the admission, the patient presented with melena and a hemoglobin level of 5.6 mg/dL. A transfusion of three units of red blood cells was required. Esophagogastroduodenoscopy revealed two giant gastric ulcers with necrotic debris and a deep hemorrhagic base without active bleeding. Furthermore, biopsies confirmed mucormycosis. Despite intensive care, the patient died 36 hours after the esophagogastroduodenoscopy.

13.
BMJ Case Rep ; 13(12)2020 Dec 13.
Article in English | MEDLINE | ID: covidwho-975665

ABSTRACT

A 53-year-old man admitted to the critical care secondary to respiratory failure due to COVID-19 developed agitation and global hypotonia. Brain MRI revealed bilateral hyperintense lesions throughout the brain and cerebrospinal fluid identified oligoclonal bands. Intravenous high-dose glucocorticoids were administered followed by an oral tapering dose and the patient clinically improved. Acute disseminated encephalomyelitis should be considered in patients with COVID-19 who present with altered mentation and polyfocal neurological deficits.


Subject(s)
COVID-19/complications , Encephalomyelitis, Acute Disseminated/virology , Encephalomyelitis, Acute Disseminated/diagnostic imaging , Encephalomyelitis, Acute Disseminated/drug therapy , Humans , Magnetic Resonance Imaging , Male , Middle Aged , Neuroimaging , SARS-CoV-2
14.
Nutrients ; 12(12)2020 Dec 07.
Article in English | MEDLINE | ID: covidwho-967092

ABSTRACT

There are limited proven therapies for COVID-19. Vitamin C's antioxidant, anti-inflammatory and immunomodulating effects make it a potential therapeutic candidate, both for the prevention and amelioration of COVID-19 infection, and as an adjunctive therapy in the critical care of COVID-19. This literature review focuses on vitamin C deficiency in respiratory infections, including COVID-19, and the mechanisms of action in infectious disease, including support of the stress response, its role in preventing and treating colds and pneumonia, and its role in treating sepsis and COVID-19. The evidence to date indicates that oral vitamin C (2-8 g/day) may reduce the incidence and duration of respiratory infections and intravenous vitamin C (6-24 g/day) has been shown to reduce mortality, intensive care unit (ICU) and hospital stays, and time on mechanical ventilation for severe respiratory infections. Further trials are urgently warranted. Given the favourable safety profile and low cost of vitamin C, and the frequency of vitamin C deficiency in respiratory infections, it may be worthwhile testing patients' vitamin C status and treating them accordingly with intravenous administration within ICUs and oral administration in hospitalised persons with COVID-19.


Subject(s)
Ascorbic Acid Deficiency/drug therapy , Ascorbic Acid/therapeutic use , COVID-19/drug therapy , Respiratory Tract Infections/drug therapy , Sepsis/drug therapy , Vitamins/therapeutic use , Administration, Intravenous , Administration, Oral , Anti-Inflammatory Agents/therapeutic use , Ascorbic Acid Deficiency/complications , COVID-19/complications , COVID-19/virology , Chemotherapy, Adjuvant , Critical Care , Hospitalization , Humans , Immunologic Factors/therapeutic use , Intensive Care Units , Nutritional Status , Pandemics , Respiration, Artificial , Respiratory Tract Infections/etiology , Respiratory Tract Infections/virology , SARS-CoV-2 , Sepsis/etiology , Sepsis/virology
15.
Anaesthesia ; 76(3): 320-326, 2021 03.
Article in English | MEDLINE | ID: covidwho-868029

ABSTRACT

Renal impairment is common in patients who are critically ill with coronavirus disease-19 (COVID-19). We examined the association between acute and chronic kidney disease with clinical outcomes in 372 patients with coronavirus disease-19 admitted to four regional intensive care units between 10 March 2020 and 31 July 2020. A total of 216 (58%) patients presented with COVID-19 and renal impairment. Acute kidney injury and/or chronic kidney disease was associated with greater in-hospital mortality compared with patients with preserved renal function (107/216 patients (50%) (95%CI 44-57) vs. 32/156 (21%) (95%CI 15-28), respectively; p < 0.001, relative risk 2.4 (95%CI 1.7-3.4)). Mortality was greatest in patients with renal transplants (6/7 patients (86%) (95%CI 47-100)). Mortality rates increased in patients with worsening renal injury according to the Kidney Disease: Improving Global Outcomes classification: stage 0 mortality 33/157 patients (21%) (95%CI 15-28) vs. stages 1-3 mortality 91/186 patients (49%) (95%CI 42-56); p < 0.001, relative risk 2.3 (95%CI 1.7-3.3). Survivors were less likely to require renal replacement therapy compared with non-survivors (57/233 patients (24%) vs. 64/139 patients (46%), respectively; p < 0.001, relative risk 1.9 (95%CI 1.4-2.5)). One-fifth of survivors who required renal replacement therapy acutely in intensive care continued to require renal support following discharge. Our data demonstrate that renal impairment in patients admitted to intensive care with COVID-19 is common and is associated with a high mortality and requirement for on-going renal support after discharge from critical care. Our findings have important implications for future pandemic planning in this patient cohort.


