Coagulative Disorders in Critically Ill COVID-19 Patients with Acute Distress Respiratory Syndrome: A Critical Review

Stroke in critically ill patients with respiratory failure due to COVID-19: Disparities between low-middle and high-income countries

PURPOSE

We aimed to compare the incidence of stroke in low-and middle-income countries (LMICs) versus high-income countries (HICs) in critically ill patients with COVID-19 and its impact on in-hospital mortality.

METHODS

International observational study conducted in 43 countries. Stroke and mortality incidence rates and rate ratios (IRR) were calculated per admitted days using Poisson regression. Inverse probability weighting (IPW) was used to address the HICs vs. LMICs imbalance for confounders.

RESULTS

23,738 patients [20,511(86.4 %) HICs vs. 3,227(13.6 %) LMICs] were included. The incidence stroke/1000 admitted-days was 35.7 (95 %CI = 28.4-44.9) LMICs and 17.6 (95 %CI = 15.8-19.7) HICs; ischemic 9.47 (95 %CI = 6.57-13.7) LMICs, 1.97 (95 %CI = 1.53, 2.55) HICs; hemorrhagic, 7.18 (95 %CI = 4.73-10.9) LMICs, and 2.52 (95 %CI = 2.00-3.16) HICs; unspecified stroke type 11.6 (95 %CI = 7.75-17.3) LMICs, 8.99 (95 %CI = 7.70-10.5) HICs. In regression with IPW, LMICs vs. HICs had IRR = 1.78 (95 %CI = 1.31-2.42, p < 0.001). Patients from LMICs were more likely to die than those from HICs [43.6% vs 29.2 %; Relative Risk (RR) = 2.59 (95 %CI = 2.29-2.93), p < 0.001)]. Patients with stroke were more likely to die than those without stroke [RR = 1.43 (95 %CI = 1.19-1.72), p < 0.001)].

CONCLUSIONS

Stroke incidence was low in HICs and LMICs although the stroke risk was higher in LMICs. Both LMIC status and stroke increased the risk of death. Improving early diagnosis of stroke and redistribution of healthcare resources should be a priority.

TRIAL REGISTRATION

ACTRN12620000421932 registered on 30/03/2020.

Significance of Initial Chest CT Severity Score (CTSS) and Patient Characteristics in Predicting Outcomes in Hospitalized COVID-19 Patients: A Single Center Study

The aim of this study is to examine the prognostic role of initial chest computed tomography severity score index (CTSS) and its association with demographic, socio-epidemiological, and clinical parameters in COVID-19 hospitalized patients. A retrospective study included patients who were hospitalized in the COVID Hospital of the Clinical Hospital Center Kosovska Mitrovica from July 2020 to March 2022. We compared patient characteristics and outcome of their hospital stay with values of CT severity score (mild, moderate, and severe form of the disease). Patients with severe disease were statistically significantly older, they treated more days, and they presented statistically significant highest mortality rate compared to mild and moderate forms. Smokers and obese were significantly more frequent among patients with higher CT, while vaccinated patients were more common among those with a mild form. Biochemical parameters at admission also showed statistical significance between the examined groups. We can conclude that by employing the initial CT severity score as the strongest predictor of mortality, it is possible to predict the outcome in hospitalized patients. A comprehensive examination of the patient upon admission, including determining the extent of inflammatory changes in the lungs using computed tomography, the levels of oxygen saturation, and other laboratory parameters, can assist doctors in making an adequate clinical evaluation and apply appropriate therapeutic protocols in the treatment of COVID-19.

Neurological Complications and Outcomes in Critically Ill Patients With COVID-19: Results From International Neurological Study Group From the COVID-19 Critical Care Consortium

Background

In this COVID-19 Critical Care Consortium (CCCC) sub-study, we qualified neurological complications associated with SARS-CoV2 infection.

Methods

The CCCC is an international, multicenter study. Eligible patients were COVID-19 patients admitted to intensive care units (ICU) across 23 centers between 1/7/2020 to 6/23/2022. Incidence of neurological complications was estimated as number of events per hospital days and per admission using Poisson regression. Associations between neurological complications and risk factors were assessed using multivariable Poisson regression.

Results

713 patients were included. Median age = 56 years (interquartile range (IQR) = 45-65). Neurological complications reported in 61/480 patients (12.7%) with the majority being ischemic stroke (2.9%), intracranial hemorrhage (ICH) (2.8%), and seizures (2.6%). Multivariable analysis for neurological complications per admitted days showed comorbid neurological conditions (incidence rate ratio (IRR) = 6.35, 2.57-15.7) were an independent risk factor for ischemic stroke. Extracorporeal membrane oxygenation (IRR = 5.32, 1.52-18.6), low-middle income countries (LMIC) vs high income countries (HIC) (IRR = 4.70, 1.62-13.7), and age >55 (IRR = 3.66, 1.23-10.9) were independent risk factors for ICH. Co-morbid neurological conditions (IRR = 3.43, 1.11-10.6), LMIC vs HIC (IRR = 8.69, 2.15-35.2), July-December 2020 vs January-June 2020 (IRR = 0.17, 0.04-0.69) and age >55 (IRR = 4.05, 1.15-14.3) were independent risk factors for seizure.

