Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19)

Real-World Inpatient Use of Medications Repurposed for Coronavirus Disease 2019 in United States Hospitals, March-May 2020

We report off-label use patterns for medications repurposed for coronavirus disease 2019 (COVID-19) at 318 US hospitals. Inpatient hydroxychloroquine use declined by 80%, whereas corticosteroids and tocilizumab were initiated 2 days earlier in May versus March 2020. Two thirds of ventilated COVID-19 patients were already receiving corticosteroids during March-May 2020, resembling pre-COVID use in mechanically ventilated influenza patients.

A Case-Control Study of Prone Positioning in Awake and Nonintubated Hospitalized Coronavirus Disease 2019 Patients

To determine the association between prone positioning in nonintubated patients with coronavirus disease 2019 and frequency of invasive mechanical ventilation or inhospital mortality.

DESIGN

A nested case-matched control analysis.

SETTING

Three hospital sites in Bronx, NY.

PATIENTS

Adult coronavirus disease 2019 patients admitted between March 1, 2020, and April 1, 2020. We excluded patients with do-not-intubate orders. Cases were defined by invasive mechanical ventilation or inhospital mortality. Each case was matched with two controls based on age, gender, admission date, and hospital length of stay greater than index time of matched case via risk-set sampling. The presence of nonintubated proning was identified from provider documentation.

INTERVENTION

Nonintubated proning documented prior to invasive mechanical ventilation or inhospital mortality for cases or prior to corresponding index time for matched controls.

MEASUREMENTS AND MAIN RESULTS

We included 600 patients, 41 (6.8%) underwent nonintubated proning. Cases had lower Spo2/Fio2 ratios prior to invasive mechanical ventilation or inhospital mortality compared with controls (case median, 97 [interquartile range, 90-290] vs control median, 404 [interquartile range, 296-452]). Although most providers (58.5%) documented immediate improvement in oxygenation status after initiating nonintubated proning, there was no difference in worst Spo2/Fio2 ratios before and after nonintubated proning in both case and control (case median Spo2/Fio2 ratio difference, 3 [interquartile range, -3 to 8] vs control median Spo2/Fio2 ratio difference, 0 [interquartile range, -3 to 50]). In the univariate analysis, patients who underwent nonintubated proning were 2.57 times more likely to require invasive mechanical ventilation or experience inhospital mortality (hazard ratio, 2.57; 95% CI, 1.17-5.64; p = 0.02). Following adjustment for patient level differences, we found no association between nonintubated proning and invasive mechanical ventilation or inhospital mortality (adjusted hazard ratio, 0.92; 95% CI, 0.34-2.45; p = 0.86).

CONCLUSIONS

There was no significant association with reduced risk of invasive mechanical ventilation or inhospital mortality after adjusting for baseline severity of illness and oxygenation status.

MATH+ protocol for the treatment of SARS-CoV-2 infection: the scientific rationale

INTRODUCTION

COVID-19 disease progresses through a number of distinct phases. The management of each phase is unique and specific. The pulmonary phase of COVID-19 is characterized by an organizing pneumonia with profound immune dysregulation, activation of clotting, and a severe microvascular injury culminating in severe hypoxemia. The core treatment strategy to manage the pulmonary phase includes the combination of methylprednisolone, ascorbic acid, thiamine, and heparin (MATH+ protocol). The rationale for the MATH+ protocol is reviewed in this paper.

AREAS COVERED

We provide an overview on the pathophysiological changes occurring in patients with COVID-19 respiratory failure and a treatment strategy to reverse these changes thereby preventing progressive lung injury and death.

EXPERT OPINION

While there is no single 'Silver Bullet' to cure COVID-19, we believe that the severely disturbed pathological processes leading to respiratory failure in patients with COVID-19 organizing pneumonia will respond to the combination of Methylprednisone, Ascorbic acid, Thiamine, and full anticoagulation with Heparin (MATH+ protocol).We believe that it is no longer ethically acceptable to limit management to 'supportive care' alone, in the face of effective, safe, and inexpensive medications that can effectively treat this disease and thereby reduce the risk of complications and death.

Early experience with critically ill patients with COVID-19 in Montreal

PURPOSE

Montreal has been the epicentre of the coronavirus disease (COVID-19) pandemic in Canada. Given the regional disparities in incidence and mortality in the general population, we aimed to describe local characteristics, treatments, and outcomes of critically ill COVID-19 patients in Montreal.

METHODS

A single-centre retrospective cohort of consecutive adult patients admitted to the intensive care unit (ICU) of Hôpital du Sacré-Coeur de Montréal with confirmed COVID-19 were included.

RESULTS

Between 20 March and 13 May 2020, 75 patients were admitted, with a median [interquartile range (IQR)] age of 62 [53-72] yr and high rates of obesity (47%), hypertension (67%), and diabetes (37%). Healthcare-related infections were responsible for 35% of cases. The median [IQR] day 1 sequential organ failure assessment score was 6 [3-7]. Invasive mechanical ventilation (IMV) was used in 57% of patients for a median [IQR] of 11 [5-22] days. Patients receiving IMV were characterized by a moderately decreased median [IQR] partial pressure of oxygen:fraction of inspired oxygen (day 1 PaO2:FiO2 = 177 [138-276]; day 10 = 173 [147-227]) and compliance (day 1 = 48 [38-58] mL/cmH2O; day 10 = 34 [28-42] mL/cmH2O) and very elevated estimated dead space fraction (day 1 = 0.60 [0.53-0.67]; day 10 = 0.72 [0.69-0.79]). Overall hospital mortality was 25%, and 21% in the IMV patients. Mortality was 82% in patients ≥ 80 yr old.

CONCLUSIONS

Characteristics and outcomes of critically ill patients with COVID-19 in Montreal were similar to those reported in the existing literature. We found an increased physiologic dead space, supporting the hypothesis that pulmonary vascular injury may be central to COVID-19-induced lung damage.

Clinical features, diagnosis, and outcomes of multisystem inflammatory syndrome in children associated with coronavirus disease 2019

The novel coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been spreading worldwide since December 2019. Hundreds of cases of children and adolescents with Kawasaki disease (KD)-like hyperinflammatory illness have been reported in Europe and the United States during the peak of the COVID-19 pandemic with or without shock and cardiac dysfunction. These patients tested positive for the polymerase chain reaction or antibody test for SARS-CoV-2 or had a history of recent exposure to COVID-19. Clinicians managing such patients coined new terms for this new illness, such as COVID-19-associated hyperinflammatory response syndrome, pediatric inflammatory multisystem syndrome temporally associated with COVID-19, or COVID-19-associated multisystem inflammatory syndrome in children (MIS-C). The pathogenesis of MIS-C is unclear; however, it appears similar to that of cytokine storm syndrome. MIS-C shows clinical features similar to KD, but differences between them exist with respect to age, sex, and racial distributions and proportions of patients with shock or cardiac dysfunction. Recommended treatments for MIS-C include intravenous immunoglobulin, corticosteroids, and inotropic or vasopressor support. For refractory patients, monoclonal antibody to interleukin-6 receptor (tocilizumab), interleukin-1 receptor antagonist (anakinra), or monoclonal antibody to tumor necrosis factor (infliximab) may be recommended. Patients with coronary aneurysms require aspirin or anticoagulant therapy. The prognosis of MIS-C seemed favorable without sequelae in most patients despite a reported mortality rate of approximately 1.5%.

