Severe Acute Respiratory Syndrome-Associated Coronavirus 2 Infection and Organ Dysfunction in the ICU: Opportunities for Translational Research

OBJECTIVES

Since the beginning of the coronavirus disease 2019 pandemic, hundreds of thousands of patients have been treated in ICUs across the globe. The severe acute respiratory syndrome-associated coronavirus 2 virus enters cells via the angiotensin-converting enzyme 2 receptor and activates several distinct inflammatory pathways, resulting in hematologic abnormalities and dysfunction in respiratory, cardiac, gastrointestinal renal, endocrine, dermatologic, and neurologic systems. This review summarizes the current state of research in coronavirus disease 2019 pathophysiology within the context of potential organ-based disease mechanisms and opportunities for translational research.

DATA SOURCES

Investigators from the Research Section of the Society of Critical Care Medicine were selected based on expertise in specific organ systems and research focus. Data were obtained from searches conducted in Medline via the PubMed portal, Directory of Open Access Journals, Excerpta Medica database, Latin American and Caribbean Health Sciences Literature, and Web of Science from an initial search from December 2019 to October 15, 2020, with a revised search to February 3, 2021. The medRxiv, Research Square, and clinical trial registries preprint servers also were searched to limit publication bias.

STUDY SELECTION

Content experts selected studies that included mechanism-based relevance to the severe acute respiratory syndrome-associated coronavirus 2 virus or coronavirus disease 2019 disease.

DATA EXTRACTION

Not applicable.

DATA SYNTHESIS

Not applicable.

CONCLUSIONS

Efforts to improve the care of critically ill coronavirus disease 2019 patients should be centered on understanding how severe acute respiratory syndrome-associated coronavirus 2 infection affects organ function. This review articulates specific targets for further research.

Muscarinic Cholinergic Receptor Agonist and Peripheral Antagonist for Schizophrenia

BACKGROUND

The muscarinic receptor agonist xanomeline has antipsychotic properties and is devoid of dopamine receptor-blocking activity but causes cholinergic adverse events. Trospium is a peripherally restricted muscarinic receptor antagonist that reduces peripheral cholinergic effects of xanomeline. The efficacy and safety of combined xanomeline and trospium in patients with schizophrenia are unknown.

METHODS

In this double-blind, phase 2 trial, we randomly assigned patients with schizophrenia in a 1:1 ratio to receive twice-daily xanomeline-trospium (increased to a maximum of 125 mg of xanomeline and 30 mg of trospium per dose) or placebo for 5 weeks. The primary end point was the change from baseline to week 5 in the total score on the Positive and Negative Syndrome Scale (PANSS; range, 30 to 210, with higher scores indicating more severe symptoms of schizophrenia). Secondary end points were the change in the PANSS positive symptom subscore, the score on the Clinical Global Impression-Severity (CGI-S) scale (range, 1 to 7, with higher scores indicating greater severity of illness), the change in the PANSS negative symptom subscore, the change in the PANSS Marder negative symptom subscore, and the percentage of patients with a response according to a CGI-S score of 1 or 2.

RESULTS

A total of 182 patients were enrolled, with 90 assigned to receive xanomeline-trospium and 92 to receive placebo. The PANSS total score at baseline was 97.7 in the xanomeline-trospium group and 96.6 in the placebo group. The change from baseline to week 5 was -17.4 points with xanomeline-trospium and -5.9 points with placebo (least-squares mean difference, -11.6 points; 95% confidence interval, -16.1 to -7.1; P<0.001). The results for the secondary end points were significantly better in the xanomeline-trospium group than in the placebo group, with the exception of the percentage of patients with a CGI-S response. The most common adverse events in the xanomeline-trospium group were constipation, nausea, dry mouth, dyspepsia, and vomiting. The incidences of somnolence, weight gain, restlessness, and extrapyramidal symptoms were similar in the two groups.

