Therapeutic plasma exchange for coronavirus disease-2019 triggered cytokine release syndrome; a retrospective propensity matched control study.

BACKGROUND: Cytokine release syndrome (CRS) plays a pivotal role in the pathophysiology and progression of Coronavirus disease-2019 (COVID-19). Therapeutic plasma exchange (TPE) by removing the pathogenic cytokines is hypothesized to dampen CRS. OBJECTIVE: To evaluate the outcomes of the patients with COVID-19 having CRS being treated with TPE compared to controls on the standard of care. METHODOLOGY: Retrospective propensity score-matched analysis in a single centre from 1st April to 31st July 2020. We retrospectively analyzed data of 280 hospitalized patients developing CRS initially. PSM was used to minimize bias from non-randomized treatment assignment. Using PSM 1:1, 90 patients were selected and assigned to 2 equal groups. Forced matching was done for disease severity, routine standard care and advanced supportive care. Many other Co-variates were matched. Primary outcome was 28 days overall survival. Secondary outcomes were duration of hospitalization, CRS resolution time and timing of viral clearance on Polymerase chain reaction testing. RESULTS: After PS-matching, the selected cohort had a median age of 60 years (range 32-73 in TPE, 37-75 in controls), p = 0.325 and all were males. Median symptoms duration was 7 days (range 3-22 days' TPE and 3-20 days controls), p = 0.266. Disease severity in both groups was 6 (6.6%) moderate, 40 (44.4%) severe and 44 (49%) critical. Overall, 28-day survival was significantly superior in the TPE group (91.1%), 95% CI 78.33-97.76; as compared to PS-matched controls (61.5%), 95% CI 51.29-78.76 (log rank 0.002), p<0.001. Median duration of hospitalization was significantly reduced in the TPE treated group (10 days vs 15 days) (p< 0.01). CRS resolution time was also significantly reduced in the TPE group (6 days vs. 12 days) (p< 0.001). In 71 patients who underwent TPE, the mortality was 0 (n = 43) if TPE was done within the first 12 days of illness while it was 17.9% (deaths 5, n = 28 who received it after 12th day (p = 0.0045). CONCLUSION: An earlier use of TPE was associated with improved overall survival, early CRS resolution and time to discharge compared to SOC for COVID-19 triggered CRS in this selected cohort of PS-matched male patients from one major hospital in Pakistan.

Percutaneous Tracheostomy by Physician Intensivists.

OBJECTIVE: To assess the safety of percutaneous tracheostomy when performed by physician intensivists. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Adult Medical ICU in the Department of Critical Care Medicine, Military Hospital, Rawalpindi, Pakistan, from September 2013 to August 2016. METHODOLOGY: Departmental record for percutaneous tracheostomies, performed by physician intensivifts, was evaluated. Variables studied were underlying primary diagnosis, details of the operating doctors, presence of immediate complications, departmental protocol for the procedure, pre-procedure safety checklist, written instructions on procedure steps, use of ultrasound and bronchoscopy. Portex Percutaneous Dilation Tracheostomy Kit with Single-Stage Dilator was used in all the patients. RESULTS: Fifty-six percutaneous tracheostomy procedures were performed with a male to female ratio 3:1; more than 2/3rd (80%) had an underlying neurological illness. All doctors performing the procedures were physicians having minimum qualification of Fellowship with at least one year experience in intensive care and had observed at least five procedures. Departmental protocol for the procedure was followed in all the cases. Minor complications were observed in three patients (5.35%). These included para-tracheal misplacement, accidental de-cannulation, and endotracheal tube cuff puncture. None of the patient died due to direct complications of the procedure. CONCLUSION: Percutaneous tracheostomy is safe in Medical ICUs of developing countries, when performed by experienced physician intensivists under defined protocols.