Pragmatic Recommendations for the Use of Diagnostic Testing and Prognostic Models in Hospitalized Patients with Severe COVID-19 in Low- and Middle-Income Countries

Management of patients with severe or critical COVID-19 is mainly modeled after care of patients with severe pneumonia or acute respiratory distress syndrome from other causes. These models are based on evidence that primarily originates from investigations in high-income countries, but it may be impractical to apply these recommendations to resource-restricted settings in low- and middle-income countries (LMICs). We report on a set of pragmatic recommendations for microbiology and laboratory testing, imaging, and the use of diagnostic and prognostic models in patients with severe COVID-19 in LMICs. For diagnostic testing, where reverse transcription-PCR (RT-PCR) testing is available and affordable, we recommend using RT-PCR of the upper or lower respiratory specimens and suggest using lower respiratory samples for patients suspected of having COVID-19 but have negative RT-PCR results for upper respiratory tract samples. We recommend that a positive RT-PCR from any anatomical source be considered confirmatory for SARS-CoV-2 infection, but, because false-negative testing can occur, recommend that a negative RT-PCR does not definitively rule out active infection if the patient has high suspicion for COVID-19. We suggest against using serologic assays for the detection of active or past SARS-CoV-2 infection, until there is better evidence for its usefulness. Where available, we recommend the use of point-of-care antigen-detecting rapid diagnostic testing for SARS-CoV-2 infection as an alternative to RT-PCR, only if strict quality control measures are guaranteed. For laboratory testing, we recommend a baseline white blood cell differential platelet count and hemoglobin, creatinine, and liver function tests and suggest a baseline C-reactive protein, lactate dehydrogenase, troponin, prothrombin time (or other coagulation test), and D-dimer, where such testing capabilities are available. For imaging, where availability of standard thoracic imaging is limited, we suggest using lung ultrasound to identify patients with possible COVID-19, but recommend against its use to exclude COVID-19. We suggest using lung ultrasound in combination with clinical parameters to monitor progress of the disease and responses to therapy in COVID-19 patients. We currently suggest against using diagnostic and prognostic models as these models require extensive laboratory testing and imaging, which often are limited in LMICs.

Association Between Early Invasive Mechanical Ventilation and Day-60 Mortality in Acute Hypoxemic Respiratory Failure Related to Coronavirus Disease-2019 Pneumonia

Supplemental Digital Content is available in the text.

Objectives:

About 5% of patients with coronavirus disease-2019 are admitted to the ICU for acute hypoxemic respiratory failure. Opinions differ on whether invasive mechanical ventilation should be used as first-line therapy over noninvasive oxygen support. The aim of the study was to assess the effect of early invasive mechanical ventilation in coronavirus disease-2019 with acute hypoxemic respiratory failure on day-60 mortality.

Design:

Multicenter prospective French observational study.

Setting:

Eleven ICUs of the French OutcomeRea network.

Patients:

Coronavirus disease-2019 patients with acute hypoxemic respiratory failure (Pao₂/Fio₂ ≤ 300 mm Hg), without shock or neurologic failure on ICU admission, and not referred from another ICU or intermediate care unit were included.

Intervention:

We compared day-60 mortality in patients who were on invasive mechanical ventilation within the first 2 calendar days of the ICU stay (early invasive mechanical ventilation group) and those who were not (nonearly invasive mechanical ventilation group). We used a Cox proportional-hazard model weighted by inverse probability of early invasive mechanical ventilation to determine the risk of death at day 60.

Measurement and Main Results:

The 245 patients included had a median (interquartile range) age of 61 years (52–69 yr), a Simplified Acute Physiology Score II score of 34 mm Hg (26–44 mm Hg), and a Pao₂/Fio₂ of 121 mm Hg (90–174 mm Hg). The rates of ICU-acquired pneumonia, bacteremia, and the ICU length of stay were significantly higher in the early (n = 117 [48%]) than in the nonearly invasive mechanical ventilation group (n = 128 [52%]), p < 0.01. Day-60 mortality was 42.7% and 21.9% in the early and nonearly invasive mechanical ventilation groups, respectively. The weighted model showed that early invasive mechanical ventilation increased the risk for day-60 mortality (weighted hazard ratio =1.74; 95% CI, 1.07–2.83, p=0.03).

Conclusions:

In ICU patients admitted with coronavirus disease-2019-induced acute hypoxemic respiratory failure, early invasive mechanical ventilation was associated with an increased risk of day-60 mortality. This result needs to be confirmed.

Predictors of intubation in COVID-19 patients treated with out-of-ICU continuous positive airway pressure

BACKGROUND

As delayed intubation may worsen the outcome of coronavirus disease 2019 (COVID-19) patients treated with continuous positive airway pressure (CPAP), we sought to determine COVID-specific early predictors of CPAP failure.

METHODS

In this observational retrospective multicentre study, we included all COVID-19 patients treated with out-of-ICU CPAP, candidates for intubation in case of CPAP failure. From these patients, we collected demographic and clinical data.

RESULTS

A total of 397 COVID-19 patients were treated with CPAP for respiratory failure, with the therapeutic goal of providing intubation in case of CPAP failure. Univariable analysis showed that, age, lactate dehydrogenase (LDH) and white cell counts were all significantly lower in patients with successful CPAP treatment compared to those failing it and undergoing subsequent intubation. The percentage changes between baseline and CPAP application in the ratio of partial pressure arterial oxygen (PaO₂) and fraction of inspired oxygen (FiO₂), PaO_2, respiratory rate and ROX index were higher in patients experiencing successful CPAP compared to those failing it. FiO₂ and male gender were also significantly associated with intubation. Multivariable analysis adjusting for age, gender, Charlson comorbidity index, percentage change in PaO₂/FiO₂ or PaO₂ and FiO₂ separately, lactate, white blood cell count, LDH and C-reactive protein levels led to an area under the curve of 0.818 and confirmed that age, LDH and percentage increase in PaO₂/FiO₂ are predictors of intubation.

CONCLUSIONS

In COVID-19 patients requiring CPAP, age, LDH and percentage change in PaO₂/FiO₂ after starting CPAP are predictors of intubation.

Evaluation of Hypertriglyceridemia in Critically Ill Patients With Coronavirus Disease 2019 Receiving Propofol

Objectives

To report the prevalence of, and evaluate risk factors for, the development of hypertriglyceridemia (defined as a serum triglyceride level of > 400 mg/dL) in patients with coronavirus disease 2019 who received propofol.

Design

Single-center, retrospective, observational analysis.

Setting

Brigham and Women's Hospital, a tertiary academic medical center in Boston, MA.

Patients

All ICU patients who with coronavirus disease 19 who received propofol between March 1, 2020, and April 20, 2020.

Interventions

None.

Measurements and Main Results

The major outcome of this analysis was to report the prevalence of, and risk factors for, the development of hypertriglyceridemia in patients with coronavirus disease 19 who received propofol. Minor outcomes included the development of acute pancreatitis and description of propofol metrics. Of the 106 patients that were included, 60 (56.6%) developed hypertriglyceridemia, with a median time to development of 46 hours. A total of five patients had clinical suspicion of acute pancreatitis, with one patient having confirmatory imaging. There was no difference in the dose or duration of propofol in patients who developed hypertriglyceridemia compared with those who did not. In the patients who developed hypertriglyceridemia, 35 patients (58.5%) continued receiving propofol for a median duration of 105 hours. Patients who developed hypertriglyceridemia had elevated levels of inflammatory markers.

Conclusions

Hypertriglyceridemia was commonly observed in critically ill patients with coronavirus disease 2019 who received propofol. Neither the cumulative dose nor duration of propofol were identified as a risk factor for the development of hypertriglyceridemia. Due to the incidence of hypertriglyceridemia in this patient population, monitoring of serum triglyceride levels should be done frequently in patients who require more than 24 hours of propofol. Many patients who developed hypertriglyceridemia were able to continue propofol in our analysis after reducing the dose.

Fever: Could A Cardinal Sign of COVID-19 Infection Reduce Mortality?

With mortality rising from the COVID-19 pandemic, we may be overlooking a key aspect of the immunological response. Fever is a cardinal sign of this rampant infection; however, little attention has been paid towards how a fever may work in our favor in overcoming this disease. Three key aspects of patient care - fever, fluid, and food - can be harmonized to overcome COVID-19 infection. Both animal and human studies have demonstrated that fever suppression during viral infections, either through low ambient temperatures or antipyretic use, may increase morbidity and prolong the illness. As fever rises, so do antidiuretic hormone levels, leading to solute-free water retention - making conservative fluid management essential. Finally, fever inhibits gastrointestinal function as energy is reallocated to the immunological response, underscoring the need to work in concert with these physiological changes. An opportunity awaits to investigate this natural barrier to infection, let us not pass it by.

