Clinical Characteristics of Severe Covid Pneumonia: Exploring New Trends in ICU

Abstract Background: In late December 2019, Covid-19 emerged as clusters of pneumonia of unknown cause in a province of china, Wuhan. Etiological agent was identified as novel coronavirus that resembles severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East Respiratory syndrome coronavirus (MERS-CoV) and has zoonotic transmission. Covid pneumonia can remain asymptomatic, present as mild infection, severe pneumonia or respiratory failure. Diagnosis is based on rRT-PCR carried out on respiratory secretions. Covid related mortality exceeds 50% once patient requires ICU admission. Objective: To study the characteristics of ICU population admitted to ICU of Shifa International hospital.Results: we prospectively analysed 74 patients which included 43.3% females and 56.7% males. Commonest symptoms were shortness of breath (94.5%), fever (74.3%) and cough (74.3%). Most of our study population consisted of non-smokers (79.7%) and had hypertension (59.4%) followed by diabetes (47.2%). Hydroxychloroquine (HCQ) and azithromycin combination is superior to hydroxychloroquine and doxycycline in reducing mortality (p=0.023) whereas Doxycycline alone resulted in increased mortality (p=0.009). Those who did not require antibiotics or required only narrow spectrum antibiotics had increased survival and reduced requirement of invasive mechanical ventilation (p=< 0.0001). in our study population, (44.9%) developed acute kidney injury, 2.7% needed re-intubations 10.8% developed surgical emphysema and 2.7 % thromboembolic events despite full anticoagulation. ICU mortality was 41.8% and was higher in females (59.4%, p=0.008), those who had SOFA score > 3.5 at time of admission, raised D-Dimers > 931 ng/ml, NLR > 9.2. It was further high in those who required invasive mechanical ventilation and vasopressor support (58.1% mortality p=< 0.001). ICU stay was more prolonged in those requiring invasive mechanical ventilation as compared to those who did not. (23 days vs 6 days, p=0.001). Mean plateau pressure was 19.6 ± 7.6; mean Driving pressures 14.4 ± 4.6; mean PaO2/FiO2 150.7 ± 73.9; mean SPO2/FiO2 173.9 ± 106.9; mean PEEP was 8.2 ±4.33.Conclusion: We concluded that severe covid pneumonia is common amongst males, non-smokers those who had comorbid. HCQ and azithromycin combination is superior to combination of HCQ and doxycycline or doxycycline alone and QT prolongation is a rare complication. Baseline NLR, APACHI II, SOFA, SAPS II, NUTRIC scores, D-Dimers, invasive ventilation and vasopressor support are important tools to predict ICU mortality. Invasive mechanical ventilation carries higher mortality and associated with more prolonged ICU stay. AKI is most common complication followed by shock and surgical emphysema. CRP, Ferritin levels has no impact on outcome.

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Perioperative use of renin-angiotensin system inhibitors and short-term outcomes in patients undergoing cardiac surgery

European Heart Journal ◽

10.1093/ehjci/ehaa946.2675 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

R.M Vieira De Melo ◽

D.C Azevedo ◽

L.N Danziato ◽

M.T.C.F Fernandes ◽

L.F.C Alcantara ◽

...

Keyword(s):

