The association between Acinetobacter baumannii infections and the COVID-19 pandemic in an intensive care unit.

We aimed to describe the increased rate of Acinetobacter baumannii infections during the COVID-19 pandemic and define its significance within the last five years. This study was performed in a tertiary hospital with 280 beds and included all patients infected with A. baumannii in the intensive care unit between January 1, 2018, and June 30, 2022. A. baumannii-infected patients in the intensive care unit 27 months before the pandemic and 27 months during the pandemic were included. Pulsed-field gel electrophoresis was performed to assess clonal relatedness. The infection control measures were specified based on the findings and targeted elimination. In total, 5718 patients were admitted to the intensive care unit from January 1st, 2018, to June 30th, 2022. A. baumannii infection was detected in 81 patients. Compared to the pre-pandemic era, the rate of A. baumannii infection during the pandemic was 1.90 times higher (OR: 1.90, 95% CI: [1.197, 3.033]). Clonality assessment of multidrug-resistant A. baumannii samples revealed eight clusters with one main cluster comprising 14/27 isolates between 2021 and 2022. The case fatality rate of the pre-pandemic and pandemic era was not different statistically (83.33% vs. 81.48%, p = 0.835). Univariate analysis revealed the association of mechanical ventilation (p = 0.002) and bacterial growth in tracheal aspirate (p = 0.001) with fatality. During the COVID-19 pandemic, potential deficits in infection control measures may lead to persistent nosocomial outbreaks. In this study, the introduction of enhanced and customized infection control measures has resulted in the containment of an A. baumannii outbreak.

COVID-19 Olgularında Görülen Trakeal Hasar: Pozisyon mu, Entübasyon Komplikasyonu mu?

Amaç: Trakeal hasar (TH) entübe hastalarda karşılaşılabilen nadir bir komplikasyondur. Sunuda COVID-19 pnömonisiyle yoğun bakım ünitesinde (YBÜ) takip edilen iki hastamızda görülen TH incelenmiştir. Olgu: Olgu 1: Yirmi yedi yaşında bilinen ek hastalığı bulunmayan erkek hasta, SARS-CoV-2 PCR pozitifliğinin 7. gününde ateş ve hemoptizi nedeniyle hastaneye yatışı yapılmıştır. Artan oksijen gereksinimi sebebiyle steroid ve tocilizumab başlanmıştır. Solunum yetersizliği ilerleyince YBÜ’ye alınmıştır. NIMV ve prone pozisyona rağmen hipoksisi nedeniyle entübe edilmiştir. Günde 16 saat prone 8 saat supine pozisyon verilmiştir. Hipoksemisi devam eden hastaya VV-ECMO başlanmıştır. Entübasyonun 7. gününde pnömotoraks, deri altı amfizemi ve bozulan enteral tolerasyon saptanmıştır. On dokuzuncu gününde toraks bilgisayarlı tomografi görüntülemesinde bilateral hidropnömotoraks, trakeaösefageal fistül (TÖF) izlenmiştir (Şekil 1). Yapılan eksploratif torakoskopide trakeada tam kat rüptür görülmesi sebebiyle inoperable kabül edilen hasta entübasyon sonrası 20. günde eksitus olmuştur. Olgu 2: Koroner arter hastalığı bulunan hasta SARS-CoV2 PCR pozitifliğinin 11. gününde NIMV ve HFNC desteğine rağmen hipoksisi nedeniyle dış merkezde entübe edilmiştir. YBÜ’müze sevk edilen hasta 16 saat prone 8 saat supin olacak şekilde takip edilmiştir. Takibinin 6. gününde çekilen toraks tomografisinde yaygın pnömomediastinum saptanmıştır, endotrakeal tüpünün (ETT) kafının distalinde trakeanın sağ posterolateralinde trakeal fistül görülmüştür (Şekil 2). Hastanın pnömomediastinumunun artmaması için ETT bölgenin distaline, tek akciğer ventilasyonuna da neden olmayacak şekilde 26 cm’de bırakılarak hasta takip edilmiştir. Hasta pnömomediastinumu takiben 11. günde prone pozisyona yanıt vermemesi üzerine hipoksi ve şok tablosunda eksitus olmuştur. Sonuç: TH’de risk faktörleri travmatik entübasyon, kaf basıncı, uzun süreli mekanik ventilasyon, hava yolu enfeksiyonları, steroid kullanımı, trakeal arka duvar yapısal sorunları ve entübasyon/nazogastrik tüpün basısı olarak sıralanabilir. Yüksek hacim düşük basınç kaflı ETT kullanımıyla TH/TÖF sıklığı azalmıştır. Prone pozisyon arka duvara basıyı artırarak yaralanma oluşturabilir. COVID-19 pnömonili hastaların prone pozisyonlanmasından ve virüsün direkt mukoza hasarından dolayı trakeal hasarla karşılaşılabilir. Bu açıdan ETT kaf basınçlarının takip edilmesi ve prone pozisyonda sedasyon uygulanması entübe hastalarda önem taşıyor olabilir. (Turkish) [ FROM AUTHOR] Copyright of Turkish Journal of Intensive Care is the property of Galenos Yayinevi Tic. LTD. STI and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

