Utility of Thromboelastography and velocity curve derivative in diagnosing COVID-19 associated coagulopathy.

BACKGROUND: COVID-19 associated coagulopathy (CAC) can either be localized or systemic hypercoagulable state with increased risk of thromboembolism. This study looked into the usefulness of Thromboelastography (TEG) and the velocity curve (V-curve) derivative from TEG in diagnosing and differentiating different stages of CAC. MATERIALS AND METHODS: A prospective single cohort study of RT-PCR confirmed COVID-19 patients was carried out for 2 weeks. Severe COVID-19 patients in the adult critical care units with a TEG report were recruited for the study. Citrated kaolin TEG was performed on the day of admission before anticoagulation. TEG parameters included were R and K time, alpha angle, maximum amplitude, clotting index, lysis at 30 min. The first-degree velocity curve of TEG is plotted as V-curve which extrapolates thrombus generation potential. Parameters analyzed were the maximum rate of thrombus generation as well as thrombus generated (TG). RESULTS: The study included 43 patients with an average age of 58.34 (±15.35). TEG as well as V-curve of all the patients were hypercoagulable compared with age-matched reference range. We had 79.06% of patients in hypercoagulable stage. The mortality rate was 32.56% and 30.23% developed thrombotic incidents. Patients who succumbed to death had prolonged PT, aPTT, MA, Ly30, with a reduced TG (p < .05). The presence of fibrinolysis was associated with thromboembolism (OR = 6.76, CI = 1.48-25.82). Repeat TEG was done randomly in 11 patients and revealed a persistent hypercoagulable stage with increasing fibrinolysis activity. CONCLUSION: TEG is a useful tool in diagnosing and categorizing Coagulopathy associated with COVID-19.

Utility of Pulse Oximetry Oxygen Saturation (SpO2) with Incorporation of Positive End-Expiratory Pressure (SpO2 ∗10/FiO2 ∗PEEP) for Classification and Prognostication of Patients with Acute Respiratory Distress Syndrome.

Background: Conventionally, PaO2/FiO2 (P/F ratio) has been used to categorize severity of acute respiratory distress syndrome (ARDS) and prognostication of outcome. Recent literature has shown that incorporation of positive end-expiratory pressure (PEEP) into the P/F ratio (PaO2 ∗10/FiO2 ∗PEEP or P/FP∗10) has a much better prognostic ability in ARDS as compared to P/F ratio. The aim of this study was to correlate SpO2 ∗10/FiO2 ∗PEEP (S/FP∗10) to PaO2 ∗10/FiO2 ∗PEEP (P/FP∗10) and evaluate the utility of S/FP∗10 as a reliable noninvasive indicator of oxygenation in ARDS to avoid repeated arterial blood sampling. Aim: To evaluate if pulse oximetry is a reliable indicator of oxygenation in ARDS patients by calculating SpO2 ∗10/FiO2 ∗PEEP (S/FP∗10). The primary objective was to determine the correlation of S/FP∗10 to P/FP∗10 ratio in ARDS patients. The secondary objective was to determine the cut-off value of S/FP∗10 ratio to predict severe ARDS and survival. Methods: Patients aged 18-80 years on invasive mechanical ventilation (MV) diagnosed with ARDS as defined by the Berlin definition were included. The values of PaO2, FiO2, and SpO2 were collected at three different time points. They were at baseline, i.e., after intubation and initiation of MV (within one hour of intubation), day one (1-24 hours of MV), and day three (48-72 hours of MV). The primary outcome was survival at the end of intensive care unit (ICU) stay. Results: A total of 85 patients with ARDS on invasive MV were included. The data points were obtained at baseline, day one, and day three of MV. S/FP∗10 ratio has an excellent correlation to P/FP∗10 ratio at baseline and day three of invasive MV (r = 0.831 and 0.853, respectively; p < 0.001) and has a strong correlation on day one of invasive MV (r = 0.733, p < 0.001). S/FP∗10 ratio ≤116 at baseline has excellent discriminant function to be categorized as severe ARDS as per Berlin definition (AUC: 0.925, p < 0.001, 90% sensitivity, 93% specificity, CI: [0.862-0.988]). The increase in S/FP∗10 ratio by ≥64.40 from baseline to day three of MV is a good predictor of survival (AUC: 0.877, p < 0.001, 73.5% sensitivity, 97% specificity, CI: [0.803-0.952]). Conclusion: S/FP∗10 has a strong correlation to P/FP∗10 in ARDS patients. S/FP∗10 ≤116 has an excellent discriminant function to be categorized as severe ARDS. The S/FP∗10 ratio on day three of MV and the change in S/FP∗10 ratio from baseline and day one to day three of MV are good predictors of survival in ARDS patients. This trial is registered with CTRI/2020/04/024940.