Mechanical Ventilation ◽

Acute Kidney Injury ◽

Cardiac Surgery ◽

Multivariate Regression ◽

Enzyme Inhibitor ◽

Kidney Injury ◽

Adverse Outcomes ◽

Icu Mortality ◽

Short Term ◽

Icu Stay

Abstract Background Controversy exists about whether preoperative angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin receptor blocker (ARB) therapy is associated with adverse outcomes after cardiac surgery. Current guidelines stated that it is uncertain about the safety of the preoperative administration of this medications because of the potential deleterious consequences of perioperative hypotension Purpose To determine the effect of preoperative therapy with ACEi or ARB on short-term outcome after cardiac surgery. Methods Single-center prospective cohort between January 2018 and December 2019. Patients were eligible if they were submitted to elective on-pump cardiac surgery and aged ≥18 years. Patients were divided into two groups according to previous use of ACEi or ARB. All preoperative demographic, clinical, and intraoperative surgical variables were collected prospectively. Outcomes of interests were intensive care unit (ICU) mortality, incidence and duration (hours) of postoperative shock (defined as the need for intravenous vasopressors or inopressors), postoperative acute kidney injury (AKI), defined as a doubling of serum creatinine, duration of mechanical ventilation (hours) and length of stay in the ICU (days). A multivariate regression was performed for categorical outcomes and Kruskal-Wallis test for non-parametric continuous variables. Results 353 patients were evaluated in the period, 182 (51.6%) of male sex, with a mean age of 54.5 (±14.7) and STS mortality and EURO scores of 1.93 (±1.81) and 1.89 (±1.9), respectively. Coronary artery bypass grafting was the common procedure, 168 (47.6%). After multivariate regression, use of ACEi or ARB preoperatively was associated with postoperative shock: RR: 2.03, CI 1.25–3.30, p=0.004; incidence of AKI: RR: 2.84, CI 1.01–7.98, increased length of ICU stay: 4 (3–6) vs 3 (2–5), p=0.03; and increased duration of shock: 10 (0–39) vs 0 (0–24), p<0.01. There was no association with the duration of mechanical ventilation: 10.5 (6–20) vs 11.0 (5–18), p=0.31 or ICU mortality: 14 (7.3%) vs 16 (10.0%), p=0,44. Conclusions The use of preoperative ACEi or ARBs was associated with increased incidence and duration of postoperative shock, incidence of acute kidney injury, and durations of mechanical ventilation and ICU stay. Funding Acknowledgement Type of funding source: None

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COVID-19 ICU and mechanical ventilation patient characteristics and outcomes - A systematic review and meta-analysis

10.1101/2020.08.16.20035691 ◽

2020 ◽

Author(s):

Raymond Chang ◽

Khaled Mossad Elhusseiny ◽

Yu-Chang Yeh ◽

Wei-zen Sun

Keyword(s):

Systematic Review ◽

Mechanical Ventilation ◽

Meta Analysis ◽

Invasive Mechanical Ventilation ◽

Ventilatory Support ◽

Kidney Injury ◽

Admission Rate ◽

Resource Planning ◽

Patient Characteristics ◽

Icu Mortality

Background Insight into COVID-19 intensive care unit (ICU) patient characteristics, rates and risks of invasive mechanical ventilation (IMV) and associated outcomes as well as any regional discrepancies is critical in this pandemic for individual case management and overall resource planning. Methods and Findings Electronic searches were performed for reports through May 1 2020 and reports on COVID-19 ICU admissions and outcomes were included using predefined search terms. Relevant data was subsequently extracted and pooled using fixed or random effects meta-analysis depending on heterogeneity. Study quality was assessed by the NIH tool and heterogeneity was assessed by I2 and Q tests. Baseline patient characteristics, ICU and IMV outcomes were pooled and meta-analyzed. Pooled odds ratios (pOR) were calculated for clinical features against ICU, IMV mortality. Subgroup analysis was carried out based on patient regions. A total of twenty-eight studies comprising 12,437 COVID-19 ICU admissions from seven countries were meta-analyzed. Pooled ICU admission rate was 21% [95% CI 0.12-0.34] and 69% of cases needed IMV [95% CI 0.61-0.75]. ICU and IMV mortality were 28.3% [95% CI 0.25-0.32], 43% [95% CI 0.29-0.58] and ICU, IMV duration was 7.78 [95% CI 6.99-8.63] and 10.12 [95% CI 7.08-13.16] days respectively. Besides confirming the significance of comorbidities and clinical findings of COVID-19 previously reported, we found the major correlates with ICU mortality were IMV [pOR 16.46, 95% CI 4.37-61.96], acute kidney injury (AKI) [pOR 12.47, 95% CI 1.52-102.7], and acute respiratory distress syndrome (ARDS) [pOR 6.52, 95% CI 2.66-16.01]. Subgroup analyses confirm significant regional discrepancies in outcomes. Conclusions This is the most comprehensive systematic review and meta-analysis of COVID-19 ICU and IMV cases and associated outcomes to date and the only analysis to implicate IMV's associtaion with COVID-19 ICU mortality. The significant association of AKI, ARDS and IMV with mortality has implications for ICU resource planning for AKI and ARDS as well as research into optimal ventilation strategies for patients. Regional differences in outcome implies a need to develop region specific protocols for ventilatory support as well as overall treatment.