Conclusions

Decision-making should incorporate salient risk factors to inform management of SARS-CoV2 infection and avoid neurological complications.

Impact of Hemoglobin Levels on Composite Cardiac Arrest or Stroke Outcome in Patients With Respiratory Failure Due to COVID-19

OBJECTIVES

Anemia has been associated with an increased risk of both cardiac arrest and stroke, frequent complications of COVID-19. The effect of hemoglobin level at ICU admission on a composite outcome of cardiac arrest or stroke in an international cohort of COVID-19 patients was investigated.

DESIGN

Retrospective analysis of prospectively collected database.

SETTING

A registry of COVID-19 patients admitted to ICUs at over 370 international sites was reviewed for patients diagnosed with cardiac arrest or stroke up to 30 days after ICU admission. Anemia was defined as: normal (hemoglobin ≥ 12.0 g/dL for women, ≥ 13.5 g/dL for men), mild (hemoglobin 10.0-11.9 g/dL for women, 10.0-13.4 g/dL for men), moderate (hemoglobin ≥ 8.0 and < 10.0 g/dL for women and men), and severe (hemoglobin < 8.0 g/dL for women and men).

PATIENTS

Patients older than 18 years with acute COVID-19 infection in the ICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 6926 patients (median age = 59 yr, male = 65%), 760 patients (11.0%) experienced stroke (2.0%) and/or cardiac arrest (9.4%). Cardiac arrest or stroke was more common in patients with low hemoglobin, occurring in 12.8% of patients with normal hemoglobin, 13.3% of patients with mild anemia, and 16.7% of patients with moderate/severe anemia. Time to stroke or cardiac arrest by anemia status was analyzed using Cox proportional hazards regression with death as a competing risk. Covariates selected through clinical knowledge were age, sex, comorbidities (diabetes, hypertension, obesity, and cardiac or neurologic conditions), pandemic era, country income, mechanical ventilation, and extracorporeal membrane oxygenation. Moderate/severe anemia was associated with a higher risk of cardiac arrest or stroke (hazard ratio, 1.32; 95% CI, 1.05-1.67).

CONCLUSIONS

In an international registry of ICU patients with COVID-19, moderate/severe anemia was associated with increased hazard of cardiac arrest or stroke.

Bioinformatics and molecular biology tools for diagnosis, prevention, treatment and prognosis of COVID-19

Since December 2019, a new form of Severe Acute Respiratory Syndrome (SARS) has emerged worldwide, caused by SARS coronavirus 2 (SARS-CoV-2). This disease was called COVID-19 and was declared a pandemic by the World Health Organization in March 2020. Symptoms can vary from a common cold to severe pneumonia, hypoxemia, respiratory distress, and death. During this period of world stress, the medical and scientific community were able to acquire information and generate scientific data at unprecedented speed, to better understand the disease and facilitate vaccines and therapeutics development. Notably, bioinformatics tools were instrumental in decoding the viral genome and identifying critical targets for COVID-19 diagnosis and therapeutics. Through the integration of omics data, bioinformatics has also improved our understanding of disease pathogenesis and virus-host interactions, facilitating the development of targeted treatments and vaccines. Furthermore, molecular biology techniques have accelerated the design of sensitive diagnostic tests and the characterization of immune responses, paving the way for precision medicine approaches in treating COVID-19. Our analysis highlights the indispensable contributions of bioinformatics and molecular biology to the global effort against COVID-19. In this review, we aim to revise the COVID-19 features, diagnostic, prevention, treatment options, and how molecular biology, modern bioinformatic tools, and collaborations have helped combat this pandemic. An integrative literature review was performed, searching articles on several sites, including PUBMED and Google Scholar indexed in referenced databases, prioritizing articles from the last 3 years. The lessons learned from this COVID-19 pandemic will place the world in a much better position to respond to future pandemics.

SARS-CoV-2 in patient with protein C deficiency: A case report

In SARS-CoV-2 pandemic different disorders in coagulation pathways in COVID-19 patients were reported. We described a 44-year-old female with COVID-19 and protein C deficiency history. She did not show any coagulation disorder during her disease course. Complete genome sequencing of SARS-CoV-2 was performed and some mutations identified and compared with Wuhan strain. Besides hospitalized patients, in COVID-19 outpatients with low concentration of protein C, early prescription of an anticoagulant such as heparin could be helpful in prevention of venous thromboembolism or pulmonary embolism.

Relationship between D-dimers and dead-space on disease severity and mortality in COVID-19 acute respiratory distress syndrome: A retrospective observational cohort study

BACKGROUND

Despite its diagnostic and prognostic importance, physiologic dead space fraction is not included in the current ARDS definition or severity classification. ARDS caused by COVID-19 (C-ARDS) is characterized by increased physiologic dead space fraction and hypoxemia. Our aim was to investigate the relationship between dead space indices, markers of inflammation, immunothrombosis, severity and intensive care unit (ICU) mortality.

