[Intensive care unit treatment for patients suffering from COVID-19: The second wave Neuchâtel experience]. / Traitement des patients souffrant de Covid-19 aux soins intensifs†: l'expérience neuchâteloise de la deuxième vague.

Between mid-October 2020 and mid-January 2021, during the second wave of COVID-19 pandemia, 125 patients have been admitted in the intensive care units of Neuchâtel network hospitals. To manage this flow, the bed capacity of intensive care unit increased by 240%. Each patient received corticosteroids, an increased prophylactic anticoagulation and an antibiotic. Similarly to the first wave, 51% patients received mechanical ventilation, 55% of which in prone position. Concerning the drug treatments, 16 patients were treated with tocilizumab and 4 with remdesivir. Despite an unprecedented rise in the number of ventilated beds, 15 patients were transferred out of the region of Neuchâtel in order to prevent a saturation point of the system. The mortality rate in the intensive care unit reached 16% of the admitted and non-transported patients.

Entre mi-octobre 2020 et mi-janvier 2021, durant la deuxième vague de pandémie de Covid-19, 125 patients ont séjourné aux soins intensifs du Réseau hospitalier neuchâtelois. Pour pouvoir recevoir cet afflux, la capacité d'accueil a augmenté de 240 %. Tous les patients ont bénéficié d'un traitement par glucocorticoïdes ainsi que d'une anticoagulation prophylactique majorée et d'une antibiothérapie. Similairement à la première vague, 51 % des patients ont nécessité une ventilation mécanique, dont 55 % ont bénéficié d'une ventilation en décubitus ventral. Par ailleurs, 16 patients ont bénéficié du tocilizumab et 4 du remdésivir. Malgré une augmentation hors norme du nombre de lits ventilés, 15 patients ont dû être transférés hors canton afin de prévenir une saturation du système. Le taux de mortalité des patients non transférés admis aux soins intensifs s'est élevé à 16 %.

Timing of VV-ECMO therapy implementation influences prognosis of COVID-19 patients.

INTRODUCTION: Current knowledge on the use of extracorporeal membrane oxygenation (ECMO) in COVID-19 remains limited to small series and registry data. In the present retrospective monocentric study, we report on our experience, our basic principles, and our results in establishing and managing ECMO in critically ill COVID-19 patients. METHODS: A cohort study was conducted in patients with severe acute respiratory distress syndrome (ARDS) related to COVID-19 pneumonia admitted to the ICU of the Geneva University Hospitals and supported by VV-ECMO from March 14 to May 31. The VV-ECMO implementation criteria were defined according to an institutional algorithm validated by the local crisis unit and the Swiss Society of Intensive Care Medicine. RESULTS: Out of 137 ARDS patients admitted to our ICU, 10 patients (age 57 ± 4 years, BMI 31.5 ± 5 kg/m2 , and SAPS II score 56 ± 3) were put on VV-ECMO. The mean duration of mechanical ventilation before ECMO and mean time under ECMO were 7 ± 3 days and 19 ± 11 days, respectively. The ICU and hospital length of stay were 26 ± 11 and 35 ± 10 days, respectively. The survival rate for patients on ECMO was 40%. The comparative analysis between survivors and non-survivors highlighted that survivors had a significantly shorter mechanical ventilation duration before ECMO (4 ± 2 days vs. 9 ± 2 days, p = 0.01). All the patients who had more than 150 h of mechanical ventilation before the application of ECMO ultimately died. CONCLUSION: The present results suggest that VV-ECMO can be safely utilized in appropriately selected COVID-19 patients with refractory hypoxemia. The main information for clinicians is that late VV-ECMO therapy (i.e., beyond the seventh day of mechanical ventilation) seems futile.

[Intensive care unit treatment for patients suffering from COVID-19: the Neuchâtel experience]. / Traitement des patients souffrant de Covid-19 aux soins intensifs : l'expérience neuchâteloise.