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Combined Renal-Pulmonary Extracorporeal Support with Low Blood Flow Techniques: A Retrospective Observational Study (CICERO Study)

Blood Purification ◽

10.1159/000517280 ◽

2021 ◽

pp. 1-10

Author(s):

Guglielmo Consales ◽

Lucia Zamidei ◽

Franco Turani ◽

Diego Atzeni ◽

Paolo Isoni ◽

...

Keyword(s):

Mechanical Ventilation ◽

Observational Study ◽

Multiorgan Failure ◽

Invasive Mechanical Ventilation ◽

Respiratory Acidosis ◽

Kidney Injury ◽

Protective Ventilation ◽

Retrospective Observational Study ◽

Organ Support ◽

Chronic Obstructive

Background: Critically ill patients with acute respiratory failure frequently present concomitant lung and kidney injury, within a multiorgan failure condition due to local and systemic mediators. To face this issue, extracorporeal carbon dioxide removal (ECCO2R) systems have been integrated into continuous renal replacement therapy (CRRT) platforms to provide a combined organ support, with efficient clearance of CO2 with very low extracorporeal blood flows (<400 mL/min). Objectives: To evaluate efficacy and safety of combined ECCO2R-CRRT support with PrismaLung®-Prismaflex® in patients affected by hypercapnic respiratory acidosis associated with AKI in a second level intensive care unit. Methods: We carried out a retrospective observational study enrolling patients submitted to PrismaLung®-Prismaflex® due to mild to moderate acute respiratory distress syndrome (ARDS) or acute exacerbation of chronic obstructive pulmonary disease (aeCOPD). The primary endpoints were the shift to protective ventilation and extubation of mechanically ventilated patients and the shift to invasive mechanical ventilation of patients receiving noninvasive ventilation (NIV). Clinical-laboratoristic data and operational characteristics of ECCO2R-CRRT were recorded. Results: Overall, 12/17 patients on mechanical ventilation shifted to protective ventilation, CO2 clearance was satisfactorily maintained during the whole observational period, and pH was rapidly corrected. Treatment prevented NIV failure in 4 out of 5 patients. No treatment-related complications were recorded. Conclusion: ECCO2R-CRRT was effective and safe in patients with aeCOPD and ARDS associated with AKI.

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Impact of Permissive Hypoxia and Hyperoxia Avoidance on Clinical Outcomes in Septic Patients Receiving Mechanical Ventilation: A Retrospective Single-Center Study

BioMed Research International ◽

10.1155/2021/7332027 ◽

2021 ◽

Vol 2021 ◽

pp. 1-10

Author(s):

Kota Nishimoto ◽

Takeshi Umegaki ◽

Sayaka Ohira ◽

Takehiro Soeda ◽

Natsuki Anada ◽

...

Keyword(s):

Mechanical Ventilation ◽

University Hospital ◽

Icu Mortality ◽

Respiratory Dysfunction ◽

Mechanically Ventilated ◽

Icu Stay ◽

Ventilation Duration ◽

Mechanical Ventilation Duration ◽

Before And After ◽

Clinical Records

Background. Septic patients often require mechanical ventilation due to respiratory dysfunction, and effective ventilatory strategies can improve survival. The effects of the combination of permissive hypoxia and hyperoxia avoidance for managing mechanically ventilated patients are unknown. This study examines these effects on outcomes in mechanically ventilated septic patients. Methods. In a retrospective before-and-after study, we examined adult septic patients (aged ≥18 years) requiring mechanical ventilation at a university hospital. On April 1, 2017, our mechanical ventilation policy changed from a conventional oxygenation target (SpO2: ≥96%) to more conservative targets with permissive hypoxia (SpO2: 88-92% or PaO2: 60 mmHg) and hyperoxia avoidance (reduced oxygenation for Pa O 2 > 110 mmHg ). Patients were divided into a prechange group (April 2015 to March 2017; n = 83 ) and a postchange group (April 2017 to March 2019; n = 130 ). Data were extracted from clinical records and insurance claims. Using a multiple logistic regression model, we examined the association of the postchange group (permissive hypoxia and hyperoxia avoidance) with intensive care unit (ICU) mortality after adjusting for variables such as Sequential Organ Failure Assessment (SOFA) score and PaO2/FiO2 ratios. Results. The postchange group did not have significantly lower adjusted ICU mortality (0.67, 0.33-1.43; P = 0.31 ) relative to the prechange group. However, there were significant intergroup differences in mechanical ventilation duration (prechange: 11.0 days, postchange: 7.0 days; P = 0.01 ) and ICU stay (prechange: 11.0 days, postchange: 9.0 days; P = 0.02 ). Conclusions. Permissive hypoxia and hyperoxia avoidance had no significant association with reduced ICU mortality in mechanically ventilated septic patients. However, this approach was significantly associated with shorter mechanical ventilation duration and ICU stay, which can improve patient turnover and ventilator access.