ADAMTS13 factor deficiency in severe COVID-19 may not be immune mediated - report from a pilot study.

BACKGROUND: The assessment of ADAMTS13 factor activity and inhibitor levels was conducted in severe COVID-19 patients as an observational study. RESULTS: A total of 14 patients were included and the average ADAMTS13 activity level at the time of admission was 28.54±30.74% (range 1.83-86.67%) which was reduced compared to controls (88.09±14.77). Nine patients had reduced ADAMTS13 factor activity (<40%) and 77.7% among them had severe deficiency (<10% activity). ADAMTS13 inhibitor was positive (>15 IU/mL) only in two patients and an overall mean value was 8.15±5.8. Elevated D-Dimer and length of hospital stay had significant correlation with ADAMTS13 activity (-0.247 and 0.306 respectively). No features of thrombotic microangiopathy were observed and hence no plasma exchange was performed. CONCLUSION: Reduced ADAMTS13 factor activity without inhibitor development may give a clue to the disease progress in COVID-19.

"Post-COVID-19 syndrome:" The New Pandemic Affecting Healthcare Workers and How the Frontline Warriors Are Battling it.

OBJECTIVES: "Post-COVID-19 syndrome," which may be the new pandemic, has affected various domains of quality of life; even among those who have recovered from mild COVID-19 disease. The aim of our study was to explore the health, social and psychological impact on healthcare workers (HCWs) who have recovered from active COVID-19 illness and highlight their needs post-recovery. MATERIALS AND METHODS: It was a web-based survey study. A total of 163 eligible consenting HCWs participated in this survey. The Institutional Ethical Committee approval was obtained before study recruitment and the study was registered with the Clinical Trial Registry of India. Each participant responded to 25 questions. RESULTS: Among those participated, 51% were doctors, 32% were nurses and others were allied health professionals and students. About 82% had mild COVID-19 illness and 40% required hospitalisation for COVID-19 treatment. In the post-recovery period, 66% experienced health issues and fatigue on mild exertion was the most common symptom (42.94%). It was followed by anosmia and ageusia (21.47%), headache and myalgia (15.34%) and breathlessness (8.59%). About 82% HCW felt the need for a post-COVID-19 recovery health care unit. Potential risk of infecting family members was the most common concern (53.46%) followed by the fear of contracting the virus again (46.54%). About 35% of HCW experienced the fear of developing post-COVID-19 complications. About 78% of HCW did not report any psychological concerns, but one-third were stressed due to the financial impact. CONCLUSION: Post-COVID-19 syndrome impacts all domains of quality of life. Fatigue, loss of taste and smell, headache, myalgia and breathlessness continue to persist beyond recovery of active illness. Most of the HCWs emphasised the need to set up post-COVID-19 care units. The fear of contracting the virus again and financial drain due to hospital expenses continued to distress HCWs.

COVID-19 Pandemic: Impact on Admission, Diagnosis, and Treatment of Non-COVID-19 Patients Admitted to SARI ICU.