CONCLUSIONS

In a 5-week trial, xanomeline-trospium resulted in a greater decrease in the PANSS total score than placebo but was associated with cholinergic and anticholinergic adverse events. Larger and longer trials are required to determine the efficacy and safety of xanomeline-trospium in patients with schizophrenia. (Funded by Karuna Therapeutics and the Wellcome Trust; ClinicalTrials.gov number, NCT03697252.).

Protocolized ventilator weaning verses usual care: A randomized controlled trial

Background:

Protocolized ventilator weaning (PW) strategies utilizing spontaneous breathing trials (SBTs) result in shorter intubation duration and intensive care unit (ICU) length of stay (LOS). We compared respiratory therapy (RT)-driven PW versus usual care (UC) as it pertains to physiologic respiratory parameters, intubation duration, extubation success/reintubation rates, and ICU LOS.

Methods:

prospective, multicentric, randomized controlled trial was performed in closed medical and surgical ICUs with 24/7 in-house intensivist coverage at six academic medical centers in a resource-limited setting from October 18, 2007, to May 03, 2014. Extubation readiness was determined by the attending physician (UC) or the respiratory therapist (PW) using predefined criteria and SBT. Physiologic variables, serial blood gas measurements, and weaning indices were assessed including the Rapid Shallow Breathing Index (RSBI), negative inspiratory force (NIF), occlusion pressure (P0.1), and dynamic and static compliance (C_dyn and C_s).

Results:

total of 5502 patients were randomized (PW 2787; UC 2715), of which 167 patients died without ventilator weaning (PW 90; UC 77) and 645 patients were excluded (PW 365; UC 280). Finally, a total of 4200 patients were analyzed (PW 2075; UC 2125). The PW group displayed improvements in minute ventilation (P < 0.001), C_s and C_dyn(both P < 0.05), P0.1 (P < 0.001), NIF (P < 0.001), and RSBI (P < 0.001). Early re-intubation (≤48 h) rates were lower in the PW group (16.7% vs. 24.8%; P < 0.0001), as were late re-intubation rates (5.2% vs. 25.8%; P < 0.0001). Intubation duration was longer in the PW group (P < 0.001), however, hospital LOS was shorter (P < 0.001). Mortality was unchanged (P = 0.19).

Conclusion:

PW with RT-driven extubation decisions is safe, effective, and associated with decreased re-intubation (early and late), shorter hospital stays, increased intubation duration (statistically but not clinically significant), and unchanged in-patient mortality.

COVID-19 Blind Spots: A Consensus Statement on the Importance of Competent Political Leadership and the Need for Public Health Cognizance

As the COVID-19 pandemic continues, important discoveries and considerations emerge regarding the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) pathogen; its biological and epidemiological characteristics; and the corresponding psychological, societal, and public health (PH) impacts. During the past year, the global community underwent a massive transformation, including the implementation of numerous nonpharmacological interventions; critical diversions or modifications across various spheres of our economic and public domains; and a transition from consumption-driven to conservation-based behaviors. Providing essential necessities such as food, water, health care, financial, and other services has become a formidable challenge, with significant threats to the existing supply chains and the shortage or reduction of workforce across many sectors of the global economy. Food and pharmaceutical supply chains constitute uniquely vulnerable and critically important areas that require high levels of safety and compliance. Many regional health-care systems faced at least one wave of overwhelming COVID-19 case surges, and still face the possibility of a new wave of infections on the horizon, potentially in combination with other endemic diseases such as influenza, dengue, tuberculosis, and malaria. In this context, the need for an effective and scientifically informed leadership to sustain and improve global capacity to ensure international health security is starkly apparent. Public health "blind spotting," promulgation of pseudoscience, and academic dishonesty emerged as significant threats to population health and stability during the pandemic. The goal of this consensus statement is to provide a focused summary of such "blind spots" identified during an expert group intense analysis of "missed opportunities" during the initial wave of the pandemic.