RESULTS

Retrospective data including demographics, gas exchange, ventilatory parameters, and respiratory mechanics in the first 24 h of invasive ventilation. Plasma concentrations of D-dimers and ferritin were not significantly different across C-ARDS severity categories. Weak relationships were found between D-dimers and VR (r = 0.07, p = 0.13), P_ETCO₂/PaCO₂ (r = -0.1, p = 0.02), or estimated dead space fraction (r = 0.019, p = 0.68). Age, PaO₂/FiO₂, pH, P_ETCO₂/PaCO₂ and ferritin, were independently associated with ICU mortality. We found no association between D-dimers or ferritin and any dead-space indices adjusting for PaO₂/FiO₂, days of ventilation, tidal volume, and respiratory system compliance.

CONCLUSIONS

We report no association between dead space and inflammatory markers in mechanically ventilated patients with C-ARDS. Our results support theories suggesting that multiple mechanisms, in addition to immunothrombosis, play a role in the pathophysiology of respiratory failure and degree of dead space in C-ARDS.

Morphological and functional findings in COVID-19 lung disease as compared to Pneumonia, ARDS, and High-Altitude Pulmonary Edema

Coronavirus disease-2019 (COVID-19) may severely affect respiratory function and evolve to life-threatening hypoxia. The clinical experience led to the implementation of standardized protocols assuming similarity to severe acute respiratory syndrome (SARS-CoV-2). Understanding the histopathological and functional patterns is essential to better understand the pathophysiology of COVID-19 and then develop new therapeutic strategies. Epithelial and endothelial cell damage can result from the virus attack, thus leading to immune-mediated response. Pulmonary histopathological findings show the presence of Mallory bodies, alveolar coating cells with nuclear atypia, reactive pneumocytes, reparative fibrosis, intra-alveolar hemorrhage, moderate inflammatory infiltrates, micro-abscesses, microthrombus, hyaline membrane fragments, and emphysema-like lung areas. COVID-19 patients may present different respiratory stages from silent to critical hypoxemia, are associated with the degree of pulmonary parenchymal involvement, thus yielding alteration of ventilation and perfusion relationships. This review aims to: discuss the morphological (histopathological and radiological) and functional findings of COVID-19 compared to acute interstitial pneumonia, acute respiratory distress syndrome (ARDS), and high-altitude pulmonary edema (HAPE), four entities that share common clinical traits, but have peculiar pathophysiological features with potential implications to their clinical management.

Treatment of Acquired von Willebrand Disease due to Extracorporeal Membrane Oxygenation in a Pediatric COVID-19 Patient with Vonicog Alfa: A Case Report and Literature Review

Acquired von Willebrand disease (aVWD) is frequently observed in patients with the need for extracorporeal membrane oxygenation (ECMO). aVWD can be treated by plasma-derived concentrates containing factor VIII (FVIII) and/or von Willebrand factor (VWF) and recombinant VWF concentrate as well as adjuvant therapies such as tranexamic acid and desmopressin. However, all of these therapeutic options possibly cause thromboembolism. Therefore, the optimal treatment remains uncertain. This report presents a case of a 16-year-old patient suffering from severe acute respiratory distress syndrome due to coronavirus disease 2019 with the need of ECMO support. Our patient developed aVWD under ECMO therapy characterized by loss of high-molecular-weight multimers (HMWM) and severe bleeding symptoms following endoscopic papillotomy due to sclerosing cholangitis. At the same time standard laboratory parameters showed hypercoagulability with increased fibrinogen level and platelet count. The patient was successfully treated with recombinant VWF concentrate (rVWF; vonicog alfa; Veyvondi) combined with topic tranexamic acid application and cortisone therapy. rVWF concentrate vonicog alfa is characterized by ultra-large multimers and absence of FVIII. Patient could be successfully weaned from ECMO support after 72 days. Multimer analysis 1 week after ECMO decannulation showed an adequate reappearance of HMWM.

SARS-CoV-2 Infection and Candidate Biomarkers

Severe acute respiratory syndrome coronavirus 2 is a virus that can still infect individuals and whose deadly effects continue despite the current vaccines and drugs. Since 2019, many studies on the pathogenesis of the disease have been completed and continue to be done. In addition to the diagnosis and treatment of the disease, many molecules that can be markers of the disease have been investigated. In the early stages of the pandemic, many nonspecific and infection-related laboratory findings and chest computed tomography were used to obtain information about the diagnosis of the disease. The more individual molecules became associated with the disease yet. The purpose of this review is to summarize the impact and role of many molecules associated with coronavirus disease-2019 infection that have been previously used and newly revealed. Numerous studies are summarized in this review. The obtained data show that previously used laboratory findings and new potential biomarkers are not specific to the disease. New potential biomarkers have been associated with the severity of the disease itself, as can be seen with lung imaging and even with routine laboratory findings. One of the important points that are seen frequently in studies is that the effectiveness of these molecules has been shown not only in coronavirus disease-2019 infection but also in many other diseases. This removes the pathogenesis of the disease from being a unique mechanism created by the Severe acute respiratory syndrome coronavirus 2 and provides a general perspective formed by viral or bacterial infections. However, there are still many molecular changes that need to be investigated. Future studies will continue to update themselves with the mutations of the virus.