A Critical Appraisal of the Effects of Anesthetics on Immune-system Modulation in Critically Ill Patients With COVID-19

Purpose

The aim of the present article was to briefly summarize current knowledge about the immunomodulatory effects of general anesthetics and the possible clinical effects of this immunomodulation in patients with COVID-19.

Methods

The PubMed, Scopus, and Google Scholar databases were comprehensively searched for relevant studies.

Findings

The novel coronavirus causes a wide spectrum of clinical manifestations, with a large absolute number of patients experiencing severe pneumonia and rapid progression to acute respiratory distress syndrome and multiple organ failure. In these patients, the equilibrium of the inflammatory response is a major determinant of survival. The impact of anesthetics on immune-system modulation may vary and includes both pro-inflammatory and anti-inflammatory effects.

Implications

Inhibition of the development of severe inflammation and/or the enhancement of inflammation resolution by anesthetics may limit organ damage and improve outcomes in patients with COVID-19.

Advances in sepsis diagnosis and management: a paradigm shift towards nanotechnology

Sepsis, a dysregulated immune response due to life-threatening organ dysfunction, caused by drug-resistant pathogens, is a major global health threat contributing to high disease burden. Clinical outcomes in sepsis depend on timely diagnosis and appropriate early therapeutic intervention. There is a growing interest in the evaluation of nanotechnology-based solutions for sepsis management due to the inherent and unique properties of these nano-sized systems. This review presents recent advancements in nanotechnology-based solutions for sepsis diagnosis and management. Development of nanosensors based on electrochemical, immunological or magnetic principals provide highly sensitive, selective and rapid detection of sepsis biomarkers such as procalcitonin and C-reactive protein and are reviewed extensively. Nanoparticle-based drug delivery of antibiotics in sepsis models have shown promising results in combating drug resistance. Surface functionalization with antimicrobial peptides further enhances efficacy by targeting pathogens or specific microenvironments. Various strategies in nanoformulations have demonstrated the ability to deliver antibiotics and anti-inflammatory agents, simultaneously, have been reviewed. The critical role of nanoformulations of other adjuvant therapies including antioxidant, antitoxins and extracorporeal blood purification in sepsis management are also highlighted. Nanodiagnostics and nanotherapeutics in sepsis have enormous potential and provide new perspectives in sepsis management, supported by promising future biomedical applications included in the review.

Safety and Efficacy of Low-Dose Corticosteroids in Patients With Non-severe Coronavirus Disease 2019: A Retrospective Cohort Study

Background To date, several pharmacological agents have been employed in the treatment and management of the coronavirus disease 2019 (COVID-19). While the utility of corticosteroids in severe COVID-19 infection is now widely touted, their efficacy in thwarting the progression of non-severe disease remains elusive. Methods A retrospective cohort study involving 25 patients with a confirmed diagnosis of non-severe COVID-19 infection was conducted. Subjects were assigned to either the steroid or the non-steroid group. A low-dose, short-course corticosteroid regimen was administered for seven days and the disease outcomes were recorded and compared among the two groups. The Kolmogorov-Smirnov test was employed to discern the data normality. Results In patients treated with low-dose, short-course steroids, the overall all-cause mortality was significantly lower compared with the non-steroid group (8.3% and 61.5%, respectively; p = 0.005). The prevalence of acute respiratory distress syndrome in the steroid group was significantly lower than that in the non-steroid group at the seven-day mark (16.7% and 84.6%, respectively; p = 0.002). Within the steroid group, the incidence of developing secondary complications was also markedly lower than that in the non-steroid group. Conclusions In patients afflicted with non-severe COVID-19, the employment of low-dose, short-course corticosteroids may confer a therapeutic advantage, significantly curtailing the mortality rate, the length of hospital stay, and the risk of developing secondary complications.

Room to Breathe: The Impact of Oxygen Rationing on Health Outcomes in SARS-CoV2

As the primary surge of coronavirus disease 2019 (COVID-19) wanes in many countries, it is important to reconsider best practice. More cases, probably the majority of cases, are yet to come. Hopefully, during this next phase, we will have more time, more resources, and more experience from which to affect better outcomes. Here, we examine the compromised oxygen strategy that many nations followed. We explore the evidence related to such strategies and discuss the potential mortality impact of delaying oxygen treatment in COVID-19 pneumonia.

Antibiotic prescribing in patients with COVID-19: rapid review and meta-analysis

Background

The proportion of patients infected with SARS-CoV-2 that are prescribed antibiotics is uncertain, and may contribute to patient harm and global antibiotic resistance.

Objective

The aim was to estimate the prevalence and associated factors of antibiotic prescribing in patients with COVID-19.

Data Sources

We searched MEDLINE, OVID Epub and EMBASE for published literature on human subjects in English up to June 9 2020.

Study Eligibility Criteria

We included randomized controlled trials; cohort studies; case series with ≥10 patients; and experimental or observational design that evaluated antibiotic prescribing.

Participants

The study participants were patients with laboratory-confirmed SARS-CoV-2 infection, across all healthcare settings (hospital and community) and age groups (paediatric and adult).

Methods

The main outcome of interest was proportion of COVID-19 patients prescribed an antibiotic, stratified by geographical region, severity of illness and age. We pooled proportion data using random effects meta-analysis.

Results

We screened 7469 studies, from which 154 were included in the final analysis. Antibiotic data were available from 30 623 patients. The prevalence of antibiotic prescribing was 74.6% (95% CI 68.3–80.0%). On univariable meta-regression, antibiotic prescribing was lower in children (prescribing prevalence odds ratio (OR) 0.10, 95% CI 0.03–0.33) compared with adults. Antibiotic prescribing was higher with increasing patient age (OR 1.45 per 10 year increase, 95% CI 1.18–1.77) and higher with increasing proportion of patients requiring mechanical ventilation (OR 1.33 per 10% increase, 95% CI 1.15–1.54). Estimated bacterial co-infection was 8.6% (95% CI 4.7–15.2%) from 31 studies.

Conclusions

Three-quarters of patients with COVID-19 receive antibiotics, prescribing is significantly higher than the estimated prevalence of bacterial co-infection. Unnecessary antibiotic use is likely to be high in patients with COVID-19.

Artesunate protects immunosuppression mice induced by glucocorticoids via enhancing pro-inflammatory cytokines release and bacterial clearance

Glucocorticoids are commonly used in clinic, but the immunosuppression seriously hinders their usage. Herein, immunomodulatory effect of artesunate (AS) on hydrocortisone (HC)-induced immunosuppression was investigated. HC-induced immunosuppression mice (HC mice) were established by intramuscular administration with HC (20 mg/kg) once a day for 5 consecutive days. The results showed HC mice challenged with Escherichia coli on the sixth day presented a lower ability to clear bacteria, decreased TNF-α in blood, decreased spleen index and thymus index. Significantly, AS (20 mg/kg) treatment not only enhanced the ability of HC mice to clear bacteria, but also increased spleen index, the levels of pro-inflammatory cytokines from 78.7 ± 12.1 ng/ml (TNF-α) and 48.7 ± 8.6 pg/ml (IL-6) to 174.0 ± 90.5 ng/ml and 783.3 ± 90.5 pg/ml, number of white blood cells in blood, and sIgA in colon. Subsequently, HC-induced immunosuppression peritoneal macrophages model (HC cells) was established via addition of HC (0.5 μg/ml) for 0.5 h, and then LPS (100 ng/ml) was added to clarify the functional status of the cells. The results showed HC inhibited TNF-α and IL-6 mRNA expressions and their release, but AS (2.5 μg/ml) could increase TNF-α and IL-6 mRNA expressions and their release. AS inhibited GILZ mRNA up-regulated by HC and increases TLR4/NF-κB p65 expressions down-regulated by HC. Our findings revealed that AS's effect is closely related to the improvement of the TLR4/NF-κB signal transduction pathway via inhibiting the up-regulation of GILZ mRNA, demonstrating AS does possess immunomodulatory effects and is worth further investigation in the future.