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Factors associated with non-invasive mechanical ventilation failure in patients with hematological neoplasia and their association with outcomes

Journal of Intensive Care ◽

10.1186/s40560-020-00484-x ◽

2020 ◽

Vol 8 (1) ◽

Author(s):

Lídia Miranda Barreto ◽

◽

Cecilia Gómez Ravetti ◽

Thiago Bragança Athaíde ◽

Renan Detoffol Bragança ◽

...

Keyword(s):

Mechanical Ventilation ◽

Clinical Judgment ◽

Oxygen Therapy ◽

Invasive Mechanical Ventilation ◽

Ventilatory Support ◽

Orotracheal Intubation ◽

Icu Mortality ◽

Factors Associated ◽

Non Invasive ◽

Ventilation Failure

Abstract Background The usefulness of non-invasive mechanical ventilation (NIMV) in oncohematological patients is still a matter of debate. Aim To analyze the rate of noninvasive ventilation failure and the main characteristics associated with this endpoint in oncohematological patients with acute respiratory failure (ARF). Methods A ventilatory support protocol was developed and implemented before the onset of the study. According to the PaO2/FiO2 (P/F) ratio and clinical judgment, patients received supplementary oxygen therapy, NIMV, or invasive mechanical ventilation (IMV). Results Eighty-two patients were included, average age between 52.1 ± 16 years old; 44 (53.6%) were male. The tested protocol was followed in 95.1% of cases. Six patients (7.3%) received IMV, 59 (89.7%) received NIMV, and 17 (20.7%) received oxygen therapy. ICU mortality rates were significantly higher in the IMV (83.3%) than in the NIMV (49.2%) and oxygen therapy (5.9%) groups (P < 0.001). Among the 59 patients who initially received NIMV, 30 (50.8%) had to eventually be intubated. Higher SOFA score at baseline (1.35 [95% CI = 1.12–2.10], P = 0.007), higher respiratory rate (RR) (1.10 [95% CI = 1.00–1.22], P = 0.048), and sepsis on admission (16.9 [95% CI = 1.93–149.26], P = 0.011) were independently associated with the need of orotracheal intubation among patients initially treated with NIMV. Moreover, NIMV failure was independently associated with ICU (P < 0.001) and hospital mortality (P = 0.049), and mortality between 6 months and 1 year (P < 0.001). Conclusion The implementation of a NIMV protocol is feasible in patients with hematological neoplasia admitted to the ICU, even though its benefits still remain to be demonstrated. NIMV failure was associated with higher SOFA and RR and more frequent sepsis, and it was also related to poor prognosis.

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Vitamin C Can Shorten the Length of Stay in the ICU: A Meta-Analysis

Nutrients ◽

10.3390/nu11040708 ◽

2019 ◽

Vol 11 (4) ◽

pp. 708 ◽

Cited By ~ 53

Author(s):

Harri Hemilä ◽

Elizabeth Chalker

Keyword(s):