Tracheostomy outcomes in critically ill patients with COVID-19: a systematic review, meta-analysis, and meta-regression

BACKGROUND

We performed a systematic review of mechanically ventilated patients with COVID-19, which analysed the effect of tracheostomy timing and technique (surgical vs percutaneous) on mortality. Secondary outcomes included intensive care unit (ICU) and hospital length of stay (LOS), decannulation from tracheostomy, duration of mechanical ventilation, and complications.

METHODS

Four databases were screened between January 1, 2020 and January 10, 2022 (PubMed, Embase, Scopus, and Cochrane). Papers were selected according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Population or Problem, Intervention or exposure, Comparison, and Outcome (PICO) guidelines. Meta-analysis and meta-regression for main outcomes were performed.

RESULTS

The search yielded 9024 potentially relevant studies, of which 47 (n=5268 patients) were included. High levels of between-study heterogeneity were observed across study outcomes. The pooled mean tracheostomy timing was 16.5 days (95% confidence interval [CI]: 14.7-18.4; I2=99.6%). Pooled mortality was 22.1% (95% CI: 18.7-25.5; I2=89.0%). Meta-regression did not show significant associations between mortality and tracheostomy timing, mechanical ventilation duration, time to decannulation, and tracheostomy technique. Pooled mean estimates for ICU and hospital LOS were 29.6 (95% CI: 24.0-35.2; I2=98.6%) and 38.8 (95% CI: 32.1-45.6; I2=95.7%) days, both associated with mechanical ventilation duration (coefficient 0.8 [95% CI: 0.2-1.4], P=0.02 and 0.9 [95% CI: 0.4-1.4], P=0.01, respectively) but not tracheostomy timing. Data were insufficient to assess tracheostomy technique on LOS. Duration of mechanical ventilation was 23.4 days (95% CI: 19.2-27.7; I2=99.3%), not associated with tracheostomy timing. Data were insufficient to assess the effect of tracheostomy technique on mechanical ventilation duration. Time to decannulation was 23.8 days (95% CI: 19.7-27.8; I2=98.7%), not influenced by tracheostomy timing or technique. The most common complications were stoma infection, ulcers or necrosis, and bleeding.

CONCLUSIONS

In patients with COVID-19 requiring tracheostomy, the timing and technique of tracheostomy did not clearly impact on patient outcomes.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO CRD42021272220.

Failed clinical trials on COVID-19 acute respiratory distress syndrome in hospitalized patients: common oversights and streamlining the development of clinically effective therapeutics

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic has put a strain on global healthcare systems. Despite admirable efforts to develop rapidly new pharmacotherapies, supportive treatments remain the standard of care. Multiple clinical trials have failed due to design issues, biased patient enrollment, small sample sizes, inadequate control groups, and lack of long-term outcomes monitoring.

AREAS COVERED

This narrative review depicts the current situation around failed and success COVID-19 clinical trials and recommendations in hospitalized patients with COVID-19, oversights and streamlining of clinically effective therapeutics. PubMed, EBSCO, Cochrane Library, and WHO and NIH guidelines were searched for relevant literature up to 5 August 2022.

EXPERT OPINION

The WHO, NIH, and IDSA have issued recommendations to better clarify which drugs should be used during the different phases of the disease. Given the biases and high heterogeneity of published studies, interpretation of the current literature is difficult. Future clinical trials should be designed to standardize clinical approaches, with appropriate organization, patient selection, addition of control groups, and careful identification of disease phase to reduce heterogeneity and bias and should rely on the integration of scientific societies to promote a consensus on interpretation of the data and recommendations for optimal COVID-19 therapies.

Predictive ability of viscoelastic testing using ClotPro® for short-term outcome in patients with severe Covid-19 ARDS with or without ECMO therapy: a retrospective study

BACKGROUND

SARS-CoV-2 infections are suspected to trigger the coagulation system through various pathways leading to a high incidence of thromboembolic complications, hypercoagulation and impaired fibrinolytic capacity were previously identified as potentially mechanisms. A reliable diagnostic tool for detecting both is still under discussion. This retrospective study is aimed to examine the prognostic relevance of early viscoelastic testing compared to conventional laboratory tests in COVID-19 patients with acute respiratory distress syndrome (ARDS).

METHODS

All mechanically ventilated patients with COVID-19 related ARDS treated in our intensive care unit (ICU) between January and March 2021 were included in this study. Viscoelastic testing (VET) was performed using the ClotPro® system after admission to our ICU. Prevalence of thromboembolic events was observed by standardized screening for venous and pulmonary thromboembolism using complete compression ultrasound and thoracic computed tomography pulmonary angiography at ICU admission, respectively. We examined associations between the severity of ARDS at admission to our ICU, in-hospital mortality and the incidence of thromboembolic events comparing conventional laboratory analysis and VET. ECMO related coagulopathy was investigated in a subgroup analysis. The data were analyzed using the Mann-Whitney U test.