An In-Person and Telemedicine "Hybrid" System to Improve Cross-Border Critical Care in COVID-19

Background

UC San Diego Health System (UCSDHS) is an academic medical center and integrated care network in the US-Mexico border area of California contiguous to the Mexican Northern Baja region. The COVID-19 pandemic deeply influenced UCSDHS activities as new public health challenges increasingly related to high population density, cross-border traffic, economic disparities, and interconnectedness between cross-border communities, which accelerated development of clinical collaborations between UCSDHS and several border community hospitals - one in the US, two in Mexico - as high volumes of severely ill patients overwhelmed hospitals.

Objective

We describe the development, implementation, feasibility, and acceptance of a novel critical care support program in three community hospitals along the US-Mexico border.

Methods

We created and instituted a hybrid critical care program involving: 1) in-person activities to perform needs assessments of equipment and supplies and hands-on training and education, and 2) creation of a telemedicine-based (Tele-ICU) service for direct patient management and/or consultative, education-based experiences. We collected performance metrics surrounding adherence to evidence-based practices and staff perceptions of critical care delivery.

Findings

In-person intervention phase identified and filled gaps in equipment and supplies, and Tele-ICU program promoted adherence to evidence-based practices and improved staff confidence in caring for critically ill COVID-19 patients at each hospital.

Conclusion

A collaborative, hybrid critical care program across academic and community centers is feasible and effective to address cross-cultural public health emergencies.

Immunotherapies and COVID-19 related Neurological manifestations: A Comprehensive Review Article

In December 2019, an outbreak of pandemic severe respiratory distress syndrome coronavirus disease 2019 (COVID-19) initially occurred in China, has spread the world resulted in serious threats to human public health. Uncommon neurological manifestations with pathophysiological symptoms were observed in infected patients including headache, seizures, and neuroimmunological disorders. Regardless of whether these neurological symptoms are direct or indirect casual infection relationship, this novel viral infection has a relevant impact on the neuroimmune system that requires a neurologist's careful assessment. Recently, the use of immunotherapy has been emerged in fighting against COVID-19 infection despite the uncertain efficiency in managing COVID-19 related disorders or even its proven failure by increasing its severity. Herein, the author is addressing the first approaches in using immunotherapies in controlling COVID-19 viral impact on the brain by highlighting their role in decreasing or increasing infection risks among subjects. This point of view review article supports the use of immunotherapies in managing COVID-19 neurological disorders but in optimal timing and duration to ensure the maximum therapeutic outcome by reducing morbidity and mortality rate. Based on recently published data, the current review article highlights the beneficial effects and drawbacks of using immunotherapies to combat COVID-19 and its neurological symptoms.

Impact of Chronic Obstructive Pulmonary Disease and Emphysema on Outcomes of Hospitalized Patients with Coronavirus Disease 2019 Pneumonia

Background

Comorbid disease is a risk factor for severe coronavirus disease 2019 (COVID-19) infection. However, initial rates of chronic obstructive pulmonary disease (COPD) in case series were low and severity of COVID-19 in COPD patients was variable.

Methods

We performed a retrospective study of patients admitted with COVID-19 and evaluated outcomes in those with and without COPD and/or emphysema. Patients were identified as having COPD if they had a diagnosis in the medical record and a history of airflow-obstruction on spirometry, or a history of tobacco use and prescribed long-acting bronchodilator(s). Computed tomography scans were evaluated by radiologists. Propensity matching was performed for age, body mass index (BMI), and serologic data correlated with severity of COVID-19 disease (D-dimer, C-reactive protein, ferritin, fibrinogen, absolute lymphocyte count, lymphocyte percentage, and lactate dehydrogenase).

Results

Of 577 patients admitted with COVID-19, 103 had a diagnosis of COPD and/or emphysema. The COPD/emphysema cohort was older (67 versus 58, p<0.0001) than the other cohort and had a lower BMI. Among unmatched cohorts those with COPD/emphysema had higher rates of intensive care unit (ICU) admission (35% versus 24.9%, p=0.036) and maximal respiratory support requirements, with more frequent invasive mechanical ventilation (21.4% versus 11.8%), but no significant difference in mortality. After propensity-matching there was no difference in ICU admission, maximal respiratory support requirements, or mortality. Univariate and multivariate regression analyses yielded similar results.

Discussion

Our propensity-matched retrospective cohort study suggests that patients hospitalized with COVID-19 who have COPD and/or emphysema may not have worse outcomes than those without these comorbid conditions.

Initial Report From a Swedish High-volume Transplant Center After the First Wave of the COVID-19 Pandemic

BACKGROUND

Solid organ transplant (SOT) recipients may be more vulnerable to coronavirus disease 2019 (COVID-19). Data on the clinical course of COVID-19 in immunosuppressed patients are limited, and the optimal management strategy for these patients is yet unclear.

METHODS

We present 53 SOT recipients (31 kidney transplant recipients, 8 liver transplant recipients, 5 heart transplant recipients, 5 lung transplant recipients, 3 liver-kidney transplant recipients, and 1 kidney-after-heart transplant recipient), transplanted at a Swedish high-volume transplant center and each diagnosed with COVID-19 between February 21, 2020 and June 22, 2020. Demographic, clinical, and treatment data were extracted from the electronic patient files.

RESULTS

Patients reported fever (61%), cough (43%), diarrhea (31%), and upper respiratory symptoms (29%). The median age was 56 years, and 57% were male. According to severity, 55% had mild, 13% had moderate, 19% had severe, and 13% had critical disease. Thirty-seven patients (70%) were hospitalized, with 8 requiring intensive care. Thirteen of the 37 patients were initially managed as outpatients but later hospitalized. One patient received hydroxychloroquine, and no patients received antivirals. Antimetabolites and calcineurin inhibitors were held or reduced in two-thirds. Twenty-seven of 37 hospitalized patients (73%) received low-molecular-weight heparin. Five (13.5%) hospitalized patients died. Overall survival for the entire cohort was 90.5%. No rejection episodes were noted.

CONCLUSIONS

Hospitalization, lowering of immunosuppression, and prophylactic anticoagulation were the most common therapeutic interventions for SOT recipients with COVID-19. A significant proportion of patients could be managed on an outpatient basis, while keeping a low threshold for admission. Mild and moderate disease forms seem to have a good outcome.

COVID-19 Airway Management Isolation Chamber

OBJECTIVE

During the coronavirus pandemic (COVID-19), health care workers are innovating patient care and safety measures. Unfortunately, many of these are not properly tested for efficacy. The objective of this study was to determine the efficacy of the novel COVID-19 Airway Management Isolation Chamber (CAMIC) to contain and evacuate particulate.

STUDY DESIGN

Multi-institutional proof-of-concept study.

SETTING

Two academic institutions: Walter Reed National Military Medical Center (WRNMMC) and Madigan Army Medical Center (MAMC).

SUBJECTS AND METHODS

Smoke, saline nebulizer, and simulated working port models were developed to assess the efficacy of the CAMIC to contain and remove ultrafine particles. Particulate counts were collected at set time intervals inside and outside the system.

RESULTS

With the CAMIC on, smoke particulate counts inside the chamber significantly decreased over time: r(18) = -0.88, P < .001, WRNMMC; r(18) = -0.91, P < .001, MAMC. Similarly, saline nebulizer particulate counts inside the chamber significantly decreased over time: r(23) = -0.82, P < .001, WRNMMC; r(23) = -0.70, P < .001, MAMC. In the working port model, particulate counts inside the chamber significantly decreased over time: r(23) = -0.95, P < .001, WRNMMC; r(23) = -0.85, P < .001, MAMC. No significant leak was detected in the smoke, saline nebulizer, or working port model when the CAMIC was turned on.

CONCLUSIONS

The CAMIC system appears to provide a barrier that actively removes particles from within the chamber and limits egress. Further studies are necessary to determine clinical applicability. The CAMIC may serve as an adjunct to improve health care worker safety and patient outcomes.