Mechanical Ventilation ◽

Length Of Stay ◽

Vitamin C ◽

Meta Analysis ◽

Kidney Injury ◽

Practical Significance ◽

Controlled Trials ◽

Elective Cardiac Surgery ◽

Icu Stay ◽

Length Of Icu Stay

A number of controlled trials have previously found that in some contexts, vitamin C can have beneficial effects on blood pressure, infections, bronchoconstriction, atrial fibrillation, and acute kidney injury. However, the practical significance of these effects is not clear. The purpose of this meta-analysis was to evaluate whether vitamin C has an effect on the practical outcomes: length of stay in the intensive care unit (ICU) and duration of mechanical ventilation. We identified 18 relevant controlled trials with a total of 2004 patients, 13 of which investigated patients undergoing elective cardiac surgery. We carried out the meta-analysis using the inverse variance, fixed effect options, using the ratio of means scale. In 12 trials with 1766 patients, vitamin C reduced the length of ICU stay on average by 7.8% (95% CI: 4.2% to 11.2%; p = 0.00003). In six trials, orally administered vitamin C in doses of 1–3 g/day (weighted mean 2.0 g/day) reduced the length of ICU stay by 8.6% (p = 0.003). In three trials in which patients needed mechanical ventilation for over 24 hours, vitamin C shortened the duration of mechanical ventilation by 18.2% (95% CI 7.7% to 27%; p = 0.001). Given the insignificant cost of vitamin C, even an 8% reduction in ICU stay is worth exploring. The effects of vitamin C on ICU patients should be investigated in more detail.

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Impact of a multidisciplinary checklist on the duration of invasive mechanical ventilation and length of ICU stay

Jornal Brasileiro de Pneumologia ◽

10.36416/1806-3756/e20180261 ◽

2020 ◽

Vol 46 (3) ◽

pp. e20180261-e20180261

Author(s):

Ruy de Almeida Barcellos ◽

José Miguel Chatkin

Keyword(s):

Mechanical Ventilation ◽

Invasive Mechanical Ventilation ◽

Icu Stay ◽

Length Of Icu Stay

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ICU-Acquired Pneumonia is a Risk Factor of a Poor Health Post-Covid-19 Syndrome

10.21203/rs.3.rs-885672/v1 ◽

2021 ◽

Author(s):

Ignacio Martin-Loeches ◽

Anna Motos ◽

Rosario Menéndez ◽

Albert Gabarrus ◽

Jessica González ◽

...

Keyword(s):

Risk Factors ◽

Mechanical Ventilation ◽

Invasive Mechanical Ventilation ◽

Poor Health ◽

Health Post ◽

Beneficial Effects ◽

Female Sex ◽

Icu Stay ◽

Discharged Patients ◽

Independent Risk Factors

Abstract Background. Some patients who had previously presented with COVID-19 have been reported to develop persistent COVID-19 symptoms. Whilst this information has been adequately recognised and extensively published with respect to non-critically ill patients, less is known about the prevalence and risk factors and characteristics of persistent COVID_19 . On other hand these patients have very often intensive care unit-acquired pneumonia (ICUAP). A second infectious hit after COVID increases the length of ICU stay and mechanical ventilation and could have an influence in the poor health post-Covid 19 syndrome in ICU discharged patientsMethods: This prospective, multicentre and observational study was done across 40 selected ICUs in Spain. Consecutive patients with COVID-19 requiring ICU admission were recruited and evaluated three months after hospital discharge. Results: A total of 1,255 ICU patients were scheduled to be followed up at 3 months; however, the final cohort comprised 991 (78.9%) patients. A total of 315 patients developed ICUAP (97% of them had ventilated ICUAP) Patients requiring invasive mechanical ventilation had persistent, post-COVID-19 symptoms than those who did not require mechanical ventilation. Female sex, duration of ICU stay, and development of ICUAP were independent risk factors for persistent poor health post-COVID-19.Conclusions: Persistent, post-COVID-19 symptoms occurred in more than two-thirds of patients. Female sex, duration of ICU stay and the onset of ICUAP comprised all independent risk factors for persistent poor health post-COVID-19. Prevention of ICUAP could have beneficial effects in poor health post-Covid 19

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ASPECTS OF INVASIVE MECHANICAL VENTILATION IN PATIENTS WITH ARDS CAUSED BY COVID-19

Pain anesthesia and intensive care ◽

10.25284/2519-2078.2(95).2021.238291 ◽

2021 ◽

pp. 9-16

Author(s):

O. A. Loskutov ◽

I. A. Kuchynska ◽

S. M. Nedashkivskyi ◽

O. S. Demchenko

Keyword(s):