Real-time audio-visual feedback with handheld nonautomated external defibrillator devices during cardiopulmonary resuscitation for in-hospital cardiac arrest: A meta-analysis

Objective:

Restoring cardiopulmonary circulation with effective chest compression remains the cornerstone of resuscitation, yet real-time compressions may be suboptimal. This project aims to determine whether in patients with in-hospital cardiac arrest (IHCA; population), chest compressions performed with free-standing audiovisual feedback (AVF) device as compared to standard manual chest compression (comparison) results in improved outcomes, including the sustained return of spontaneous circulation (ROSC), and survival to the intensive care unit (ICU) and hospital discharge (outcomes).

Methods:

Scholarly databases and relevant bibliographies were searched, as were clinical trial registries and relevant conference proceedings to limit publication bias. Studies were not limited by date, language, or publication status. Clinical randomized controlled trials (RCT) were included that enrolled adults (age ≥ 18 years) with IHCA and assessed real-time chest compressions delivered with either the standard manual technique or with AVF from a freestanding device not linked to an automated external defibrillator (AED) or automated compressor.

Results:

Four clinical trials met inclusion criteria and were included. No ongoing trials were identified. One RCT assessed the Ambu CardioPump (Ambu Inc., Columbia, MD, USA), whereas three assessed Cardio First Angel™ (Inotech, Nubberg, Germany). No clinical RCTs compared AVF devices head-to-head. Three RCTs were multi-center. Sustained ROSC (4 studies, n = 1064) was improved with AVF use (Relative risk [RR] 1.68, 95% confidence interval [CI] 1.39–2.04), as was survival to hospital discharge (2 studies, n = 922; RR 1.78, 95% CI 1.54–2.06) and survival to hospital discharge (3 studies, n = 984; RR 1.91, 95% CI 1.62–2.25).

Conclusion:

The moderate-quality evidence suggests that chest compressions performed using a non-AED free-standing AVF device during resuscitation for IHCA improves sustained ROSC and survival to ICU and hospital discharge.

Trial Registration:

PROSPERO (CRD42020157536).

The Shikani HME: A New Tracheostomy Heat and Moisture Exchanger

Purpose Tracheostomy patients face many adversities including loss of phonation and essential airway functions including air filtering, warming, and humidification. Heat and moisture exchangers (HMEs) facilitate humidification and filtering of inspired air. The Shikani HME (S-HME) is a novel turbulent airflow HME that may be used in-line with the Shikani Speaking Valve (SSV), allowing for uniquely preserved phonation during humidification. The aims of this study were to (a) compare the airflow resistance (R _airflow) and humidification efficiency of the S-HME and the Mallinckrodt Tracheolife II tracheostomy HME (M-HME) when dry (time zero) and wet (after 24 hr) and (b) determine if in-line application of the S-HME with a tracheostomy speaking valve significantly increases R _airflow over a tracheostomy speaking valve alone (whether SSV or Passy Muir Valve [PMV]). Method A prospective observational ex vivo study was conducted using a pneumotachometer lung simulation unit to measure airflow (Q) amplitude and R _airflow, as indicated by a pressure drop (P _Drop) across the device (S-HME, M-HME, SSV + S-HME, and PMV). Additionally, P _Drop was studied for the S-HME and M-HME when dry at time zero (T₀) and after 24 hr of moisture testing (T₂₄) at Q of 0.5, 1, and 1.5 L/s. Results R _airflow was significantly less for the S-HME than M-HME (T₀ and T₂₄). R _airflow of the SSV + S-HME in series did not significant increase R _airflow over the SSV or PMV alone. Moisture loss efficiency trended toward greater efficiency for the S-HME; however, the difference was not statistically significant. Conclusions The turbulent flow S-HME provides heat and moisture exchange with similar or greater efficacy than the widely used laminar airflow M-HME, but with significantly lower resistance. The S-HME also allows the innovative advantage of in-line use with the SSV, hence allowing concurrent humidification and phonation during application, without having to manipulate either device.

Disease specific thresholds for determining extubation readiness: The optimal negative inspiratory force for chronic obstructive pulmonary disease patients

Objectives:

The negative inspiratory force (NIF) has been used to help clinicians predict a patient's likelihood of successful liberation from mechanical ventilation (MV). However, the utility of the traditional threshold of ≤−30 cmH ₂O may not be appropriate for patients with chronic obstructive pulmonary disease (COPD). This study aims to define the optimal predictive NIF threshold for COPD patients.

