[Bed capacity management in times of the COVID-19 pandemic : A simulation-based prognosis of normal and intensive care beds using the descriptive data of the University Hospital Augsburg]. / Bettenkapazitätssteuerung in Zeiten der COVID-19-Pandemie : Eine simulationsbasierte Prognose der Normal- und Intensivstationsbetten anhand der deskriptiven Daten des Universitätsklinikums Augsburg.

BACKGROUND: Following the regional outbreak in China, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread all over the world, presenting the healthcare systems with huge challenges worldwide. In Germany the coronavirus diseases 2019 (COVID-19) pandemic has resulted in a slowly growing demand for health care with a sudden occurrence of regional hotspots. This leads to an unpredictable situation for many hospitals, leaving the question of how many bed resources are needed to cope with the surge of COVID-19 patients. OBJECTIVE: In this study we created a simulation-based prognostic tool that provides the management of the University Hospital of Augsburg and the civil protection services with the necessary information to plan and guide the disaster response to the ongoing pandemic. Especially the number of beds needed on isolation wards and intensive care units (ICU) are the biggest concerns. The focus should lie not only on the confirmed cases as the patients with suspected COVID-19 are in need of the same resources. MATERIAL AND METHODS: For the input we used the latest information provided by governmental institutions about the spreading of the disease, with a special focus on the growth rate of the cumulative number of cases. Due to the dynamics of the current situation, these data can be highly variable. To minimize the influence of this variance, we designed distribution functions for the parameters growth rate, length of stay in hospital and the proportion of infected people who need to be hospitalized in our area of responsibility. Using this input, we started a Monte Carlo simulation with 10,000 runs to predict the range of the number of hospital beds needed within the coming days and compared it with the available resources. RESULTS: Since 2 February 2020 a total of 306 patients were treated with suspected or confirmed COVID-19 at this university hospital. Of these 84 needed treatment on the ICU. With the help of several simulation-based forecasts, the required ICU and normal bed capacity at Augsburg University Hospital and the Augsburg ambulance service in the period from 28 March 2020 to 8 June 2020 could be predicted with a high degree of reliability. Simulations that were run before the impact of the restrictions in daily life showed that we would have run out of ICU bed capacity within approximately 1 month. CONCLUSION: Our simulation-based prognosis of the health care capacities needed helps the management of the hospital and the civil protection service to make reasonable decisions and adapt the disaster response to the realistic needs. At the same time the forecasts create the possibility to plan the strategic response days and weeks in advance. The tool presented in this study is, as far as we know, the only one accounting not only for confirmed COVID-19 cases but also for suspected COVID-19 patients. Additionally, the few input parameters used are easy to access and can be easily adapted to other healthcare systems.

Case report: Duodenal perforation in a critically ill patient with covid-19

Aims We report the case of a 54-year old male who was admitted to our intensive care unit due to respiratory failure andCOVID-19 disease. The patients' comorbidities were allergic asthma and obesity;he was on no regular medication. On day15 after admission to the ICU, invasive ventilation was started, and on day 19, melena, with a drop in hemoglobin levelfrom 12.9 g/dl to 8.5 g/dl, was observed. Methods In the emergency gastroscopy, three ulcerations were seen in the duodenal bulb. Two ulcerations showed visiblevessels (Forrest IIa), and were treated with a standard hemoclip as well as an “Over-the-Scope-Clip” (OTSC, Ovesco). Thethird ulceration was covered by a large clot (F IIb). After mobilization of the clot, the ulceration was seen to have perforatedinto the retroperitoneum. Results The patient underwent emergency surgery in which the perforation was sutured. Conclusions Studies have shown a high risk for gastrointestinal complications, such as gastrointestinal ischemia and ileusin critically ill patients with COVID-19 disease. In this case, we postulate that critically ill patients with COVID-19 may havea higher risk of GI bleeding and ulcer perforation. However, it is unclear whether these complications can be specificallyattributed to the underlying COVID-19 disease or the therapeutic anticoagulation, which all critically ill patients with COVID-19 recieve as standard of care. Further studies are needed to confirm or rule out these assumptions. Nevertheless, specialattention should be paid to gastrointestinal complications in critically ill COVID-19 patients.

Outcomes of covid-2019 in renal transplant recipients versus chronic hemodialysis patients: Analysis of a regional cohort

Introduction: SARS-CoV-2 causing COVID-19 has rapidly spread around the world with the first German cluster emerging in the area around Heinsberg. Mortality rates are reported to vary between 1-14%. While end-stage renal disease is a putative risk factor for adverse outcomes of COVID-19, the impact of carrying a renal transplant (KTX) versus being on chronic hemodialysis (HD) is not well defined. Methods: We describe a cohort of 21 patients on renal replacement therapy (7 KTX and 11 HD treated for COVID-19 plus 3 asymptomatic HD carriers of SARS-CoV-2) in the Heinsberg area. Data were collected systematically via the two local dialysis care providers specifically serving the area as well as the local tertiary care hospital and renal transplant center at the University Hospital Aachen. All patients were followed for the entire course of the disease over a median of 66 days (40-71 IQR). Medication, comorbidities and clinical outcome were recorded. Results: Of the seven KTX patients four were hospitalized with an acute respiratory distress syndrome (ARDS), three of which died;two of fulminant multiorgan failure and one of multiple complications of intensive care medicine after prolonged weaning and viral encephalitis. These three patients also developed acute kidney injury requiring renal replacement therapy. In all hospitalized KTX recipients MPA was stopped directly upon admission while CNIs were held only as a more severe clinical course ensued. Of the 11 HD patients with COVID-19 six were hospitalized. Three developed ARDS, two of them died. While requirement for hospitalization and duration of viral RNAshedding were similar in KTX versus HD patients, the duration of illness and of hospitalization were longer in the KTX group by 8 and 14 days, respectively. Conclusion: COVID-19 has a variable course in renal transplant recipients as well as patients on chronic hemodialysis ranging from (almost) asymptomatic infection to severe ARDS with lethal outcome. Patients on renal replacement therapy seem to have a more favorable outcome than patients after kidney transplantation (mortality 18% vs. 43% following KTX). Early reduction of immunosuppression did not seem to prevent mortality.

[Hemoptysis and acute kidney injury in COVID-19]. / Hämoptysen und akutes Nierenversagen bei COVID-19.

The present case describes the diagnostic and therapy of the pulmorenal syndrome of a 40-year-old patient who presented in our clinic due to increasing respiratory insufficiency and hemoptysis with confirmed COVID-19 disease.