RESULTS

Of 55 patients enrolled in this study, 22 patients required treatment with ECMO. Thromboembolic complications occurred in 51% of all patients. Overall hospital mortality was 55%. In patients with thromboembolic complications, signs of reduced fibrinolytic capacity could be detected in the TPA assay with prolonged lysis time, median 460 s (IQR 350-560) vs 359 s (IQR 287-521, p = 0.073). Patients with moderate to severe ARDS at admission to our ICU showed increased maximum clot firmness as a sign of hypercoagulation in the EX-test (70 vs 67 mm, p < 0.05), FIB-test (35 vs 24 mm, p < 0.05) and TPA-test (52 vs 36 mm, p < 0.05) as well as higher values of inflammatory markers (CRP, PCT and IL6). ECMO patients suffered more frequently from bleeding complications (32% vs 15%).

CONCLUSION

Although, the predictive value for thromboembolic complications or mortality seems limited, point-of-care viscoelastic coagulation testing might be useful in detecting hypercoagulable states and impaired fibrinolysis in critically ill COVID-19 ARDS patients and could be helpful in identifying patients with a potentially very severe course of the disease.

Coronavirus Disease 2019-Associated Coagulopathy

Coronavirus disease 2019 (COVID-19)-associated coagulopathy is an acute illness characterized by thrombosis with or without hemorrhage after COVID-19 infection. Clinical symptoms of COVID-19-associated coagulopathy can occur at any anatomical site. Various forms of venous thromboembolism, including deep vein thrombosis and pulmonary embolism, are common in acutely ill patients with COVID-19. Laboratory findings, such as D-dimer and platelet counts, can help diagnose COVID-19-associated coagulopathy. Anticoagulation using direct oral anticoagulants and low-molecular-weight heparin is essential for the treatment of COVID-19-associated coagulopathy. Prophylactic anticoagulants are important in preventing COVID-19-associated coagulopathy in patients with severe COVID-19. In particular, the early initiation of prophylactic anticoagulation in patients with COVID-19 can improve survival rates without the risk of serious bleeding events.

Neurological Manifestations of SARS-CoV-2 Infection: Protocol for a Sub-analysis of the COVID-19 Critical Care Consortium Observational Study

Introduction

Neurological manifestations and complications in coronavirus disease-2019 (COVID-19) patients are frequent. Prior studies suggested a possible association between neurological complications and fatal outcome, as well as the existence of potential modifiable risk factors associated to their occurrence. Therefore, more information is needed regarding the incidence and type of neurological complications, risk factors, and associated outcomes in COVID-19.

Methods

This is a pre-planned secondary analysis of the international multicenter observational study of the COVID-19 Critical Care Consortium (which collected data both retrospectively and prospectively from the beginning of COVID-19 pandemic) with the aim to describe neurological complications in critically ill COVID-19 patients and to assess the associated risk factors, and outcomes. Adult patients with confirmed COVID-19, admitted to Intensive Care Unit (ICU) will be considered for this analysis. Data collected in the COVID-19 Critical Care Consortium study includes patients' pre-admission characteristics, comorbidities, severity status, and type and severity of neurological complications. In-hospital mortality and neurological outcome were collected at discharge from ICU, and at 28-days.

Ethics and Dissemination

The COVID-19 Critical Care Consortium main study and its amendments have been approved by the Regional Ethics Committee of participating sites. No further approval is required for this secondary analysis.

Trial Registration Number

ACTRN12620000421932.

Dysregulated Interferon Response and Immune Hyperactivation in Severe COVID-19: Targeting STATs as a Novel Therapeutic Strategy

A disease outbreak in December 2019, caused by a novel coronavirus SARS-CoV-2, was named COVID-19. SARS-CoV-2 infects cells from the upper and lower respiratory tract system and is transmitted by inhalation or contact with infected droplets. Common clinical symptoms include fatigue, fever, and cough, but also shortness of breath and lung abnormalities. Still, some 5% of SARS-CoV-2 infections progress to severe pneumonia and acute respiratory distress syndrome (ARDS), with pulmonary edema, acute kidney injury, and/or multiple organ failure as important consequences, which can lead to death. The innate immune system recognizes viral RNAs and triggers the expression of interferons (IFN). IFNs activate anti-viral effectors and components of the adaptive immune system by activating members of the STAT and IRF families that induce the expression of IFN-stimulated genes (ISG)s. Among other coronaviruses, such as Middle East respiratory syndrome coronavirus (MERS-CoV) and SARS-CoV, common strategies have been identified to antagonize IFN signaling. This typically coincides with hyperactive inflammatory host responses known as the “cytokine storm” that mediate severe lung damage. Likewise, SARS-CoV-2 infection combines a dysregulated IFN response with excessive production of inflammatory cytokines in the lungs. This excessive inflammatory response in the lungs is associated with the local recruitment of immune cells that create a pathogenic inflammatory loop. Together, it causes severe lung pathology, including ARDS, as well as damage to other vulnerable organs, like the heart, spleen, lymph nodes, and kidney, as well as the brain. This can rapidly progress to multiple organ exhaustion and correlates with a poor prognosis in COVID-19 patients. In this review, we focus on the crucial role of different types of IFN that underlies the progression of SARS-CoV-2 infection and leads to immune cell hyper-activation in the lungs, exuberant systemic inflammation, and multiple organ damage. Consequently, to protect from systemic inflammation, it will be critical to interfere with signaling cascades activated by IFNs and other inflammatory cytokines. Targeting members of the STAT family could therefore be proposed as a novel therapeutic strategy in patients with severe COVID-19.