Methods:

A prospective-observational multi-center study was conducted in intensive care units of six academic medical centers. All patients had COPD and were intubated for hypercapnic respiratory failure. The process of weaning from MV was conducted according to the defined hospital protocol. NIF was measured after 120 min of spontaneous breathing trial (SBT). The sensitivity, specificity, positive, and negative predictive value (PPV, NPV), positive and negative likelihood ratios (LR+, LR−) were calculated, and the diagnostic accuracy recorded.

Results:

A total of 90 patients with COPD (39 males and 51 females) were included. Of these, 43 patients (47.8%) were successfully extubated whereas 47 patients (52.2%) failed SBT or required re-intubation (P = 0.654). The threshold value of ≤−25 cmH₂O offered the optimal performance in COPD patients: area under the receiver operating characteristic (ROC) curves ROC curves 0.836, sensitivity 95.0%, specificity 86.0%, PPV 84.4%, and NPV 95.6%., LR+ 6.79, LR− 0.06, and the diagnostic accuracy 90.7%.

Conclusions:

In mechanically ventilated COPD patients with hypercapnic respiratory failure, the NIF threshold of ≤−25 cmH₂O was a moderate-to-good predictor for successful ventilator liberation, and outperforms the traditional threshold of ≤−30 cmH₂O.

The 2019-2020 Novel Coronavirus (Severe Acute Respiratory Syndrome Coronavirus 2) Pandemic: A Joint American College of Academic International Medicine-World Academic Council of Emergency Medicine Multidisciplinary COVID-19 Working Group Consensus Paper

What started as a cluster of patients with a mysterious respiratory illness in Wuhan, China, in December 2019, was later determined to be coronavirus disease 2019 (COVID-19). The pathogen severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel Betacoronavirus, was subsequently isolated as the causative agent. SARS-CoV-2 is transmitted by respiratory droplets and fomites and presents clinically with fever, fatigue, myalgias, conjunctivitis, anosmia, dysgeusia, sore throat, nasal congestion, cough, dyspnea, nausea, vomiting, and/or diarrhea. In most critical cases, symptoms can escalate into acute respiratory distress syndrome accompanied by a runaway inflammatory cytokine response and multiorgan failure. As of this article's publication date, COVID-19 has spread to approximately 200 countries and territories, with over 4.3 million infections and more than 290,000 deaths as it has escalated into a global pandemic. Public health concerns mount as the situation evolves with an increasing number of infection hotspots around the globe. New information about the virus is emerging just as rapidly. This has led to the prompt development of clinical patient risk stratification tools to aid in determining the need for testing, isolation, monitoring, ventilator support, and disposition. COVID-19 spread is rapid, including imported cases in travelers, cases among close contacts of known infected individuals, and community-acquired cases without a readily identifiable source of infection. Critical shortages of personal protective equipment and ventilators are compounding the stress on overburdened healthcare systems. The continued challenges of social distancing, containment, isolation, and surge capacity in already stressed hospitals, clinics, and emergency departments have led to a swell in technologically-assisted care delivery strategies, such as telemedicine and web-based triage. As the race to develop an effective vaccine intensifies, several clinical trials of antivirals and immune modulators are underway, though no reliable COVID-19-specific therapeutics (inclusive of some potentially effective single and multi-drug regimens) have been identified as of yet. With many nations and regions declaring a state of emergency, unprecedented quarantine, social distancing, and border closing efforts are underway. Implementation of social and physical isolation measures has caused sudden and profound economic hardship, with marked decreases in global trade and local small business activity alike, and full ramifications likely yet to be felt. Current state-of-science, mitigation strategies, possible therapies, ethical considerations for healthcare workers and policymakers, as well as lessons learned for this evolving global threat and the eventual return to a "new normal" are discussed in this article.

