Intensive Care Resources and 60-Day Survival of Critically-Ill COVID-19 Patients

In-hospital survival of critically ill COVID-19 patients treated with glucocorticoids: a multicenter real-world data study

The COVID-19 pandemic has posed a major challenge to healthcare systems globally. Millions of people have been infected, and millions of deaths have been reported worldwide. Glucocorticoids have attracted worldwide attention for their potential efficacy in the treatment of COVID-19. Various glucocorticoids with different dosages and treatment durations have been studied in patients with different severities, with a suitable dosage and treatment duration not yet defined. This study aimed to investigate whether in-hospital survival differs between critically ill patients treated with low-dose glucocorticoids, high-dose glucocorticoids or no glucocorticoids. All critically ill patients admitted to the intensive care unit of the Charité Hospital-Universitätsmedizin Berlin between February 2020 and December 2021 with COVID-19 pneumonia receiving supplemental oxygen were eligible to participate in this multicenter real-world data study. Patients were retrospectively assigned to one of three groups: the high corticosteroid dose (HighC) group (receiving 6 mg parenteral dexamethasone or an equivalent corticosteroid dosage for ten days), the low corticosteroid dose (LowC) group (receiving less than 6 mg parenteral dexamethasone or an equivalent corticosteroid dosage for ten days), or the no corticosteroid (NoC) group. Overall survival and risk effects were compared among groups within the total observation period, as well as at 35 days after the onset of COVID-19 symptoms. Adjusted multivariable Cox proportional hazard regression analysis was performed to compare the risk of death between the treatment groups. Out of 1561 critically ill COVID-19 patients, 1014 were included in the baseline analysis. In the survival study, 1009 patients were assigned to the NoC (n = 346), HighC (n = 552), or LowC group (n = 111). The baseline characteristics were balanced between groups, except for age, BMI, APACHE II score, SOFA and SAPS II. While the 35-day survival did not show any differences, a landmark analysis of the patients surviving beyond 35 days revealed differences between groups. The restricted mean survival time was 112 days in the LowC group [95% CI: 97 - 128], 133 days in the HighC group [95% CI: 124 - 141] and 144 days in the NoC group [95% CI: 121 - 167]. The multivariable-adjusted Cox proportional hazard analysis indicated that, regardless of age, sex, health status or invasive oxygenation, a low-dose treatment increased the hazard of death of critically ill COVID-19 patients by a factor of 2.09 ([95% CI: 0.99, 4.4], p = 0.05) and a high-dose corticosteroid treatment increased the risk by a factor of 1.07 ([95% CI: 0.53, 2.15], p = 0.85) compared to no treatment with glucocorticoids. The analysis reveals that corticosteroid treatment does not influence the survival of critically ill COVID-19 patients in the intensive care unit within 35 days. Our evaluations further suggest that regardless of ventilation status, the decision-making process for administering corticosteroid therapy should account for the individual severity of the illness.

Respiratory system mechanics, gas exchange, and outcomes in mechanically ventilated patients with COVID-19-related acute respiratory distress syndrome: a systematic review and meta-analysis

The association of respiratory mechanics, particularly respiratory system static compliance (C_RS), with severity of hypoxaemia in patients with COVID-19-related acute respiratory distress syndrome (ARDS) has been widely debated, with some studies reporting distinct ARDS phenotypes based on C_RS. Ascertaining whether such phenotypes exist is important, because they might indicate the need for ventilation strategies that differ from those used in patients with ARDS due to other causes. In a systematic review and meta-analysis of studies published between Dec 1, 2019, and March 14, 2022, we evaluated respiratory system mechanics, ventilator parameters, gas exchange parameters, and clinical outcomes in patients with COVID-19-related ARDS. Among 11 356 patients in 37 studies, mean reported C_RS, measured close to the time of endotracheal intubation, was 35·8 mL/cm H₂O (95% CI 33·9-37·8; I²=96·9%, τ²=32·6). Pooled mean C_RS was normally distributed. Increasing ARDS severity (assessed by PaO₂/FiO₂ ratio as mild, moderate, or severe) was associated with decreasing C_RS. We found no evidence for distinct C_RS-based clinical phenotypes in patients with COVID-19-related ARDS, and we therefore conclude that no change in conventional lung-protective ventilation strategies is warranted. Future studies should explore the personalisation of mechanical ventilation strategies according to factors including respiratory system mechanics and haemodynamic status in patients with ARDS.

Intracerebral bleeding after Janus-kinase inhibitor baricitinib for COVID-19

Objectives

Intracerebral hemorrhage/bleeding (ICH) after an infection with SARS-CoV-2 (COVID-19) treated with the Janus-kinase inhibitor baricitinib has not been reported.

Case presentation

A 86yo Caucasian female suddenly developed aphasia with a systolic blood pressure of 220 mmHg. Cerebral imaging revealed an ICH in the left temporal lobe without mass effect and no need for neurosurgical intervention. Her previous history was positive for arterial hypertension, hyperlipidemia, heart failure, renal insufficiency, hyperuricemia, macula degeneration, lumbalgia, and glaucoma bilaterally. Additionally, she had experienced an infection with SARS-CoV-2 with onset 44 days earlier having been treated with ceftriaxone (2 g/d for 7 d), dexamethasone (6 mg for 6 d), and bariticinib (2 mg for 6 d).

Conclusions

Though ICH was time-linked to COVID-19, a causal relation could not be unequivocally established. Whether baricitinib increased the bleeding risk remains speculative. As long as causalities between ICH and baricitinib remain unproven, it should be given with caution and only under close blood pressure monitoring.