Laboratory Biomarkers for Diagnosis and Prognosis in COVID-19

Severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) causes a wide spectrum of clinical manifestations, with progression to multiorgan failure in the most severe cases. Several biomarkers can be altered in coronavirus disease 2019 (COVID-19), and they can be associated with diagnosis, prognosis, and outcomes. The most used biomarkers in COVID-19 include several proinflammatory cytokines, neuron-specific enolase (NSE), lactate dehydrogenase (LDH), aspartate transaminase (AST), neutrophil count, neutrophils-to-lymphocytes ratio, troponins, creatine kinase (MB), myoglobin, D-dimer, brain natriuretic peptide (BNP), and its N-terminal pro-hormone (NT-proBNP). Some of these biomarkers can be readily used to predict disease severity, hospitalization, intensive care unit (ICU) admission, and mortality, while others, such as metabolomic and proteomic analysis, have not yet translated to clinical practice. This narrative review aims to identify laboratory biomarkers that have shown significant diagnostic and prognostic value for risk stratification in COVID-19 and discuss the possible clinical application of novel analytic strategies, like metabolomics and proteomics. Future research should focus on identifying a limited but essential number of laboratory biomarkers to easily predict prognosis and outcome in severe COVID-19.

Point of care coagulation management in anesthesiology and critical care

Point of care (POC) devices are increasingly used in the ICU and in anesthesia. Besides POC-devices for blood gas analysis, several devices are available for coagulation measurements. Although basic principles for thromboelastographic measurements are not novel, some promising developments were made during the last decade improving both user-friendliness and measurement reliability. For instance, POC measurements of activated clotting time (ACT) for heparin monitoring is still regarded as standard-of-care in cardiac interventions and surgery. In the field of anesthesia and intensive care medicine, POC-devices for thromboelastographic and platelet aggregation measurements are widely used. Their impact in case of bleeding and patient blood management for cardiothoracic and trauma surgery is well known. Moreover, there are promising concepts for anticoagulation monitoring including new oral anticoagulant drugs. Coagulation POC-devices may also identify patients at specific risk for thromboembolic events quickly. On the other hand, benefits of POC-devices need to be balanced against limitations, which include technical restrictions and operator related errors, mainly affecting reproducibility and interpretation of results. Therefore, it is recommendable to consider results of POC-coagulation testing in comparison to standard laboratory tests (SLT). Nevertheless, in urgent or emergency situations POC results enable fast decision making to optimize patient care.

CYTOKINES AS POTENTIAL MARKERS OF COVID-19 SEVERITY AND OUTCOMES

The continual propagation of SARS-CoV-2 has changed health care systems globally. Ranging degrees of clinical severity in COVID-19 patients have been noted in numerous literature sources. Cytokines play a crucial role in the development of key immunological processes in COVID-19. SARS-CoV-2 causes imbalance of the immune system and might culminate in cytokine storm and multiple organ involvement. The prevailing role of some special cytokines might serve as indicators of disease severity. Further stratification of patients in the context of specific cytokines can be beneficial for diagnosing disease stages. It can prevent critical states owing to timely diagnosis and targeted therapy. Targeting peculiar cytokines can markedly reduce complications. The aim of this article is to comprehensively overview the role of the main cytokines in COVID-19 pathogenesis and distinguish prognostic factors. Insights into specific cytokine involvement in COVID-19 pathogenesis may open new avenues for diagnosing hyperinflammatory COVID-19, predicting its outcomes and providing individualized cytokine-targeted therapeutic approaches.

Ischemic and Hemorrhagic Stroke Among Critically Ill Patients With Coronavirus Disease 2019: An International Multicenter Coronavirus Disease 2019 Critical Care Consortium Study

OBJECTIVES

Stroke has been reported in observational series as a frequent complication of coronavirus disease 2019, but more information is needed regarding stroke prevalence and outcomes. We explored the prevalence and outcomes of acute stroke in an international cohort of patients with coronavirus disease 2019 who required ICU admission.

DESIGN

Retrospective analysis of prospectively collected database.

SETTING

A registry of coronavirus disease 2019 patients admitted to ICUs at over 370 international sites was reviewed for patients diagnosed with acute stroke during their stay.

PATIENTS

Patients older than 18 years old with acute coronavirus disease 2019 infection in ICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 2,699 patients identified (median age 59 yr; male 65%), 59 (2.2%) experienced acute stroke: 0.7% ischemic, 1.0% hemorrhagic, and 0.5% unspecified type. Systemic anticoagulant use was not associated with any stroke type. The frequency of diabetes, hypertension, and smoking was higher in patients with ischemic stroke than in stroke-free and hemorrhagic stroke patients. Extracorporeal membrane oxygenation support was more common among patients with hemorrhagic (56%) and ischemic stroke (16%) than in those without stroke (10%). Extracorporeal membrane oxygenation patients had higher cumulative 90-day probabilities of hemorrhagic (relative risk = 10.5) and ischemic stroke (relative risk = 1.7) versus nonextracorporeal membrane oxygenation patients. Hemorrhagic stroke increased the hazard of death (hazard ratio = 2.74), but ischemic stroke did not-similar to the effects of these stroke types seen in noncoronavirus disease 2019 ICU patients.