Mechanical Ventilation ◽

Multiorgan Failure ◽

Invasive Mechanical Ventilation ◽

Severe Pneumonia ◽

Ideal Body Weight ◽

Plateau Pressure ◽

Invasive Ventilation ◽

Number Of Patients ◽

Number Of Publications ◽

Main Components

Mortality among patients with severe pneumonia and / or acute respiratory distress syndrome (ARDS) due to COVID-19 infection, who underwent mechanical ventilation (MV), is characterized by a fairly high frequency. However, despite the large number of patients receiving appropriate treatment, the question of choosing the optimal ventilation parameters remains poorly understood. In our article, we reviewed the available literature data on the indications for mechanical ventilation, parameters of MV, the need for prone-positioning of patients with ARDS caused by COVID-19 infection in intensive care units to identify unresolved issues.Despite the large number of publications about respiratory support in patients with severe coronavirus infection, there are only general principles regarding the indications for switching to invasive ventilation. Most authors identified the following clinical situations: progression of hypoxemia and / or respiratory failure but with constant oxygen support with increasing percentage of oxygen in the respiratory mixture, use of high-flow cannula or non-invasive ventilation for 1 hour without improvement; persistent hypercapnia, multiorgan failure, coma, high risk of aspiration, hemodynamic instability.According to most of the studies analyzed, the main components of the ventilation strategy should be based on the principles of pulmonary protective ventilation and include the use of low tidal volumes (Vt = 4-8 ml / kg of ideal body weight) and ventilation with plateau pressure Pplat <30 cm H2O (plateau pressure - air pressure measured after an inspiratory pause of 0.5 s). At the same time, many authors recommend using prone position and high levels of positive end-expiratory pressure (PEEP) compared to low levels in patients with ARDS on the background of COVID-19.The approach to invasive mechanical ventilation in ARDS caused by SARS-CoV-2 still requires further research and answers to a number of questions.

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Acute kidney injury in patients with severe COVID-19 in Mexico

10.1101/2020.08.28.20167379 ◽

2020 ◽

Author(s):

GUSTAVO CASAS ◽

MARIA-ISABEL LEON ◽

MAURICIO GONZALEZ-NAVARRO ◽

CLAUDIA ALVARADO DE LA BARRERA ◽

Santiago Avila-Rios ◽

...

Keyword(s):

Risk Factors ◽

Mechanical Ventilation ◽

Acute Kidney Injury ◽

Serum Creatinine ◽

Systemic Disease ◽

Invasive Mechanical Ventilation ◽

Laboratory Data ◽

Kidney Injury ◽

Vasoactive Drugs ◽

D Dimer

Introduction: Some patients with COVID-19 pneumonia present systemic disease involving multiple systems. There is limited information about the clinical characteristics and events leading to acute kidney injury (AKI). We described the factors associated with the development of AKI and explored the relation of AKI and mortality in Mexican population with severe COVID-19. Methods: We retrospectively reviewed the medical records of individuals with severe pneumonia caused by SARS-CoV-2 hospitalized at the largest third-level reference institution for COVID-19 care in Mexico between March and April 2020. Demographic information, comorbidities, clinical and laboratory data, dates of mechanical ventilation and hospitalization, mechanical-ventilator settings and use of vasoactive drugs were recorded. Results: Of 99 patients studied, 58 developed AKI (58.6%). The group with AKI had higher body mass index (p=0.0003) and frequency of obesity (p=0.001); a higher requirement of invasive mechanical ventilation (p=0.008) and vasoactive drugs (p=0.004); greater levels of serum creatinine (p<0.001) and D-dimer on admission (p<0.001); and lower lymphocyte counts (p=0.001) than the non-AKI group. The multivariate analysis indicated that risk factors for AKI were obesity (adjusted hazard ratio (HR)=2.71, 95% confidence interval (CI)=1.33-5.51, p=0.005); higher serum creatinine (HR=1.44, CI=1.02-2.02, p=0.035) and D-dimer levels on admission (HR=1.14, CI=1.06-1.23, p<0.001). In-hospital mortality was higher in the AKI group than in the non-AKI group (65.5% vs. 14.6%; p=0.001). Conclusions: AKI was common in our cohort of patients with severe COVID-19 and it was associated with mortality. The risk factors for AKI were obesity, elevated creatinine levels and higher D-dimer levels on admission. Key words: Acute kidney injury; AKI; acute renal failure; COVID-19; SARS-CoV-2.

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