COVID-19 related acute respiratory distress syndrome: Pathological, radiological and clinical concordance.

Severe coronavirus 2019 disease (COVID-19) represents viral pneumonia from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection leading to acute respiratory distress syndrome (ARDS). However, when ARDS occurs as part of COVID-19, it has different features. The strategy of breathing support is very important in treating COVID-19 related ARDS (CARDS). Though it meets the CARDS Berlin definition, COVID-19 pneumonia is a specific disease with different phenotypes. Recently, it has been suggested that CARDS has two phenotypes, type L (Type 1 or non-ARDS) and type H (Type 2, ARDS), and these phenotypes respond differently to respiratory support treatments. In this review, after mentioning the pathophysiology and radiological relationship of CARDS, the definition and treatment approaches of two different forms of CARDS were discussed.

Corticosteroid use in COVID-19 pneumonia.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) has a 1-2% fatality rate, where no specific treatment has yet been defined. Although corticosteroids are recommended for selected COVID-19 patients without acute respiratory distress syndrome (ARDS) and septic shock, there is no consensus regarding patient subgroups, dose, and duration. In this study, it was aimed to examine the contribution of corticosteroid treatment to the management of COVID-19 pneumonia without ARDS, septic shock both in acute and recovery setting. MATERIALS AND METHODS: The study population was divided into two as those who used corticosteroids during the recovery phase (who did not develop sufficient radiological or clinical improvement) and those who did so during the activation phase (non-ARDS/septic shock condition, clinical, laboratory or radiological progression). RESULT: We identified 47 patients, 26 of which were males, and mean age was 60.5 ± 16.5 years. Seventeen patients were found to receive corticosteroids during the recovery phase and the rest (n= 30) during the activation period. After corticosteroid therapy, we found reduction of increased pre-treatment levels of D-dimer, ferritin, fibrinogen, CRP, increment of decreased pre-treatment lymphocyte count and saturation. Complete symptomatic improvement was detected in 6.9% and 17.6% of the patients in the activation phase and recovery phase, respectively. Complete radiological improvement was found in 11.5% and 35.3% of the patients in the activation phase and recovery phase, respectively. While corticosteroid treatment was initiated on day 4.2 ± 2.6 and continued for a mean of 5.9 ± 2.8 days in the activation group, it was started on day 8.1 ± 11.3 and administered for 7.8 ± 3.8 days in the recovery group. In both groups, methylprednisolone was given at a median dose of 40 mg/day. CONCLUSIONS: Short-term low-dose corticosteroid therapy may improve clinical, radiological, laboratory outcomes in the management of COVID-19 pneumonia during the activation period without ARDS and non-septic shock and during recovery period with no satisfactory response. Further randomized controlled studies will be useful in demonstrating its efficacy.

Succesful Use of Lipid Emulsion Theraphy In a Case of Extremely High Dose Olanzapine Intoxication.

In olanzapine intoxication alterations in consciousness defined as "agitation despite sedation" as well as cardiovascular and extrapyramidal side effects due to anticholinergic effects can be seen. In this case report, we aimed to present a patient who received a very high dose of olanzapine for suicide purposes benefited from intravenous lipid emulsion treatment (LET). A 20-year-old male patient, who received 840 mg of olanzapine for suicide, was brought to the emergency room, when the Glasgow Coma Scale was 5, he was intubated and given a single dose of activated charcoal. Later, he was admitted to the intensive care unit (ICU) intubated. The olanzapine level was measured as 653 µg L-1. The patient was started on LET and woke up at the sixth hour. In addition to the lack of strong evidence regarding the use of LET in olanzapine intoxication, it is seen that lipid therapy has been used successfully in patients. Compared with the cases in the literature, LET was successfully applied in our case, where the blood olanzapine level was very high. Although there is no evidence-based treatment in olanzapine intoxication, we believe that LET has a positive effect on neurological recovery and survival.

Secondary Infections in Critical Patients with COVID-19 Associated ARDS in the ICU: Frequency, Microbiologic Characteristics and Risk Factors.