CONCLUSIONS

In an international registry of ICU patients with coronavirus disease 2019, stroke was infrequent. Hemorrhagic stroke, but not ischemic stroke, was associated with increased mortality. Further, both hemorrhagic stroke and ischemic stroke were associated with traditional vascular risk factors. Extracorporeal membrane oxygenation use was strongly associated with both stroke and death.

Case Report: Acute Splenic Artery Thrombosis in a COVID 19, Postpartum Patient

The incidence of thromboembolic disease is reported to be high in SARS-CoV₂ disease. Pregnancy, an already physiologically hypercoagulable state, associated to COVID 19, generates even more concern regarding the potentially increased risk of thrombotic events. The exact incidence of such complications is yet unknown, but there is data suggesting that coagulopathy and thromboembolism are both increased in pregnancies affected by COVID-19. Since the outbreak of the COVID 19 pandemics, the most common described thrombotic events associated with SARS-COV2 infection have been venous thromboembolism and disseminated intravascular coagulation, while arterial thrombotic events are less commonly described. Splenic infarction is a rare disorder that can be secondary to a hypercoagulable state. There are only few cases of splenic infraction described, but none with splenic artery thrombosis, in a post-partum patient, on therapeutic anticoagulation regimen. We present the case of a 31-year-old Caucasian, 26 weeks pregnant woman, with no prior medical history, admitted to the hospital with a severe form of COVID 19 pneumonia and who, during the course of the disease, developed a massive splenic infarction with splenic artery thrombosis.

Serum Neurofilament Light is elevated in COVID-19 Positive Adults in the ICU and is associated with Co-Morbid Cardiovascular Disease, Neurological Complications, and Acuity of Illness

In critically ill COVID-19 patients, the risk of long-term neurological consequences is just beginning to be appreciated. While recent studies have identified that there is an increase in structural injury to the nervous system in critically ill COVID-19 patients, there is little known about the relationship of COVID-19 neurological damage to the systemic inflammatory diseases also observed in COVID-19 patients. The purpose of this pilot observational study was to examine the relationships between serum neurofilament light protein (NfL, a measure of neuronal injury) and co-morbid cardiovascular disease (CVD) and neurological complications in COVID-19 positive patients admitted to the intensive care unit (ICU). In this observational study of one-hundred patients who were admitted to the ICU in Tucson, Arizona between April and August 2020, 89 were positive for COVID-19 (COVID-pos) and 11 was COVID-negative (COVID-neg). A healthy control group (n=8) was examined for comparison. The primary outcomes and measures were subject demographics, serum NfL, presence and extent of CVD, diabetes, sequential organ failure assessment score (SOFA), presence of neurological complications, and blood chemistry panel data. COVID-pos patients in the ICU had significantly higher mean levels of Nfl (229.6 ± 163 pg/ml) compared to COVID-neg ICU patients (19.3 ± 5.6 pg/ml), Welch's t-test, p =.01 and healthy controls (12.3 ± 3.1 pg/ml), Welch's t-test p =.005. Levels of Nfl in COVID-pos ICU patients were significantly higher in patients with concomitant CVD and diabetes (n=35, log Nfl 1.6±.09), and correlated with higher SOFA scores (r=.5, p =.001). These findings suggest that in severe COVID-19 disease, the central neuronal and axonal damage in these patients may be driven, in part, by the level of systemic cardiovascular disease and peripheral inflammation. Understanding the contributions of systemic inflammatory disease to central neurological degeneration in these COVID-19 survivors will be important to the design of interventional therapies to prevent long-term neurological and cognitive dysfunction.

Impact of COVID-19 infection on the cardiovascular system: An evidence-based analysis of risk factors and outcomes

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), also known as COVID-19, emerged in late 2019 in Wuhan, China. The World Health Organization declared the virus a pandemic on March 11, 2020. Disease progression from COVID-19 infection has shown significant symptom manifestations within organ systems beyond the respiratory system. The literature has shown increasing evidence of cardiovascular involvement during disease course and an associated increase in mortality among infected patients. Although the understanding of this novel virus is continually evolving, it is currently proposed that the mechanism by which the SARS-CoV-2 virus contributes to cardiovascular manifestations involves the ACE2 transmembrane protein. The protein ACE2 is highly expressed in blood vessel pericytes, and infection can result in microvascular dysfunction and subsequent acute coronary syndromes. Complications involving the cardiovascular system include myocardial infarction, arrhythmias, shock, and heart failure. In this evidence-based review, we discuss risk factors of cardiovascular involvement in COVID-19 infection, pathophysiology of COVID-19-related cardiovascular infection, and injury, COVID-19 effects on the cardiovascular system and corresponding treatments, and hematologic effects of COVID-19 and COVID-19 in heart transplant patients. Clinicians managing COVID-19 patients should appreciate the potential cardiovascular effects related to the disease process.