Combating hypoxemia in COVID-19 patients with a natural oxygen carrier, HEMO2Life® (M101)

BACKGROUND

Infection with SARS-CoV-2 is responsible for the COVID-19 crisis affecting the whole world. This virus can provoke acute respiratory distress syndrome (ARDS) leading to overcrowed the intensive care unit (ICU). Over the last months, worldwide experience demonstrated that the ARDS in COVID-19 patients are in many ways "atypical". The mortality rate in ventilated patients is high despite the application of the gold standard treatment (protective ventilation, curare, prone position, inhaled NO). Several studies suggested that the SARS-CoV-2 could interact negatively on red blood cell homeostasis. Furthermore, SarsCov2 creates Reactive Oxygen Species (ROS), which are toxic and generate endothelial dysfunction. Hypothesis/objective(s) We hypothesis that HEMO2Life® administrated intravenously is safe and could help symptomatically the patient condition. It would increase arterial oxygen content despite lung failure and allow better tissue oxygenation control. The use of HEMO2Life® is also interesting due to its anti-oxidative effect preventing cytokine storm induced by the SARS-CoV-2. Evaluation of the hypothesis: Hemarina is based on the properties of the hemoglobin of the Arenicola marina sea-worm (HEMO2Life®). This extracellular hemoglobin has an oxygen capacity 40 times greater than the hemoglobin of vertebrates. Furthermore, the size of this molecule is 250 times smaller than a human red blood cell, allowing it to diffuse in all areas of the microcirculation, without diffusing outside the vascular sector. It possesses an antioxidative property du a Superoxide Dismutase Activity. This technology has been the subject of numerous publications and HEMO2Life® was found to be well-tolerated and did not induce toxicity. It was administered intravenously to hamsters and rats, and showed no acute effect on heart rate and blood pressure and did not cause microvascular vasoconstriction. In preclinical in vivo models (mice, rats, and dogs), HEMO2Life® has enabled better tissue oxygenation, especially in the brain. This molecule has already been used in humans in organ preservation solutions and the patients showed no abnormal clinical signs.

CONSEQUENCES OF THE HYPOTHESIS

The expected benefits of HEMO2Life® for COVID-19 patients are improved survival, avoidance of tracheal intubation, shorter oxygen supplementation, and the possibility of treating a larger number of patients as molecular respirator without to use an invasive machine.

Pharmacists’ role in infectious pandemics: illustration with COVID-19

In 2020 pharmacists around the globe were faced with overwhelming challenges due to the global coronavirus pandemic. This chapter describes salient issues impacting pharmacists’ response to the COVID-19 infectious disease pandemic. The chapter emphasizes the response in the United States and within regions to inform the readers of principles related to the scope of practice and practice in the community, point-of-care testing, critical care and health systems, and long-term care. Pharmacy educators responded to graduate essential healthcare workers on time. The chapter ends following the lead of World Health Organization Director-General advising “first, prepare and be ready; second, detect, protect, and treat; third, reduce transmission; and fourth, innovate and learn.”

Transforming a paediatric ICU to an adult ICU for severe Covid-19: lessons learned

During the first Covid-19 wave, our paediatric intensive care unit (PICU), like many others across the globe, was transformed into an adult ICU for patients with severe Covid-19, due to a shortage of adult ICU beds. Here, we provide a comprehensive description of all the conditions that must be fulfilled to successfully accomplish this transformation. Strong support from all hospital departments was crucial, as their activity was modified by the change. Healthcare workers from various units, notably the paediatric anaesthesiology department, worked in the adult ICU to ensure sufficient staffing. The number of physiotherapists and psychologists was increased. A support system for both healthcare workers and patients' relatives was set up with the help of the mobile paediatric palliative care and support team. Supplies suitable for adults were ordered. Protocols for numerous procedures were written within a few days. Video tutorials, checklists, and simulation sessions were circulated to the entire staff. The head nurses guided and supported the new staff and usual PICU staff. The transformation was achieved within a week. The main difficulties were healthcare worker stress, changes in recommendations over time, absence of visits from relatives, and specific adult issues that paediatricians are unfamiliar with.Conclusion: For the staff, caring for adult patients was made easier by working in their familiar unit instead of being moved to an adult hospital with unfamiliar staff members and equipment. Strong support from the hospital and the assistance of consultants from adult hospital departments were crucial. What is Known: • The dramatic spread across the world of coronavirus disease 2019 generated critical care needs that drastically exceeded resources in many countries worldwide. • Paediatric ICU activity during this period decreased due to lockdown measures and the fact that children rarely required ICU for coronavirus disease 2019. What is New: • We describe how an 18-bed adult Covid-19 ICU was successfully set up in a paediatric hospital during the first wave of the Covid-19 pandemic. • Specific requirements regarding supply, human resources, and procedures, as well as difficulties encountered, are described.

Convalescent plasma for COVID-19 in the intensive care unit

INTRODUCTION

We aimed to investigate the clinical features and mortality of critically ill patients treated with convalescent plasma for COVID-19 in the intensive care unit (ICU).

MATERIAL AND METHODS

We retrospectively collected clinical and laboratory data of COVID-19 patients treated in the ICU. The patients were divided into two groups: those who received convalescent plasma and those who did not. We evaluated changes in the laboratory parameters and PaO2/FiO2 of the patients in the convalescent plasma group on days 0, 7, and 14.

RESULTS

A total of 188 patients were included, 89 of whom received convalescent plasma. There were no significant differences in length of hospitalization [median: 17 vs. 16 days, P = 0.13] or 28-day mortality between the two groups (59% vs. 65%, P = 0.38). The ICU stay of patients who received convalescent plasma was longer (P = 0.001). The dynamics of the laboratory parameters of 44 patients in the convalescent plasma group, who were still in intensive care on the 14th day, were analysed. There was no differences in CRP or PaO2/FiO2 on day 0, 7 or 14 (P = 0.12; P = 0.10, respectively).

CONCLUSIONS

Convalescent plasma treatment was not associated with shorter hospitalisation or lower mortality in patients diagnosed with COVID-19. However, the ICU stay was longer in patients who received convalescent plasma.

Outcomes of non-COVID-19 critically ill patients during the COVID-19 pandemic : A retrospective propensity score-matched analysis

BACKGROUND

Coronavirus disease 2019 (COVID-19) disrupts routine care and alters treatment pathways in every medical specialty, including intensive care medicine, which has been at the core of the pandemic response. The impact of the pandemic is inevitably not limited to patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and their outcomes; however, the impact of COVID-19 on intensive care has not yet been analyzed.

METHODS

The objective of this propensity score-matched study was to compare the clinical outcomes of non-COVID-19 critically ill patients with the outcomes of prepandemic patients. Critically ill, non-COVID-19 patients admitted to the intensive care unit (ICU) during the first wave of the pandemic were matched with patients admitted in the previous year. Mortality, length of stay, and rate of readmission were compared between the two groups after matching.

RESULTS

A total of 211 critically ill SARS-CoV‑2 negative patients admitted between 13 March 2020 and 16 May 2020 were matched to 211 controls, selected from a matching pool of 1421 eligible patients admitted to the ICU in 2019. After matching, the outcomes were not significantly different between the two groups: ICU mortality was 5.2% in 2019 and 8.5% in 2020, p = 0.248, while intrahospital mortality was 10.9% in 2019 and 14.2% in 2020, p = 0.378. The median ICU length of stay was similar in 2019: 4 days (IQR 2-6) compared to 2020: 4 days (IQR 2-7), p = 0.196. The rate of ICU readmission was 15.6% in 2019 and 10.9% in 2020, p = 0.344.

CONCLUSION

In this retrospective single center study, mortality, ICU length of stay, and rate of ICU readmission did not differ significantly between patients admitted to the ICU during the implementation of hospital-wide COVID-19 contingency planning and patients admitted to the ICU before the pandemic.