COVID ve Non-COVID ARDS Hastalarında Statik Kompliyans ve Yoğun Bakım Mortalite Ílişkisinin Karşılaştırılması

Amaç: Koronavirüs hastalığı-2019 ile ilişkili akut solunum yetersizliği sendromu (COVID-19 ARDS) bazı patofizyolojik yönleri ile non-COVID-19 ARDS’den farklılıklar göstermektedir. COVID-19 ARDS’de belirgin hipoksemiye rağmen korunmuş kompliyans bunlar arasında en çok üzerinde durulan konulardan biridir. Biz bu retrospektif veri tabanı çalışmasında, kontrollü mekanik ventilasyonda ilk 24 saatte ideal kiloya göre hesaplanan kompliyans (Crs) ve tidal volüm (VT) değerlerinin COVID19 ARDS ve non-COVID-19 ARDS hasta gruplarında mortaliteli ile ilişkisini karşılaştırmayı amaçladık. Gereç ve Yöntem: Koç Üniversitesi etik kurul onamıyla, 2015-2021 yılları arasında VKV Amerikan Hastanesi Yoğun Bakım Ünitesi’ne kabul edilen;18 yaş üstü 24 saatten fazla mekanik ventilasyon uygulanan hastalar incelenmiştir. Berlin sınıflamasına göre ARDS kriterlerini karşılayan, Crs, DP, TV verileri eksiksiz hastalar çalışmaya dahil edilmiştir. Demografik bilgileri, APACHE II ve SOFA skorları, kan gazları, mekanik ventilatör ayarları IMDSoft (MetaVision, QlinICU) sisteminden kaydedilmiştir. Elli bir tane COVID-19 ARDS hastasına demografik olarak eşdeğer 52 tane nonCOVID-19 ARDS hastası belirlenmiştir. Íki grubun kompliyans ve mortalite ilişkisi Mann-Whitney U, Student t-test ve ki-kare testi ile incelendi. Bulgular: Demografik bulgular Tablo 1, solunum parametreleri ve mortaliteyle ilgili bulgular Tablo 2 ve 3’te yer almaktadır. Sonuç: COVID-19 ve non-COVID-19 ARDS hasatlarında kompliyans değerlerinde Peep uygulaması, MV süresi ve YBÜ kalış süresinde anlamlı farklılıklar görülmesine rağmen mortalitede anlamlı farklılık bulunmamıştır. Beklenenin tersine COVID ARDS olgularında daha düşük kompliyans izlenmiştir. (Turkish) [ FROM AUTHOR] Copyright of Turkish Journal of Intensive Care is the property of Galenos Yayinevi Tic. LTD. STI and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Simplified calculation of mechanical power for pressure controlled ventilation in Covid-19 ARDS patients.

BACKGROUND: Mechanical power (MP) is a promising tool for guidance of lung protective ventilation. Different equations have been proposed to calculate MP in pressure control ventilation (PCV). The aim of this study is to introduce an easy to use MP equation MPpcv(m-simpl) and compare it to an equation proposed by Van der Meijden et al. (MPpcv) which considered as the reference equation in PCV. METHODS: Ventilatory parameters of 206 Covid-19 ARDS patients recorded between 24-72 hours after admission to intensive care unit. The PCV data from these patients were retrospectively investigated. MP in PCV was calculated with a modified equation (MPpcv(m-simpl)) derived from the equation (MPpcv) of Van der Meijden et al.: 0.098xRRx∆Vx(PEEP+∆Pinsp - 1). The results from MPpcv(slope), MPpcv(simpl), and MPpcv(m-simpl) were compared to MPpcv at 15 cmH2O ∙ s/L inspiratory resistance levels by univariable regression and Bland-Altman analysis. RESULTS: Inspiratory resistance levels at 15 cmH2O s/L was found to be correlated between the power values calculated by MPpcv(simpl)/MPpcv(m-simpl) and the MPpcv(slope)/MPpcv based on univariable logistic regression (R2≥98) analyses. In the comparison of all patients average MP values computed by the MPpcv(m-simpl) equation and the MPpcv reference equation. Bland-Altman analysis mean difference and p values at 15 cmH2O s/L inspiratory resistance values (J/min) were found to be MPpcv(m-simpl) vs MPpcv=-0,04 (P=0.014); MPpcv(slope) vs. MPpcv=0.63 (P<0.0001); MPpcv(simpl) vs. MPpcv=0.64 J/min (P<0.0001), respectively. CONCLUSIONS: The results of this study confirmed that the MPpcv(m-simpl) equation can be used easily to calculate MP at bedside in pressure control ventilated COVID-19 ARDS patients.