Subject(s)
Acute Kidney Injury/mortality , COVID-19/mortality , Adult , Aged , Aged, 80 and over , Causality , Cohort Studies , Comorbidity , Critical Illness , England/epidemiology , Female , Hospital Mortality , Humans , Male , Middle Aged , Retrospective Studies , Risk Assessment , SARS-CoV-2 , Severity of Illness Index , Young Adult
16.
Clin Nutr ESPEN ; 41: 423-428, 2021 02.
Article in English | MEDLINE | ID: covidwho-856568

ABSTRACT

INTRODUCTION: The nutritional diagnosis and early nutritional management of COVID-19 patients must be integrated into the overall therapeutic strategy. The aim of our study is to assess the nutritional status of patients with COVID-19 after a stay in intensive care, to describe the prevalence of undernutrition, to determine the factors influencing undernutrition and to describe the nutritional management. TOOLS AND METHODS: This is a descriptive observational study of adult patients admitted to the endocrinology service for additional care after a stay in intensive care during the period from April 17, 2020 to May 26, 2020. The assessment tool used was the Mini Nutritional Assessment (MNA). RESULTS: Our study included 41 patients; the average age of the patients was 55 years, 51.2% had a severe or critical form of COVID-19, 75.6% stayed in intensive care, 12.2% had a loss of autonomy. The average BMI was 25.2 kg/m2 (17-42 kg/m2), 42.5% were overweight, 61% had weight loss, 26.2% had weight loss greater than 10%, 14.6% of our patients were undernourished, 65.9% were at risk of undernutrition, 19.5% had hypoalbuminemia, 17.1% had hypoprotidemia, 19.5% hypocalcemia, 34.1% anemia, 12.2% hypomagnesemia and 51.2% had a deficiency in vitamin D. A positive correlation was found between poor nutritional status and a longer stay in intensive care (>5 days) (p = 0.011) and lymphopenia (p = 0,02). CONCLUSION: Despite a personalized diet, 14.6% of patients presented undernutrition. Particular attention should be paid to patients with a long stay in intensive care.


Subject(s)
COVID-19 , Critical Care , Intensive Care Units , Length of Stay , Malnutrition/etiology , Nutritional Status , Adult , Aged , Body Mass Index , COVID-19/therapy , Deficiency Diseases/diagnosis , Deficiency Diseases/epidemiology , Deficiency Diseases/etiology , Deficiency Diseases/therapy , Diet , Female , Humans , Lymphopenia/etiology , Male , Malnutrition/diagnosis , Malnutrition/epidemiology , Malnutrition/therapy , Middle Aged , Nutrients/deficiency , Nutrition Assessment , Overweight/epidemiology , Pandemics , Patient Discharge , Prevalence , SARS-CoV-2 , Weight Loss
17.
Semin Dial ; 2020 Sep 15.
Article in English | MEDLINE | ID: covidwho-787940

ABSTRACT

The COVID-19 pandemic has put a strain on many aspects of health care including the provision of dialysis. Two categories of patients have had the greatest impact on dialysis capacity. Those with COVID-19-related acute kidney injury and those chronic dialysis patients who required isolation or cohort dialysis because of the pandemic. Limited information on incidence hampers capacity planning and the rapid change in demand provides further challenges. In the 4 weeks after our first patient, the incidence of confirmed infection in our dialysis population has been 5.1%. By the third week, hemodialysis had to be provided in critical care as the in-house capacity for hemofiltration had been overwhelmed. The interventions that enabled these needs to be met are detailed in this paper alongside a review of international recommendations and how they have been adapted to meet local pressures.

18.
Dtsch Arztebl Int ; 117(31-32): 528-533, 2020 08 03.
Article in English | MEDLINE | ID: covidwho-750754

ABSTRACT

BACKGROUND: The reported high mortality of COVID-19 patients in intensive care has given rise to a debate over whether patients with this disease are being intubated too soon and might instead benefit from more non-invasive ventilation. METHODS: This review is based on articles published up to 12 June 2020 that were retrieved by a selective literature search on the topic of invasive and non-invasive ventilation for respiratory failure in COVID-19. Guideline recommendations and study data on patients with respiratory failure in settings other than COVID-19 are also considered, as are the current figures of the intensive care registry of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin). RESULTS: The high mortality figures among patients receiving invasive ventilation that have been reported in studies from abroad cannot be uncritically applied to the current situation in Germany. Study data on ventilation specifically in COVID-19 patients would be needed to do justice to the special pathophysiology of this disease, but such data are lacking. Being intubated too early is evidently associated with risks for the patient, but being intubated too late is as well. A particularly im - portant consideration is the potential harm associated with prolonged spontaneous breathing, with or without non-invasive assistance, as any increase in respiratory work can seriously worsen respiratory failure. On the other hand, it is clearly unacceptable to intubate patients too early merely out of concern that the medical staff might become infected with COVID-19 if they were ventilated non-invasively. CONCLUSION: Nasal high flow, non-invasive ventilation, and invasive ventilation with intubation should be carried out in a stepwise treatment strategy, under appropriate intensive-care monitoring and with the observance of all relevant anti-infectious precautions. Germany is better prepared that other countries to provide COVID-19 patients with appropriate respiratory care, in view of the high per capita density of intensive-care beds and the availability of a nationwide, interdisciplinary intensive care registry for the guidance and coordination of intensive care in patients who need it.