Global Initiative for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease. The 2020 GOLD Science Committee Report on COVID-19 and Chronic Obstructive Pulmonary Disease

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has raised many questions about the management of patients with chronic obstructive pulmonary disease (COPD) and whether modifications of their therapy are required. It has raised questions about recognizing and differentiating coronavirus disease (COVID-19) from COPD given the similarity of the symptoms. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) Science Committee used established methods for literature review to present an overview of the management of patients with COPD during the COVID-19 pandemic. It is unclear whether patients with COPD are at increased risk of becoming infected with SARS-CoV-2. During periods of high community prevalence of COVID-19, spirometry should only be used when it is essential for COPD diagnosis and/or to assess lung function status for interventional procedures or surgery. Patients with COPD should follow basic infection control measures, including social distancing, hand washing, and wearing a mask or face covering. Patients should remain up to date with appropriate vaccinations, particularly annual influenza vaccination. Although data are limited, inhaled corticosteroids, long-acting bronchodilators, roflumilast, or chronic macrolides should continue to be used as indicated for stable COPD management. Systemic steroids and antibiotics should be used in COPD exacerbations according to the usual indications. Differentiating symptoms of COVID-19 infection from chronic underlying symptoms or those of an acute COPD exacerbation may be challenging. If there is suspicion for COVID-19, testing for SARS-CoV-2 should be considered. Patients who developed moderate-to-severe COVID-19, including hospitalization and pneumonia, should be treated with evolving pharmacotherapeutic approaches as appropriate, including remdesivir, dexamethasone, and anticoagulation. Managing acute respiratory failure should include appropriate oxygen supplementation, prone positioning, noninvasive ventilation, and protective lung strategy in patients with COPD and severe acute respiratory distress syndrome. Patients who developed asymptomatic or mild COVID-19 should be followed with the usual COPD protocols. Patients who developed moderate or worse COVID-19 should be monitored more frequently and accurately than the usual patients with COPD, with particular attention to the need for oxygen therapy.

Clinical Characteristics and Outcomes of Non-ICU Hospitalization for COVID-19 in a Nonepicenter, Centrally Monitored Healthcare System

BACKGROUND

The clinical characteristics and outcomes associated with non-intensive care unit (non-ICU) hospitalizations for coronavirus disease 2019 (COVID-19) outside disease epicenters remain poorly characterized.

METHODS

Systematic analysis of all non-ICU patient hospitalizations for COVID-19 completing discharge between March 13 and May 1, 2020, in a large US health care system utilizing off-site central monitoring. Variables of interest were examined in relation to a composite event rate of death, ICU transfer, or increased oxygen requirement to high-flow nasal cannula, noninvasive ventilation, or mechanical ventilation.

RESULTS

Among 350 patients (age, 64 ± 16 years; 55% male), most (73%) required 3 L/min or less of supplemental oxygen during admission. Telemetry was widely utilized (79%) yet arrhythmias were uncommon (14%) and were predominantly (90%) among patients with abnormal troponin levels or known cardiovascular disease. Ventricular tachycardia was rare (5%), nonsustained, and not associated with hydroxychloroquine/azithromycin treatment. Adverse events occurred in 62 patients (18%), including 22 deaths (6%), 48 ICU transfers (14%), and 49 patients with increased oxygen requirement (14%) and were independently associated with elevated C-reactive protein (odds ratio, 1.09 per 1 mg/dL; 95% CI, 1.01-1.18; P = .04) and lactate dehydrogenase (OR, 1.006 per 1U/L; 95% CI, 1.001-1.012; P = .03) in multivariable analysis.

CONCLUSION

Among non-critically ill patients hospitalized within a nonepicenter health care system, overall survival was 94% with the development of more severe illness or death independently associated with higher levels of C-reactive protein and lactate dehydrogenase on admission. Clinical decompensation was largely respiratory-related, while serious cardiac arrhythmias were rare, which suggests that telemetry can be prioritized for high-risk patients.

Antirheumatic Disease Therapies for the Treatment of COVID-19: A Systematic Review and Meta-Analysis

OBJECTIVE

Antirheumatic disease therapies have been used to treat coronavirus disease 2019 (COVID-19) and its complications. We conducted a systematic review and meta-analysis to describe the current evidence.

METHODS

A search of published and preprint databases in all languages was performed. Included studies described ≥1 relevant clinical outcome for ≥5 patients who were infected with severe acute respiratory syndrome coronavirus 2 and were treated with antirheumatic disease therapy between January 1, 2019 and May 29, 2020. Pairs of reviewers screened articles, extracted data, and assessed risk of bias. A meta-analysis of effect sizes using random-effects models was performed when possible.

RESULTS

The search identified 3,935 articles, of which 45 were included (4 randomized controlled trials, 29 cohort studies, and 12 case series). All studies evaluated hospitalized patients, and 29 of the 45 studies had been published in a peer-reviewed journal. In a meta-analysis of 3 cohort studies with a low risk of bias, hydroxychloroquine use was not significantly associated with mortality (pooled hazard ratio [HR] 1.41 [95% confidence interval (95% CI) 0.83, 2.42]). In a meta-analysis of 2 cohort studies with some concerns/higher risk of bias, anakinra use was associated with lower mortality (pooled HR 0.25 [95% CI 0.12, 0.52]). Evidence was inconclusive with regard to other antirheumatic disease therapies, and the majority of other studies had a high risk of bias.

CONCLUSION

In this systematic review and meta-analysis, hydroxychloroquine use was not associated with benefit or harm regarding COVID-19 mortality. The evidence supporting the effect of other antirheumatic disease therapies in COVID-19 is currently inconclusive.

Temporal evolution, most influential studies and sleeping beauties of the coronavirus literature

Following the outbreak of SARS-CoV-2 disease, within less than 8 months, the 50 years-old scholarly literature of coronaviruses grew to nearly three times larger than its size prior to 2020. Here, temporal evolution of the coronavirus literature over the last 30 years (N = 43,769) is analysed along with its subdomain of SARS-CoV-2 articles (N = 27,460) and the subdomain of reviews and meta-analytic studies (N = 1027). The analyses are conducted through the lenses of co-citation and bibliographic coupling of documents. (1) Of the N = 1204 review and meta-analytical articles of the coronavirus literature, nearly 88% have been published and indexed during the first 8 months of 2020, marking an unprecedented attention to reviews and meta-analyses in this domain, prompted by the SARS-CoV-2 pandemic. (2) The subset of 2020 SARS-CoV-2 articles is bibliographically distant from the rest of this literature published prior to 2020. Individual articles of the SARS-CoV-2 segment with a bridging role between the two bodies of articles (i.e., before and after 2020) are identifiable. (3) Furthermore, the degree of bibliographic coupling within the 2020 SARS-CoV-2 cluster is much poorer compared to the cluster of articles published prior to 2020. This could, in part, be explained by the higher diversity of topics that are studied in relation to SARS-CoV-2 compared to the literature of coronaviruses published prior to the SARS-CoV-2 disease. (4) The analyses on the subset of SARS-CoV-2 literature identified studies published prior to 2020 that have now proven highly instrumental in the development of various clusters of publications linked to SARS-CoV-2. In particular, the so-called "sleeping beauties" of the coronavirus literature with an awakening in 2020 were identified, i.e., previously published studies of this literature that had remained relatively unnoticed for several years but gained sudden traction in 2020 in the wake of the SARS-CoV-2 outbreak. This work documents the historical development of the literature on coronaviruses as an event-driven literature and as a domain that exhibited, arguably, the most exceptional case of publication burst in the history of science. It also demonstrates how scholarly efforts undertaken during peace time or prior to a disease outbreak could suddenly play a critical role in prevention and mitigation of health disasters caused by new diseases.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11192-021-04036-4.

Diminishing returns, increasing risks: Impact of antibiotic duration of therapy on respiratory bacterial isolates in hospitalized patients during the coronavirus disease 2019 (COVID-19) pandemic

In 829 hospital encounters for patients with COVID-19, 73.2% included orders for antibiotics; however, only 1.8% had respiratory cultures during the first 3 hospital days isolating bacteria. Case–control analysis of 30 patients and 96 controls found that each antibiotic day increased the risk of isolating multidrug-resistant gram-negative bacteria (MDR-GNB) in respiratory cultures by 6.5%.