Propensity-Adjusted Comparison of Mortality of Elderly Versus Very Elderly Ventilated Patients.

BACKGROUND: The growing proportion of elderly intensive care patients constitutes a public health challenge. The benefit of critical care in these patients remains unclear. We compared outcomes in elderly versus very elderly subjects receiving mechanical ventilation. METHODS: In total, 5,557 mechanically ventilated subjects were included in our post hoc retrospective analysis, a subgroup of the VENTILA study. We divided the cohort into 2 subgroups on the basis of age: very elderly subjects (age ≥ 80 y; n = 1,430), and elderly subjects (age 65-79 y; n = 4,127). A propensity score on being very elderly was calculated. Evaluation of associations with 28-d mortality was done with logistic regression analysis. RESULTS: Very elderly subjects were clinically sicker as expressed by higher SAPS II scores (53 ± 18 vs 50 ± 18, P < .001), and their rates of plateau pressure < 30 cm H2O were higher, whereas other parameters did not differ. The 28-d mortality was higher in very elderly subjects (42% vs 34%, P < .001) and remained unchanged after propensity score adjustment (adjusted odds ratio 1.31 [95% CI 1.16-1.49], P < .001). CONCLUSIONS: Age was an independent and unchangeable risk factor for death in mechanically ventilated subjects. However, survival rates of very elderly subjects were > 50%. Denial of critical care based solely on age is not justified. (ClinicalTrials.gov registration NCT02731898.).

Comparison of Respiratory and Hemodynamic Parameters of COVID-19 and Non-COVID-19 ARDS Patients.

BACKGROUND: COVID-19 can cause a clinical spectrum from asymptomatic disease to life-threatening respiratory failure and acute respiratory distress syndrome (ARDS). There is an ongoing discussion whether the clinical presentation and ventilatory parameters are the same as typical ARDS or not. There is no clear understanding of how the hemodynamic parameters have been affected in COVID-19 ARDS patients. We aimed to compare hemodynamic and respiratory parameters of moderate and severe COVID-19 and non-COVID-19 ARDS patients. These patients were monitored with an advanced hemodynamic measurement system by the transpulmonary thermodilution method in prone and supine positions. PATIENTS AND METHODS: Data of 17 patients diagnosed with COVID-19 and 16 patients diagnosed with other types of diseases with moderate and severe ARDS, mechanically ventilated, placed in a prone position, had advanced hemodynamic measurements with PiCCO, and stayed in the intensive care unit for more than a week were analyzed retrospectively. Patient characteristics and arterial blood gases analysis recorded at admission and respiratory and advanced hemodynamic parameters during the first week were compared in prone and supine positions. RESULTS: No difference was observed in the respiratory parameters including respiratory system compliance between COVID-19 and non-COVD-19 patients in prone and supine positions. In comparison of advanced hemodynamic parameters in the first week of intensive care, the extravascular lung water and pulmonary vascular permeability indexes measured in supine position of COVID-19 ARDS patients were found to be significantly higher than non-COVID-19 patients. Duration of prone position was significantly longer in patients diagnosed with COVID-19 ARDS. CONCLUSIONS: The results of this study suggested that COVID-19 ARDS is a variant of typical ARDS with a different pathophysiology. HOW TO CITE THIS ARTICLE: Asar S, Acicbe Ö, Sabaz MS, Tontu F, Canan E, Cukurova Z, et al. Comparison of Respiratory and Hemodynamic Parameters of COVID-19 and Non-COVID-19 ARDS Patients. Indian J Crit Care Med 2021;25(6):704-708.

Is elective cancer surgery feasible during the lock-down period of the COVID-19 pandemic? Analysis of a single institutional experience of 404 consecutive patients.