Spontaneous psoas haematoma: a life-threatening complication of anticoagulation in COVID-19. A case series of four episodes

BACKGROUND

Anticoagulant prophylaxis is part of the standard management of hospitalized COVID-19 patients. Despite adequate thromboprophylaxis, one-third of COVID-19 patients with pneumonia developed pulmonary embolism. This high rate of thrombotic complications has led to higher doses of anticoagulants according to clinical complexity (e.g. intensive care unit (ICU) patients) and D-dimer levels. On the other side of the coin, haemorrhagic complications are being increasingly reported.

CASES PRESENTATION

We herein report four cases of spontaneous psoas haematomas (SPH) among 548 patients hospitalized for SARS-CoV-2 pneumonia between March 2020 and January 2021 (incidence of 7.3 cases per 1000 patients). All patients had pneumonia, with age ranging between 62 and 83 years. All patients received anticoagulant therapy with low weight molecular heparin (100 U.I. anti-Xa/kg 2 times/d) from admission: in two cases, a diagnosis of pulmonary embolism was made. In another case, a thrombosis of left axillary and basilic veins was found, and only in one case anticoagulant therapy was started because of elevated levels of D-dimer. In all cases, signs of anaemia were detected and patients experienced low back or abdominal pain. The diagnosis of spontaneous psoas haematoma was made by computed tomography (CT) after a median of 12.5 d (9;16) from admission and 19.5 d (14.75; 24.25) from the beginning of COVID-19 symptoms. Half of these patients died from haemorrhagic shock.

CONCLUSIONS

Given the potential life-threatening of SPH and the possible subtle clinical presentation, we believe it is crucial to raise clinicians awareness of this complication among COVID-19 patients undergoing anticoagulants.

Infectious disease-associated encephalopathies

Infectious diseases may affect brain function and cause encephalopathy even when the pathogen does not directly infect the central nervous system, known as infectious disease-associated encephalopathy. The systemic inflammatory process may result in neuroinflammation, with glial cell activation and increased levels of cytokines, reduced neurotrophic factors, blood-brain barrier dysfunction, neurotransmitter metabolism imbalances, and neurotoxicity, and behavioral and cognitive impairments often occur in the late course. Even though infectious disease-associated encephalopathies may cause devastating neurologic and cognitive deficits, the concept of infectious disease-associated encephalopathies is still under-investigated; knowledge of the underlying mechanisms, which may be distinct from those of encephalopathies of non-infectious cause, is still limited. In this review, we focus on the pathophysiology of encephalopathies associated with peripheral (sepsis, malaria, influenza, and COVID-19), emerging therapeutic strategies, and the role of neuroinflammation.

Ten golden rules for individualized mechanical ventilation in acute respiratory distress syndrome

Considerable progress has been made over the last decades in the management of acute respiratory distress syndrome (ARDS). Mechanical ventilation(MV) remains the cornerstone of supportive therapy for ARDS. Lung-protective MV minimizes the risk of ventilator-induced lung injury (VILI) and improves survival. Several parameters contribute to the risk of VILI and require careful setting including tidal volume (V_T), plateau pressure (P_plat), driving pressure (ΔP), positive end-expiratory pressure (PEEP), and respiratory rate. Measurement of energy and mechanical power allows quantification of the relative contributions of various parameters (V_T, P_plat, ΔP, PEEP, respiratory rate, and airflow) for the individualization of MV settings. The use of neuromuscular blocking agents mainly in cases of severe ARDS can improve oxygenation and reduce asynchrony, although they are not known to confer a survival benefit. Rescue respiratory therapies such as prone positioning, inhaled nitric oxide, and extracorporeal support techniques may be adopted in specific situations. Furthermore, respiratory weaning protocols should also be considered. Based on a review of recent clinical trials, we present 10 golden rules for individualized MV in ARDS management.

Tracheostomy Timing and Outcome in Severe COVID-19: The WeanTrach Multicenter Study

BACKGROUND

Tracheostomy can be performed safely in patients with coronavirus disease 2019 (COVID-19). However, little is known about the optimal timing, effects on outcome, and complications.

METHODS

A multicenter, retrospective, observational study. This study included 153 tracheostomized COVID-19 patients from 11 intensive care units (ICUs). The primary endpoint was the median time to tracheostomy in critically ill COVID-19 patients. Secondary endpoints were survival rate, length of ICU stay, and post-tracheostomy complications, stratified by tracheostomy timing (early versus late) and technique (surgical versus percutaneous).

RESULTS

The median time to tracheostomy was 15 (1-64) days. There was no significant difference in survival between critically ill COVID-19 patients who received tracheostomy before versus after day 15, nor between surgical and percutaneous techniques. ICU length of stay was shorter with early compared to late tracheostomy (p < 0.001) and percutaneous compared to surgical tracheostomy (p = 0.050). The rate of lower respiratory tract infections was higher with surgical versus percutaneous technique (p = 0.007).

CONCLUSIONS

Among critically ill patients with COVID-19, neither early nor percutaneous tracheostomy improved outcomes, but did shorten ICU stay. Infectious complications were less frequent with percutaneous than surgical tracheostomy.