Ethical Issues Confronting Muslim Patients in Perioperative and Critical Care Environments: A Survey of Islamic Jurisprudence

Ethical dilemmas may arise when medical management conflicts with a patient's values, culture, religion, or legal considerations. Many Muslims encounter ethical dilemmas as patients in perioperative and critical care settings. This article discusses the fundamentals of Islamic jurisprudence and how this may affect hospitalized patients in terms of cleanliness and prayer in the setting of stoma and urinary catheters, fasting, transfusion, transplants, xenografts and animal-based medications, do-not-resuscitate orders, and postmortem examinations. Provider familiarity with how such situations may affect Muslim patients is important to navigate potential conflict and to deliver competent care.

A comparison of cardiopulmonary resuscitation with standard manual compressions versus compressions with real-time audiovisual feedback: A randomized controlled pilot study

Background:

Strategies that improve cardiopulmonary resuscitation (CPR) guideline adherence may improve in-hospital cardiac arrest (IHCA) outcomes. Real-time audiovisual feedback (AVF) is one strategy identified by the American Heart Association and the International Liaison Committee on Resuscitation as an area needing further investigation. The aim of this study was to determine if in patients with IHCA, does the addition of a free-standing AVF device to standard manual chest compressions during CPR improve sustained return of spontaneous circulation (ROSC) rates (primary outcome) or CPR quality or guideline adherence (secondary outcomes).

Methods:

This was a prospective, randomized, controlled, parallel study of patients undergoing resuscitation with chest compressions for IHCA in the mixed medical-surgical intensive care units (ICUs) of two academic teaching hospitals. Patients were randomized to receive either standard manual chest compressions or compressions using the Cardio First Angel™ feedback device.

Results:

Sixty-seven individuals were randomized, and 22 were included. CPR quality evaluation and guideline adherence scores were improved in the intervention group (P = 0.0005 for both). The incidence of ROSC was similar between groups (P = 0.64), as was survival to ICU discharge (P = 0.088) and survival to hospital discharge (P = 0.095).

Conclusion:

The use of the Cardio First Angel™ compression feedback device improved adherence to publish CPR guidelines and CPR quality. The insignificant change in rates of ROSC and survival to ICU or hospital discharge may have been related to small sample size. Further clinical studies comparing AVF devices to standard manual compressions are needed, as are device head-to-head comparisons.

Periapical abscess progressing to parotitis and descending necrotizing mediastinitis with thoracic abscess in a patient on etanercept: A case report

Patients on Type 2 biologics, such as etanercept, are at increased risk for aggressive infections. This may be further exacerbated by concomitant systemic corticosteroid use or comorbidities such as diabetes. We report a case of a patient with rheumatoid arthritis on etanercept with poor dentition and periodontal disease, who developed parotitis with peritonsillar abscess and descending necrotizing mediastinitis (DNM) with periaortic abscess arising from a periapical abscess. Morbidity and mortality of such infections is high. A multimodal assessment and treatment team is required to optimize patient survival and outcomes. This manuscript discusses the diagnostic and treatment challenges of DNM of immunocompromised patients.

Neuroblastoma presenting as hip pain and skull prominence in a child

Neuroblastoma is a common cancer in children especially those under 5-years old, however they can have varied presentations that may make diagnosis difficult. Neuroblastoma is not usually high on a clinician's differential for a child's gait dysfunction. We describe a case of a 6-year-old female who presented to the Emergency Department for new onset right hip pain. She had associated gait disturbance and pain with ambulation as well as a new lump on her right parietal skull. An MRI of the brain, lumbar spine, and pelvis revealed the diagnosis of a left adrenal neuroblastoma that had metastasized to the femur, the lumbar spine, and the skull. This case shows the importance of early suspicion of malignancy in a patient with seemingly disparate symptoms to ensure early intervention.

Intravenous Magnesium Sulfate to Treat Acute Headaches in the Emergency Department: A Systematic Review

INTRODUCTION

Non-traumatic headaches comprise up to 4% of all emergency department (ED) visits. Current practice is moving toward multimodal analgesia regimens that limit narcotic use.