Subject(s)
Coronavirus Infections/therapy , Pneumonia, Viral/therapy , Respiration, Artificial/methods , Respiratory Insufficiency/therapy , COVID-19 , Coronavirus Infections/epidemiology , Germany/epidemiology , Humans , Noninvasive Ventilation , Pandemics , Pneumonia, Viral/epidemiology
19.
Indian J Crit Care Med ; 24(7): 506-508, 2020 Jul.
Article in English | MEDLINE | ID: covidwho-749199

ABSTRACT

The COVID-19 pandemic has infiltrated all over our lives in every aspect and led to complete lockdown in almost every country and affected millions of people. It has overwhelmed the healthcare systems even of the most developed nations and this could be our future as well if situation is not controlled. We might fall short of ICU beds, ventilators, and trained manpower. Having understood that, many companies or even individuals have started to produce new and innovative kind of ventilators which prima facie are not at par with the standard ICU ventilators. Such ventilators, if approved for use in COVID-19 acute respiratory distress syndrome (ARDS), may not be of much use and rather cause harm. This commentary shall deal with the basics of COVID-19 ARDS, basics of an ICU ventilator, innovative low-cost ventilators, and the stark differences between the two and why their use may not be appropriate in the condition of our concern. HOW TO CITE THIS ARTICLE: Malani AS. Cosmetic Ventilators (Co-V) for COVID-19. Indian J Crit Care Med 2020;24(7):506-508.

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Lancet Respir Med ; 8(12): 1201-1208, 2020 12.
Article in English | MEDLINE | ID: covidwho-731950

ABSTRACT

BACKGROUND: Patients with COVID-19 can develop acute respiratory distress syndrome (ARDS), which is associated with high mortality. The aim of this study was to examine the functional and morphological features of COVID-19-associated ARDS and to compare these with the characteristics of ARDS unrelated to COVID-19. METHODS: This prospective observational study was done at seven hospitals in Italy. We enrolled consecutive, mechanically ventilated patients with laboratory-confirmed COVID-19 and who met Berlin criteria for ARDS, who were admitted to the intensive care unit (ICU) between March 9 and March 22, 2020. All patients were sedated, paralysed, and ventilated in volume-control mode with standard ICU ventilators. Static respiratory system compliance, the ratio of partial pressure of arterial oxygen to fractional concentration of oxygen in inspired air, ventilatory ratio (a surrogate of dead space), and D-dimer concentrations were measured within 24 h of ICU admission. Lung CT scans and CT angiograms were done when clinically indicated. A dataset for ARDS unrelated to COVID-19 was created from previous ARDS studies. Survival to day 28 was assessed. FINDINGS: Between March 9 and March 22, 2020, 301 patients with COVID-19 met the Berlin criteria for ARDS at participating hospitals. Median static compliance was 41 mL/cm H2O (33-52), which was 28% higher than in the cohort of patients with ARDS unrelated to COVID-19 (32 mL/cm H2O [25-43]; p<0·0001). 17 (6%) of 297 patients with COVID-19-associated ARDS had compliances greater than the 95th percentile of the classical ARDS cohort. Total lung weight did not differ between the two cohorts. CT pulmonary angiograms (obtained in 23 [8%] patients with COVID-19-related ARDS) showed that 15 (94%) of 16 patients with D-dimer concentrations greater than the median had bilateral areas of hypoperfusion, consistent with thromboembolic disease. Patients with D-dimer concentrations equal to or less than the median had ventilatory ratios lower than those of patients with D-dimer concentrations greater than the median (1·66 [1·32-1·95] vs 1·90 [1·50-2·33]; p=0·0001). Patients with static compliance equal to or less than the median and D-dimer concentrations greater than the median had markedly increased 28-day mortality compared with other patient subgroups (40 [56%] of 71 with high D-dimers and low compliance vs 18 [27%] of 67 with low D-dimers and high compliance, 13 [22%] of 60 with low D-dimers and low compliance, and 22 [35%] of 63 with high D-dimers and high compliance, all p=0·0001). INTERPRETATION: Patients with COVID-19-associated ARDS have a form of injury that, in many aspects, is similar to that of those with ARDS unrelated to COVID-19. Notably, patients with COVID-19-related ARDS who have a reduction in respiratory system compliance together with increased D-dimer concentrations have high mortality rates. FUNDING: None.


Subject(s)
COVID-19/physiopathology , Respiratory Distress Syndrome/physiopathology , Aged , COVID-19/mortality , Computed Tomography Angiography , Female , Fibrin Fibrinogen Degradation Products/metabolism , Humans , Lung/diagnostic imaging , Lung/pathology , Male , Middle Aged , Pandemics , Prospective Studies , Respiration, Artificial , Respiratory Distress Syndrome/mortality , SARS-CoV-2
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