Background: Coronavirus disease 2019 (COVID-19) pandemic has caused a huge burden on healthcare services worldwide, severely affecting the management of non-COVID-19 patients as well. The Government of India has updated guidelines for the clinical management of COVID-19 illness, including severe acute respiratory infections (SARI) definition for triaging suspected COVID-19 cases in an isolated intensive care unit (ICU). The aim of this study was to estimate the adherence of clinicians in triaging COVID-19 suspects as per SARI definition to SARI ICU. This study also observed the impact of such triaging on admission, diagnosis, and treatment process of non-COVID-19 patients admitted to SARI ICU. Patients and methods: This cross-sectional study was conducted in a designated SARI ICU of two tertiary care medical college hospitals involving 78 patients from the month of June to July 2020. Data related to demographics, the severity of illness, advanced life supports, delay in diagnosis, intervention, and treatment of patients in SARI ICU due to suspected COVID-19 status were documented. Results: Adherence to SARI definition for triaging COVID-19-suspect cases was 19.2%. Despite hindrance in diagnosis (17.9%) and treatment (12.8%), mortality among patients in SARI ICU was limited to 14.10%. Results were insignificant when checked for various factors associated with mortality. Conclusion: Nonadherence to SARI definition may lead to undue delay in diagnosis, intervention, and treatment of non-COVID-19 cases. This may result in increased morbidity, mortality, and economic burden on patients and the healthcare system. key message: A rationale and just utilization of healthcare resources are need of the hour in the face of an enormous volume of SARI cases during COVID-19 pandemic. SARI criteria as implemented by the Ministry of Health and Family Welfare (MOHFW), Government of India, are a very important tool in triaging of COVID-19-suspect cases. Adequate measures should be in place in order to mitigate the inadequacies and deficiencies in the treatment of non-COVID-19 cases, which have occurred as a result of COVID-19 pandemic. How to cite this article: Arunachala S, Venkatesh BT, Bhatt MT, Puranik A, Rao S, Ravindranath S. COVID-19 Pandemic: Impact on Admission, Diagnosis, and Treatment of Non-COVID-19 Patients Admitted to SARI ICU. Indian J Crit Care Med 2021;25(8):853-859.

A Multicenter Cross-sectional Questionnaire-based Study to Know the Practices and Strategies of Ventilatory Management of COVID-19 Patients among the Treating Physicians.

INTRODUCTION: COVID-19 has been declared a pandemic by the World Health Organization (WHO). Many of the COVID-19 patients develop acute respiratory distress syndrome (ARDS) and require ventilatory support based on their severity for which conventional strategies are being used along with few newer strategies. We conducted this multicenter survey to know the physician's current ventilation strategies adopted for the care of COVID-19 patients. MATERIALS AND METHODS: The survey was conducted after taking the ethical committee clearance. The web-based multicenter, cross-sectional questionnaire study was sent to physicians, who were involved in the management of COVID-19 patients. The questionnaire was segregated into three parts: part one consisted of general information and consent form, part two was concerned regarding demographic characteristics, and part three was concerned about their practices and strategies for ventilation of COVID-19 patients. RESULTS: A total of 223 responders replied for the questionnaire; 190 participated in the study saying that they are involved in the management of COVID-19 patients. The answers to the questionnaires were expressed as a percentage of total responses. 86% of the respondents said they have a designated intensive care unit (ICU) and 89% of the responders said they have an intubation/extubation protocol for suspect/confirmed COVID-19 patients. The responses of junior residents (JRs), senior residents (SRs), assistant professors/junior consultants, and professors/consultants were analyzed separately, and a few significant differences were observed. 39% of JRs were aware of prone ventilation as the most effective rescue ventilation strategy compared to 69% of consultants/professors. Extracorporeal membranous oxygenation (ECMO) strategy was also more significant in consultants/professors (40%) vs JRs (12%). The responders were also diverged based on medical college and corporate hospitals, and their responses were noted. Most commonly, responders in the corporate hospitals had a facility to ventilate COVID-19 patients in a negative pressure isolation facility compared to a nonnegative pressure room isolation facility in medical colleges. CONCLUSION: Most of the responders were practicing ventilation strategies in a standard manner. JRs need to undergo further training in a few aspects of the ventilatory management, and also, they need to update themselves with newer treatment modalities as they keep evolving. Medical colleges are providing at par facility compared to corporate hospitals except for few advance care facilities. CLINICAL SIGNIFICANCE: This study highlights the current practice of ventilatory management of COVID-19 patients, which is satisfactory. The survey can be used to develop study tools, to educate resident doctors, to further improve quality of care of critical COVID-19 patients. HOW TO CITE THIS ARTICLE: Maddani SS, Deepa HC, Rao S, Chaudhuri S. A Multicenter Cross-sectional Questionnaire-based Study to know the Practices and Strategies of Ventilatory Management of COVID-19 Patients among the Treating Physicians. Indian J Crit Care Med 2020;24(8):643-648.