BACKGROUND: We aimed to assess the feasibility and short-term clinical outcomes of surgical procedures for cancer at an institution using a coronavirus disease 2019 (COVID-19)-free surgical pathway during the peak phase of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. MATERIALS AND METHODS: This was a single-center study, including cancer patients from all surgical departments, who underwent elective surgical procedures during the first peak phase between March 10 and June 30, 2020. The primary outcomes were the rate of postoperative SARS-CoV-2 infection and 30-day pulmonary or non-pulmonary related morbidity and mortality associated with SARS-CoV-2 disease. RESULTS: Four hundred and four cancer patients fulfilling inclusion criteria were analyzed. The rate of patients who underwent open and minimally invasive procedures was 61.9% and 38.1%, respectively. Only one (0.2%) patient died during the study period due to postoperative SARS-CoV2 infection because of acute respiratory distress syndrome. The overall non-SARS-CoV2 related 30-day morbidity and mortality rates were 19.3% and 1.7%, respectively; whereas the overall SARS-CoV2 related 30-day morbidity and mortality rates were 0.2% and 0.2%, respectively. CONCLUSIONS: Under strict institutional policies and measures to establish a COVID-19-free surgical pathway, elective and emergency cancer operations can be performed with acceptable perioperative and postoperative morbidity and mortality.

Physical rehabilitation in Intensive Care Unit in acute respiratory distress syndrome patients with COVID-19.

BACKGROUND: The risk of muscle weakness is high in the survivors of acute respiratory distress syndrome with COVID-19 following discharge from intensive care unit. AIM: To evaluate the effects of early rehabilitation program in intensive care unit in patients with acute respiratory distress syndrome secondary to COVID-19. DESIGN: The design of the study is observational. SETTING: The setting of the study is inpatient. POPULATION: Thirty-five patients with acute respiratory distress syndrome secondary to COVID-19 were enrolled. METHODS: This study was performed in an intensive care unit of a university hospital. Early rehabilitation program consisting of passive or active range of motion exercises and neuromuscular electrical stimulation in addition to standard intensive care (N.=18) compared to standard intensive care (N.=17). Primary outcome was hand grip strength following discharge. RESULTS: Rehab group had higher prevalence of chronic pulmonary diseases and neurologic diseases. There was no difference in hand grip or manual muscle strength following discharge between rehab and non-rehab groups. No adverse event was noted. CONCLUSIONS: The results did not support the beneficial effects of early rehabilitation in intensive care unit on improving muscle strength. More patients with pulmonary and neurologic diseases in rehab group might impede the impact of rehabilitation on outcomes. On the other hand, these comorbidities underline the role and need of rehabilitation. It is safe both for the patients and the health care workers when necessary precautions are taken. CLINICAL REHABILITATION IMPACT: This study guide how to rehabilitate patients with acute respiratory distress syndrome with COVID-19 during intensive care unit in a safe way.

Appropriate use of tocilizumab in COVID-19 infection.

OBJECTIVE: This study aimed to describe the effectiveness and optimum use of tocilizumab (TCZ) treatment by the support of clinical, laboratory and radiologic observations. METHODS: All patients were followed up in the hospital with daily interleukin-6 (IL-6), C-reactive protein (CRP), ferritin, d-dimer, full blood count, and procalcitonin. Thoracic computed tomography (CT) was performed on admission, when oxygen support was necessary, and seven days after TCZ started. Disease course of the patients was grouped as severe or critical, according to their clinical, laboratory and radiologic evaluations. RESULTS: Forty-three patients were included: 70% were male; the median age was 64 years (minimum-maximum: 27-94); and six (14%) patients died. The median duration of oxygen support before the onset of TCZ was shorter among the severe patient group than the critical patient group (1 vs. 4 days, p < 0.001). Three cases of 21 (14%) who received TCZ in the ward were transferred to ICU, and none of them died. The levels of IL-6, CRP, ferritin, d-dimer, and procalcitonin were significantly lower in the severe cases group than the critical cases group (p = 0.025, p = 0.002, p = 0.008, p = 0.002, and p = 0.001, respectively). Radiological improvement was observed in severe cases on the seventh day of TCZ. Secondary bacterial infection was detected in 41% of critical cases, but none of the severe ones. CONCLUSION: Earlier use of TCZ in COVID-19 infection was beneficial for survival, length of hospitalization and duration of oxygen support. The recommendation for administration of TCZ was based on an increase in requirement of oxygen support, progression in thoracic CT, and elevation of inflammation markers, including IL-6, CRP, ferritin, and d-dimer, and decrease in % lymphocytes.