Echocardiography findings in COVID-19 patients admitted to intensive care units: a multi-national observational study (the ECHO-COVID study).

PURPOSE: Severely ill patients affected by coronavirus disease 2019 (COVID-19) develop circulatory failure. We aimed to report patterns of left and right ventricular dysfunction in the first echocardiography following admission to intensive care unit (ICU). METHODS: Retrospective, descriptive study that collected echocardiographic and clinical information from severely ill COVID-19 patients admitted to 14 ICUs in 8 countries. Patients admitted to ICU who received at least one echocardiography between 1st February 2020 and 30th June 2021 were included. Clinical and echocardiographic data were uploaded using a secured web-based electronic database (REDCap). RESULTS: Six hundred and seventy-seven patients were included and the first echo was performed 2 [1, 4] days after ICU admission. The median age was 65 [56, 73] years, and 71% were male. Left ventricle (LV) and/or right ventricle (RV) systolic dysfunction were found in 234 (34.5%) patients. 149 (22%) patients had LV systolic dysfunction (with or without RV dysfunction) without LV dilatation and no elevation in filling pressure. 152 (22.5%) had RV systolic dysfunction. In 517 patients with information on both paradoxical septal motion and quantitative RV size, 90 (17.4%) had acute cor pulmonale (ACP). ACP was associated with mechanical ventilation (OR > 4), pulmonary embolism (OR > 5) and increased PaCO2. Exploratory analyses showed that patients with ACP and older age were more likely to die in hospital (including ICU). CONCLUSION: Almost one-third of this cohort of critically ill COVID-19 patients exhibited abnormal LV and/or RV systolic function in their first echocardiography assessment. While LV systolic dysfunction appears similar to septic cardiomyopathy, RV systolic dysfunction was related to pressure overload due to positive pressure ventilation, hypercapnia and pulmonary embolism. ACP and age seemed to be associated with mortality in this cohort.

Assessment of Right Ventricular Mechanics by 3D Transesophageal Echocardiography in the Early Phase of Acute Respiratory Distress Syndrome.

Aim: To compare global and axial right ventricular ejection fraction in ventilated patients for moderate-to-severe acute respiratory distress syndrome (ARDS) secondary to early SARS-CoV-2 pneumonia or to other causes, and in ventilated patients without ARDS used as reference. Methods: Retrospective single-center cross-sectional study including 64 ventilated patients: 21 with ARDS related to SARS-CoV-2 (group 1), 22 with ARDS unrelated to SARS-CoV-2 (group 2), and 21 without ARDS (control group). Real-time three-dimensional transesophageal echocardiography was performed for hemodynamic assessment within 24 h after admission. Contraction pattern of the right ventricle was decomposed along the three anatomically relevant axes. Relative contribution of each spatial axis was evaluated by calculating ejection fraction along each axis divided by the global right ventricular ejection fraction. Results: Global right ventricular ejection fraction was significantly lower in group 2 than in both group 1 and controls [median: 43% (25-75th percentiles: 40-57) vs. 58% (55-62) and 65% (56-68), respectively: p < 0.001]. Longitudinal shortening had a similar relative contribution to global right ventricular ejection fraction in all groups [group 1: 32% (28-39), group 2: 29% (24-40), control group: 31% (28-38), p = 0.6]. Radial shortening was lower in group 2 when compared to both group 1 and controls [45% (40-53) vs. 57% (51-62) and 56% (50-60), respectively: p = 0.005]. The relative contribution of right ventricular shortening along the anteroposterior axis was not statistically different between groups [group 1: 51% (41-55), group 2: 56% (46-63), control group; 56% (50-64), p = 0.076]. Conclusion: During early hemodynamic assessment, the right ventricular systolic function appears more impaired in ARDS unrelated to SARS-CoV-2 when compared to early stage SARS-CoV-2 ARDS. Radial shortening appears more involved than longitudinal and anteroposterior shortening in patients with ARDS unrelated to SARS-CoV-2 and decreased right ventricular ejection fraction.

High prevalence of infections in non-COVID-19 patients admitted to the Emergency Department with severe lymphopenia.

BACKGROUND: In the Emergency Department (ED), early and accurate recognition of infection is crucial to prompt antibiotic therapy but the initial presentation of patients is variable and poorly characterized. Lymphopenia is commonly associated with bacteraemia and poor outcome in intensive care unit patients. The objective of this retrospective study was to assess the prevalence of community-acquired infection in a cohort of unselected patients admitted to the ED with undifferentiated symptoms and severe lymphopenia. METHODS: This is a retrospective single-center study conducted over a 1 year-period before the COVID-19 pandemic. Consecutive adult patients admitted to the ED with severe lymphopenia (lymphocyte count < 0.5 G/L) were studied. Patients with hematological or oncological diseases, HIV infection, hepato-cellular deficiency, immunosuppression, or patients over 85 years old were excluded. Diagnoses of infection were validated by an independent adjudication committee. The association between various parameters and infection was assessed using a multivariate logistic regression analysis. RESULTS: Of 953 patients admitted to the ED with severe lymphopenia, 245 were studied (148 men; mean age: 63 ± 19 years). Infection was confirmed in 159 patients (65%) (bacterial: 60%, viral: 30%, other: 10%). Only 61 patients (25%) were referred to the ED for a suspected infection. In the univariate analysis, SIRS criteria (OR: 5.39; 95%CI: 3.04-9.70; p < 0.001) and temperature ≥ 38.3 °C (OR: 10.95; 95%CI: 5.39-22.26; p < 0.001) were strongly associate with infection. In the multivariate analysis, only SIRS criteria (OR: 2.4; 95%CI: 1.48-3.9; p < 0.01) and fever (OR: 3.35; 95%CI: 1.26-8.93; p = 0.016) were independently associated with infection. CONCLUSIONS: The prevalence of underlying infection is high in patients admitted to the ED with lymphopenia, irrespective of the reason for admission. Whether lymphopenia could constitute a valuable marker of underlying infection in this clinical setting remains to be confirmed prospectively in larger cohorts. TRIAL REGISTRATION: No registration required as this is a retrospective study.

Immature granulocytes can help the diagnosis of pulmonary bacterial infections in patients with severe COVID-19 pneumonia.

During COVID-19, immature granulocyte (IG) concentration is heterogeneous with higher concentrations than those found in bacterial sepsis. We investigated the relationship between IG levels at ICU admission and on days 7 (± 2) and 15 (± 2) and associated pulmonary bacterial infections in intensive care unit (ICU) patients hospitalized for an acute respiratory distress syndrome (ARDS) related to SARS-CoV-2. Patients with associated pulmonary bacterial infection had a peak of IGs. IG thresholds of 18% or 2 G/L allowed discriminating patients with ventilator associated pneumonia with 100% sensitivity and specificity. Our study supports that IGs could help identifying pulmonary bacterial infections in this population.