[Infection prevention and control for COVID-19 in healthcare settings]

In healthcare facilities, the initial response to emerging and reemerging infectious diseases, including COVID-19, requires systematic management. The first step is to establish an initial risk assessment and subsequent response flow, using a combination of triage and clinical examination for patients. Screening tests are performed for the early diagnosis of asymptomatic patients who are judged to be at low risk in the initial assessment. However, regardless of the test results, subsequent patient care should be taken cautiously to avoid inadequate initial evaluation at the time of admission, follow-up of symptoms and infection control measures after admission. The basic principle is standard precautions, with particular emphasis on compliance with hand hygiene. Universal masking for preventing transmission from asymptomatic/pre-symptomatic patients and reducing droplet emission and inhalation become the new essential precaution. For suspected/confirmed patients with COVID-19, surgical mask or N95 mask, gloves, gown, eye protection, and cap are basically used. The policy for personal protective equipment is made based on the medical environment of each facility. A negative pressure room is not always required but should be considered in high-risk environments, if possible. While the risk of transmission from the surface environment in a standard healthcare delivery system is limited, a continuous review of the facility environment is expected, considering the importance of ventilation.

Potential Risks and Benefits of Multiple Sclerosis Immune Therapies in the COVID-19 Era: Clinical and Immunological Perspectives

Coronavirus SARS-CoV2 has emerged as one of the greatest infectious disease health challenges in a century. Patients with multiple sclerosis (MS) have a particular vulnerability to infections through their use of immunosuppressive disease-modifying therapies (DMTs). Specific DMTs pose particular risk based on their mechanisms of action (MOA). As a result, patients require individualized approaches to starting new treatments and continuation of therapy. Additionally, vaccinations must be considered carefully, and individuals on long-term B cell-depleting therapies may have diminished immune responses to vaccination, based on preserved T cells and diminished but present antibody titers to influenza vaccines. We review the immunology behind these treatments and their impact on COVID-19, as well as the current recommendations for best practices for use of DMTs in patients with MS.

High flow nasal cannula oxygenation in COVID-19 related acute respiratory distress syndrome: a safe way to avoid endotracheal intubation?

BACKGROUNDS

High flow nasal cannula (HFNC) is an alternative therapy for acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19). This study aimed first to describe outcomes of patients suffering from COVID-19-related ARDS treated with HFNC; secondly to evaluate safety of HFNC (patients and healthcare workers) and compare patients according to respiratory outcome.

METHODS

A retrospective cohort was conducted in French general hospital intensive care unit (ICU). Patients were included if receiving HFNC for hypoxemia (saturation pulse oxygen (SpO2) <92% under oxygen ⩾6 L/min) associated with ARDS and positive SARS-CoV-2 polymerase chain reaction (PCR). Main clinical characteristics and outcomes are described in patients: (a) with do not intubate order (HFNC-DNIO); (b) who did not need intubation (HFNC-only); and (c) eventually intubated (HFNC-intubation). Medians are presented with (1st-3rd) interquartile range.

RESULTS

From 26 February to 30 June 2020, 46 patients of median age 75 (70-79) years were included. In the HFNC-DNIO group (n = 11), partial arterial oxygen pressure (PaO2)/inhaled fraction of oxygen (FiO2) ratio median worst PaO2/FiO2 ratio was 109 (102-172) and hospital mortality was 54.5%. Except the HFNC-DNIO patients (n = 35), 20 patients (57%) were eventually intubated (HFNC-intubation group) and 15 were only treated by HFNC (HFNC-only). HFNC-intubation patients presented higher worst respiratory rates per minute in ICU [37 (34-41) versus 33 (24-34) min, p < 0.05] and worsened ICU admission PaO2/FiO2 ratios [121 (103-169) versus 191 (162-219), p < 0.001] compared with HFNC-only patients. Hospital mortality was 35% (n = 7/20) in HFNC-intubation group, 0% in HFNC-only group with a global mortality of these two groups of 20% (n = 7/35). Among tests performed in healthcare workers, 1/12 PCR in symptomatic healthcare workers and 1.8% serologies in asymptomatic healthcare workers were positive. After review of each case, COVID-19 was likely to be acquired outside hospital.

CONCLUSIONS

HFNC seems to be useful for COVID-19-related ARDS and safe for healthcare workers. ARDS severity with PaO2/FiO2 <150 associated with respiratory rate >35/min could be regarded as a predictor of intubation.The reviews of this paper are available via the supplemental material section.

Echocardiographic assessment of the right ventricle in COVID -related acute respiratory syndrome

In patients with the novel coronavirus (COVID-19) infection, the echocardiographic assessment of the right ventricle (RV) represents a pivotal element in the understanding of current disease status and in monitoring disease progression. The present manuscript is aimed at specifically describing the echocardiographic assessment of the right ventricle, mainly focusing on the most useful parameters and the time of examination. The RV direct involvement happens quite often due to preferential lung tropism of COVID-19 infection, which is responsible for an interstitial pneumonia characterized also by pulmonary hypoxic vasoconstriction (and thus an RV afterload increase), often evolving in acute respiratory distress syndrome (ARDS). The indirect RV involvement may be due to the systemic inflammatory activation, caused by COVID-19, which may affect the overall cardiovascular system mainly by inducing an increase in troponin values and in the sympathetic tone and altering the volemic status (mainly by affecting renal function). Echocardiographic parameters, specifically focused on RV (dimensions and function) and pulmonary circulation (systolic pulmonary arterial pressures, RV wall thickness), are to be measured in a COVID-19 patient with respiratory failure and ARDS. They have been selected on the basis of their feasibility (that is easy to be measured, even in short time) and usefulness for clinical monitoring. It is advisable to measure the same parameters in the single patient (based also on the availability of valid acoustic windows) which are identified in the first examination and repeated in the following ones, to guarantee a reliable monitoring. Information gained from a clinically-guided echocardiographic assessment holds a clinical utility in the single patients when integrated with biohumoral data (indicating systemic activation), blood gas analysis (reflecting COVID-19-induced lung damage) and data on ongoing therapies (in primis ventilatory settings).

Critical Care Surge During the COVID-19 Pandemic: Implementation and Feedback From Frontline Providers

Purpose:

Montefiore Medical Center (MMC) in the Bronx, New York, was subjected to an unprecedented surge of critically ill patients with COVID-19 disease during the initial outbreak of the pandemic in New York State in the spring of 2020. It is important to describe our experience in order to assist hospitals in other areas of the country that may soon be subjected to similar surges.

Materials and Methods:

We retrospectively reviewed the expansion of critical care medicine services at Montefiore during the COVID-19 surge in terms of space, staff, stuff, and systems. In addition, we report on a debriefing session held with a multidisciplinary group of frontline CCM providers at Montefiore.

Findings:

The surge of critically ill patients from COVID-19 disease necessitated a tripling of critical care bed capacity at (MMC), with attendant increased needs for staffing, equipment, and systematic innovations to increase efficiency and effectiveness. Feedback from a multidisciplinary group of frontline providers revealed multiple opportunities for improvement for the next potential surge at MMC as well as guidance for other hospitals.

Conclusions:

Given increasing cases and burden of critical illness from COVID-19 across the US, engineering safe and effective expansions of critical care capacity will be crucial. We hope that our description of what worked and what did not at MMC will help guide other hospitals in their pandemic preparedness.

Rapid deployment of an emergency department-intensive care unit for the COVID-19 pandemic

The coronavirus disease 2019 (COVID-19) pandemic mandated rapid, flexible solutions to meet the anticipated surge in both patient acuity and volume. This paper describes one institution’s emergency department (ED) innovation at the center of the COVID-19 crisis, including the creation of a temporary ED–intensive care unit (ICU) and development of interdisciplinary COVID-19–specific care delivery models to care for critically ill patients. Mount Sinai Hospital, an urban quaternary academic medical center, had an existing five-bed resuscitation area insufficiently rescue due to its size and lack of negative pressure rooms. Within 1 week, the ED-based observation unit, which has four negative pressure rooms, was quickly converted into a COVID-19–specific unit, split between a 14-bed stepdown unit and a 13-bed ED-ICU unit. An increase in staffing for physicians, physician assistants, nurses, respiratory therapists, and medical technicians, as well as training in critical care protocols and procedures, was needed to ensure appropriate patient care. The transition of the ED to a COVID-19–specific unit with the inclusion of a temporary expanded ED-ICU at the beginning of the COVID-19 pandemic was a proactive solution to the growing challenges of surging patients, complexity, and extended boarding of critically ill patients in the ED. This pandemic underscores the importance of ED design innovation with flexible spacing, interdisciplinary collaborations on structure and services, and NP ventilation systems which will remain important moving forward.