OBJECTIVE

The objective of this systematic review is to address the following research question: In patients with non-traumatic headaches (Population), does administration of intravenous magnesium sulfate (Intervention) compared to placebo, corticosteroids, dopamine antagonists, ergot alkaloids, non-steroidal anti-inflammatory drugs (NSAIDs), triptans, or usual care result in better pain control, lower rate of recurrence at 24 hours, lower requirements for rescue analgesia, and less adverse medication effects (Outcomes)?

METHODS

Scholarly databases and relevant bibliographies were searched, as were clinical trial registries and relevant conference proceedings to limit publication bias. Studies were not limited by date, language, or publication status. Inclusion criteria were: (1) randomized clinical trial (RCT), (2) patients age ≥18 years, (3) non-traumatic headache, (4) patients treated in ED or an outpatient acute care treatment center, and (5) magnesium sulfate administered intravenously (IV). Eligible comparison groups included: placebo, conventional therapy, dopamine antagonist, NSAID, corticosteroid, ergot alkaloid, or triptans.

RESULTS

Out of 4018 identified references, 7 RCTs (545 participants) that treated migraine headaches (n = 6) and benign non-traumatic headaches (n = 1) met inclusion criteria. Pain intensity was improved with magnesium sulfate vs comparators at 60-120 minutes, but not at earlier time points. Result for the endpoint of pain reduction by 50% were conflicting as 3 studies reported that headache was improved, unchanged, and less with magnesium sulfate. Complete pain relief was improved with magnesium sulfate in 1 study, and in the migraine with aura (MA) subgroup in another. The need for rescue analgesia at any point was improved with magnesium sulfate in 1 study, and in the MA subgroup in another. Twenty-four-hour headache recurrence was improved with magnesium sulfate in 1 study, but unchanged in a second. The intended meta-analysis was not performed due to the clinical heterogeneity among studies.

CONCLUSION

While we cannot draw a firm conclusion on the efficacy or benefit of intravenous magnesium sulfate in the treatment of acute non-traumatic headaches, the existing evidence indicates potential benefits in pain control beyond 1 hour, aura duration, and need for rescue analgesia.

Opinions on the Legitimacy of Death Declaration by Neurological Criteria from the Perspective of 3 Abrahamic Faiths

Traditional criteria to identify death may not fit all circumstances. This manuscript explores religious jurisprudence to ascertain whether death declaration by neurological criteria (DDNC) is accepted as a valid method by 3 Abrahamic religious traditions ie. Islam, Judaism, and Catholicism. Among Islamic sources (order of primacy), neither the Qur'an, Sunnah as reported in Hadith, Ijma' (scholarly consensus), nor Qiyas (precedent-based analogy) clearly describe death determination criteria. Through Ijtihad (lowest level of Shari 'ah), 5 of 6 identified non-binding fatwa support DDNC. Faith-based medical organizations are divided. Eleven of 13 surveyed Muslim-majority countries have laws supporting DDNC. Concern exists that premature death declaration could violate the Shari'ah concept of Hifz-An-nafs (saving life). As such, DDNC remains debated in Islamic circles. Among the 3 main sources of Jewish law (Halacha), the Torah (oral and written) does not clearly define death declaration criteria. Although Talmudic interpretations of Misnah Oholot 1:6 and Gamara Hullin 21a suggest a possible justification for death determination using neurologic criteria in some conditions, the bulk of mitzvot d'rabbanan (Rabbinic Law) rejects DDNC and adheres to cardiorespiratory criteria. Lastly, Catholic Church Cannon Law and the Holy Scripture recorded in Bible does not define death determination criteria. Following the Council of Vienne, Saint Thomas's loss of integration view has predominated. In 2000, Pope John Paul II expressed tentative and qualifid support for DDNC, however the topic remains controversial. Despite dissenting opinions in each faith, DDNC is currently accepted as valid by many Muslims and Catholics, while rejected by Judaism.