SARS-CoV-2 appeared in Switzerland in February 2020 and reached Neuchâtel in March. During 2 months, 43 patients were admitted in the intensive care unit. 55% of ICU admitted patients received mechanical ventilation, 66% of which in prone position. All patients were treated with hydroxychloroquine. The majority of patients received antiretrovirals. One patient was treated with remdesivir. Near half the patients were treated with tocilizumab. One patient received a convalescent plasma obtained from patients who had recovered from COVID-19. The mortality rate was 17%. These results are in line with those from university intensive care units in Switzerland.

Le SARS-CoV-2 est apparu en Suisse en février 2020, avec les premiers cas déclarés dans le canton de Neuchâtel en mars. 43 patients ont été admis aux soins intensifs du Réseau hospitalier neuchâtelois sur une période de 2 mois. 55 % ont été intubés et ventilés, dont 66 % ont bénéficié d'une ventilation en décubitus ventral. Tous les patients ont été traités par hydroxychloroquine. Les traitements antirétroviraux ont été introduits dans la majorité des cas. Une patiente a bénéficié de remdésivir. Près de la moitié des patients ont été traités par tocilizumab. Un patient a bénéficié de la transfusion de plasma de patients convalescents. Le taux de mortalité a atteint 17 %. Ces résultats sont comparables à ceux des centres universitaires de soins intensifs en Suisse.

Veno-arterial extracorporeal membrane oxygenation: an overview of different cannulation techniques.

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has known a widespread application over the last decade and is now an effective and valuable therapeutic option in refractory cardiogenic shock of various etiologies. In this subgroup of critically ill and unstable patients in cardiogenic shock, VA-ECMO allows, on the one hand, temporary hemodynamic stabilization with improvement of end-organ function and, on the other hand, gives the time to perform complementary diagnostic exams and to decide the therapeutic strategy in these high-risk candidates for immediate long-term mechanical circulatory support (MCS) implantation. VA-ECMO could also be suggested as a rescue therapeutic option for refractory cardiac arrest. It showed promising results in the specific setting of in-hospital cardiac arrest and survival rates with good neurological outcome are reported between 20% and 40%. Conversely, there are contrasting data in the literature about survival after VA-ECMO for out-of-hospital cardiac arrest, as results are highly dependent on low-flow time. The aim of the present report is to offer an overview of different cannulation techniques of VA-ECMO.

Veno-venous extracorporeal membrane oxygenation: cannulation techniques.

The development of extracorporeal membrane oxygenation (ECMO) technology allows a new approach for the intensive care management of acute cardiac and/or respiratory failure in adult patients who are not responsive to conventional treatment. Current ECMO therapies provide a variety of options for the multidisciplinary teams who are involved in the management of these critically ill patients. In this regard, veno-venous ECMO (VV-ECMO) can provide quite complete respiratory support, even if this highly complex technique presents substantial risks, such as bleeding, thromboembolic events and infection. While VV-ECMO circuits usually include the cannulation of two vessels (double cannulation) in its classic configuration, the use of a single cannula is now possible for VV-ECMO support. Recently, experienced centers have employed more advanced approaches by cannulating three vessels (triple cannulation) which follows veno-arterio-venous (VAV) or veno-arterio-pulmonary-arterial cannulation (VAPa). However, 'triple' cannulation expands the field of application but increases the complexity of ECMO systems. In the present review, the authors focus on the indications for VV-ECMO, patient assessment prior to cannulation, the role of ultrasound-guided vessel puncture, double lumen single bicaval cannulations, and finally triple cannulation in VV-ECMO.

[Non-invasive ventilation: indication for acute respiratory failure]. / Ventitation non invasive: indications dans l'insuffisance respiratoire aiguë.

Mask or Non-invasive ventilation (NIV) is used for critically ill patients with acute respiratory failure (ARF): acute exacerbation of chronic obstructive bronchopulmonary disease and severe cardiogenic pulmonary edema are considered as the best indications for NIV since it improves the outcome of these patients. This technique is also proposed for hypoxemic respiratory failure, with more various results. To be effective here, NIV must be established early enough and should not delay intubation if required. NIV is also proposed after invasive ventilation or in patients in whom endotracheal intubation is not desirable. Its use has increased and its effectiveness seems to have improved, due to a better understanding of the technique but also thanks to technological progress.