Four-phase safety checklist for health care providers in COVID-19 hospitals: A practical tool for survival!

Pandemic of coronavirus disease 2019 (COVID-19) has generated immense viral exposure risk among frontline health care providers (HCPs), especially due to aerosol-generating events and procedures. This further increased the risk of serious mental health disorders amongst them. Hitherto, there is lack of any specific safety protocol specially during the pre- and post-exposure period for HCPs, who provide direct clinical care to patients suffering from COVID-19. We propose a four-phase checklist approach, which may help them in mental preparedness as well as organizing themselves prior and following virus exposure in clinical postings and may enhance the safety standards. The checklist comprises simple steps and may work as a documented track record of precautionary and preventive measures which must be followed by HCWs working in dedicated COVID-19 hospitals.

Structural Variability, Expression Profile, and Pharmacogenetic Properties of TMPRSS2 Gene as a Potential Target for COVID-19 Therapy

The human serine protease serine 2 TMPRSS2 is involved in the priming of proteins of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and represents a possible target for COVID-19 therapy. The TMPRSS2 gene may be co-expressed with SARS-CoV-2 cell receptor genes angiotensin-converting enzyme 2 (ACE2) and Basigin (BSG), but only TMPRSS2 demonstrates tissue-specific expression in alveolar cells according to single-cell RNA sequencing data. Our analysis of the structural variability of the TMPRSS2 gene based on genome-wide data from 76 human populations demonstrates that a functionally significant missense mutation in exon 6/7 in the TMPRSS2 gene is found in many human populations at relatively high frequencies, with region-specific distribution patterns. The frequency of the missense mutation encoded by rs12329760, which has previously been found to be associated with prostate cancer, ranged between 10% and 63% and was significantly higher in populations of Asian origin compared with European populations. In addition to single-nucleotide polymorphisms, two copy number variants were detected in the TMPRSS2 gene. A number of microRNAs have been predicted to regulate TMPRSS2 and BSG expression levels, but none of them is enriched in lung or respiratory tract cells. Several well-studied drugs can downregulate the expression of TMPRSS2 in human cells, including acetaminophen (paracetamol) and curcumin. Thus, the interactions of TMPRSS2 with SARS-CoV-2, together with its structural variability, gene-gene interactions, expression regulation profiles, and pharmacogenomic properties, characterize this gene as a potential target for COVID-19 therapy.

COVID-19 infection and stroke risk

Coronavirus disease 2019 (COVID-19), due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), emerged in Wuhan city, China in December 2019 and rapidly spread to other countries. The most common reported symptoms are fever, dry cough, myalgia and fatigue, headache, anorexia, and breathlessness. Anosmia and dysgeusia as well as gastrointestinal symptoms including nausea and diarrhea are other notable symptoms. This virus also can exhibit neurotropic properties and may also cause neurological diseases, including epileptic seizures, cerebrovascular accident, Guillian barre syndrome, acute transverse myelitis, and acute encephalitis. In this study, we discuss stroke as a complication of the new coronavirus and its possible mechanisms of damage.

Multi-organ point-of-care ultrasound for COVID-19 (PoCUS4COVID): international expert consensus

COVID-19 has caused great devastation in the past year. Multi-organ point-of-care ultrasound (PoCUS) including lung ultrasound (LUS) and focused cardiac ultrasound (FoCUS) as a clinical adjunct has played a significant role in triaging, diagnosis and medical management of COVID-19 patients. The expert panel from 27 countries and 6 continents with considerable experience of direct application of PoCUS on COVID-19 patients presents evidence-based consensus using GRADE methodology for the quality of evidence and an expedited, modified-Delphi process for the strength of expert consensus. The use of ultrasound is suggested in many clinical situations related to respiratory, cardiovascular and thromboembolic aspects of COVID-19, comparing well with other imaging modalities. The limitations due to insufficient data are highlighted as opportunities for future research.

Coronavirus Disease 2019 Calls for Predictive Analytics Monitoring-A New Kind of Illness Scoring System

Coronavirus disease 2019 can lead to sudden and severe respiratory failure that mandates endotracheal intubation, a procedure much more safely performed under elective rather than emergency conditions. Early warning of rising risk of this event could benefit both patients and healthcare providers by reducing the high risk of emergency intubation. Current illness severity scoring systems, which usually update only when clinicians measure vital signs or laboratory values, are poorly suited for early detection of this kind of rapid clinical deterioration. We propose that continuous predictive analytics monitoring, a new approach to bedside management, is more useful. The principles of this new practice anchor in analysis of continuous bedside monitoring data, training models on diagnosis-specific paths of deterioration using clinician-identified events, and continuous display of trends in risks rather than alerts when arbitrary thresholds are exceeded.

Retrospective Analysis of Peri-Intubation Hypoxemia During the Coronavirus Disease 2019 Epidemic Using a Protocol for Modified Airway Management

Supplemental Digital Content is available in the text.

This single-center retrospective study evaluated a protocol for the intubation of patients with confirmed or suspected coronavirus disease 2019 (COVID-19). Twenty-one patients were intubated, 9 of whom were found to have COVID-19. Adherence to the airway management protocol was high. COVID-19 patients had lower peripheral capillary oxygen saturation by pulse oximetry (Spo₂) nadirs during intubation (Spo₂, 73% [72%–77%] vs 89% [86%–94%], P = .024), and a greater percentage experienced severe hypoxemia defined as Spo₂ ≤80% (89% vs 25%, P = .008). The incidence of severe hypoxemia in COVID-19 patients should be considered in the development of guidelines that incorporate high-flow nasal cannula and noninvasive positive pressure ventilation.

Bacterial co-infections and antibiotic resistance in patients with COVID-19

Background: Bacterial co-infections are frequently identified in viral respiratory infections and are significant reasons for morbidity and mortality. Information on the prevalence of bacterial co-infection in patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is lacking. The purpose of this study was to determine the prevalence of bacterial infections and antibiotic resistance in patients with coronavirus disease (COVID-19). Methods: In a cross-sectional study, blood culture (BC) and endotracheal aspirate (ETA) were obtained from COVID-19 patients (RT-PCR positive for SARS-CoV-2). The bacterial isolates were confirmed by the standard microbiological methods. Antibiotic resistance was determined using the disk diffusion method. Results: Among these 340 patients with COVID-19, a total of 43 (12.46%) patients had secondary bacterial infections. The most common bacteria isolated through ETA and BC included Klebsiella species 11 (25.59%), methicillin-sensitive Staphylococcus aureus (MSSA) 9 (20.93%), Escherichia coli 7 (16.28%), methicillin-resistant Staph ylo coccus aureus (MRSA) 6 (13.95%), Enterobacter species 5 (11.63%), Streptococcus pneumoniae 1 (2.32%), and Pseudomonas aeruginosa 4 (9.30%). The results showed that Enterobacteriaceae isolates from COVID-19 patients had the highest resistance to cotrimoxazole (74%), piperacillin (67.5%), ceftazidime (47.5%), and cefepime (42.5%). All isolates were susceptible to amikacin (100%). S. aureus isolates were susceptible to vancomycin (100%) and the rates of resistance to oxacillin, erythromycin and clindamycin were over (90%). P. aeruginosa was susceptible (90%) to imipenem. Conclusions: Bacterial co-infection is relatively infrequent in hospitalized COVID-19 patients. According to the results, one of the causes of death of these patients could be a secondary infections.