RESUMO
Background: Patients with coronavirus disease 2019 (COVID-19) pneumonitis may progress to acute respiratory distress syndrome (ARDS) requiring endotracheal intubation and prolonged mechanical ventilation (MV). There are limited data on the optimum time of tracheostomy in COVID-19 patients progressing to ARDS. Methods: This was a retrospective observational study of all patients diagnosed with COVID-19 who progressed to ARDS requiring MV and undergone tracheostomy. We aimed to conduct a study to observe the impact of tracheostomy on the mortality of these patients and the impact of timing of tracheostomy on outcomes in these patients. Results: Of the total 162 patients, 128 (79%) were male and 34 (21%) were female. Early group (≤14 days) comprised 37 patients, while 125 patients were included in late group (>14 days). A total of 91 (56%) patients died at the end of this period. Among the patients who died, 21were included in the early group, while the late group comprised the remaining 70 patients. On comparing the patients who died, the duration of stay in the intensive care unit (ICU) was significantly different in the two groups (median [Q1-Q3]: 12 [11-13] vs. 23 [19-28] days, P < 0.001). The number of days to death also differed significantly between the two groups (median [Q1-Q3]: 28 [21-38] vs. 24 [14-30] days, P = 0.009). Conclusion: Early tracheostomy is associated with significantly shorter length of ICU stay in COVID-19 patients that have progressed to ARDS. However, the timing of tracheostomy had no influence on the overall mortality rate in these patients.
RESUMO
Carbon monoxide poisoning (COP) is a common cause of death due to poisoning. After COP, a significant number of patients may develop a distinct type of neurological dysfunction called delayed neurological sequel (DNS). Recently, we came across a disaster of COP cases after a fire in a shared accommodation. The hostel was overcrowded and had a faulty air-conditioning/exhaust system. A total of five patients with loss of consciousness and shock were brought to us. They were diagnosed with acute COP based on their history of exposure to carbon monoxide (CO) and elevated carboxyhemoglobin levels in blood gas measurements. All patients were intubated and mechanically ventilated. Standard intensive care management was given to them, which included oxygenation, sedation, fluid resuscitation, and vasopressors. Their carboxyhemoglobin was rapidly reversed with normobaric oxygen therapy (NBO2). Three patients showed good response and neurological recovery after NBO2. Unfortunately, two patients developed DNS. DNS is a neuropsychological condition that may have cognitive, psychiatric, vestibulocochlear, motor, sensory, or diffuse demyelinating effects after COP. DNS is diagnosed in patients with a typical history of exposure to CO and a constellation of signs and symptoms. Neuroimaging, specifically magnetic resonance imaging of the brain with gadolinium contrast, is the method of choice for diagnosis. Treatment of DNS after COP begins with anticipation. All patients should receive appropriate oxygen therapy to bring down carboxyhemoglobin as soon as possible. Hyperbaric oxygen therapy (HBO2) for the treatment of COP and prevention of DNS is still debatable. In the available medical literature, there are conflicting recommendations regarding the use of HBO2 in COP/DNS. Moreover, apart from a lack of consensus, there is also a lack of clarity about optimum timing, duration, atmospheric pressure, and number of sessions of HBO2 in preventing DNS after COP. The development of DNS after COP is not directly responsible for mortality, but recovery sometimes takes a long time, which can contribute to increased morbidity and costs of treatment.