OBJECTIVE:  To determine frequency, microbiologic characteristics and risks of secondary infections in patients with Coronavirus disease 2019 (COVID-19) associated acute respiratory distress syndrome (ARDS). STUDY DESIGN: An Observational study. PLACE AND DURATION OF STUDY:  COVID-19 intensive care unit (ICU), University of Health Sciences, Diskapi Yildirim Beyazit Research and Training Hospital, Turkey, from July 2020 to January 2021. METHODOLOGY: Demographic data of the COVID-19 patients with ARDS, was collected with reference to (age, gender), comorbidities, illness scores, ICU management modalities, hospital, and ICU stay durations and ICU outcomes. Secondary infections [bloodstream infection (BSI), possible lower respiratory tract infection (pLRTI) or urinary tract infections (UTI)], microbiologic pathogens, and resistant patterns were recorded. RESULTS:  A total of 205 COVID-19-related ARDS patients were included in this study. Out of them, 61 (29.8%) were diagnosed with secondary infection, 27 (13.1%) had at least one BSI, 20 (9.8%) had at least one pLRTI, and 34 (16.6%) had at least one UTI. Gram-negative pathogens were the most common cause of secondary infections (66/91, 72.5%). Klebsiella spp for BSI (10/19, 52.6%), Acinetobacter baumannii for pLRTI (10/18, 55.6%), and Escherichia coli for UTI (29/40, 72.5%) were the main causative agents. Among all Gram-negative bacteria, Carbapenem resistant was 62.1% (41/66) and extended-spectrum beta-lactamases positivity was 22.7% (15/66). At multivariable analysis, application of mechanical ventilation (MV) longer than 48 h, central catheterisation longer than 72 h, ICU stay longer than 10 days, and the time from hospitalisation to admission to the ICU longer than 48 h were associated with secondary infections. CONCLUSION: Patients with COVID-19 associated ARDS had a high rate of secondary infections. In order to reduce secondary infection in these patients, MV duration and ICU stay should be shortened and invasive catheters should be removed as soon as possible. KEY WORDS: SARS-CoV-2, COVID-19, Acute respiratory distress syndrome, Secondary infections.

Hematological manifestations of COVID-19 acute respiratory distress syndrome patients and the impact of thrombocytopenia on disease outcomes: A retrospective study.

Background: Platelet count is a simple and readily available biomarker, in which thrombocytopenia was shown to be independently associated with disease severity and risk of mortality in the critical coronavirus disease-19 (COVID-19) patients. The aim of this study was to investigate the impact of thrombocytopenia on disease progression in critically ill COVID-19 patients with acute respiratory distress syndrome (ARDS) admitted to a medical intensive care unit (ICU). Methods: COVID-19-associated ARDS patients in our research hospitals' ICU were retrospectively investigated. Patients were divided into two groups as thrombocytopenic (<150 × 109/ml) patients on admission or those who developed thrombocytopenia during ICU follow-up (Group 1) and those without thrombocytopenia during ICU course and follow-up (Group 2). Results: The median platelet count of all patients was 240 × 109/ml, and the median D-dimer was 1.16 mg/ml. On admission, 32 (18.3%) patients had thrombocytopenia. The mean platelet count of Group 1 was 100.0 ± 47.5 × 109/ml. Group 1 was older and their Acute Physiology and Chronic Health Evaluation II and sequential organ failure assessment scores were higher. Group 1 had lower hemoglobin, neutrophil, and lymphocyte counts and higher ferritin and procalcitonin level. Invasive mechanical ventilation was more commonly needed, and disseminated intravascular coagulation (DIC) was more frequently observed in Group 1. The ICU and hospital length of stay of Group 1 was longer with higher mortality. Conclusion: Patients with thrombocytopenia had increased inflammatory markers, frequency of DIC, duration of ICU stay, and mortality. The presence of thrombocytopenia may reflect the progression of COVID-19 toward an unfavorable outcome.

Air Embolism Developed As A Result Of Opening The Central Catheter Tip By The Patient's Relative.

Central catheterization can be placed in critically ill patients in the intensive care unit (ICU) for some purposes such as dialysis, nutrition, and hemodynamic monitoring. Air embolism is a very rare complication of central catheterization. A 46-year-old male patient with no known comorbidities underwent laparoscopic total colectomy and protective loop ileostomy for colon cancer. He was taken to the general surgery ICU for close hemodynamic follow-up in the postoperative period. Since he was cachectic and could not reach the target of oral nutrition within 1 week, a central catheter was inserted in the right internal jugular vein with ultrasonographic imaging, and total parenteral nutrition (TPN) was started. The patient, who had no additional problems in the follow-up, was transferred to the general surgery ward. Three and half hours after the transfer, the patient became unconscious and had extensor posture. Therefore, emergency cranial computed tomography (CT) was performed and he was taken back to the ICU. There was no finding in favour of bleeding in cranial CT. The patient was intubated to protect the airway, as he had a generalized tonic-clonic seizure during his follow-up. Air bubbles were seen in the main pulmonary artery and right ventricle in the multidetector thorax CT. Cranial CT angiography was taken at the 24th hour, and diffusion cranial MRI was performed for diagnosis of central air embolism. No air was detected to be aspirated in the cerebral arteries in cranial CT angiography. On the 6th day, the patient regained consciousness, extubated, and physical therapy was started. On the 12th day of hospitalization, the patient was discharged with 2/5 loss of motor power in the left upper extremity. When the patient's wife's anamnesis was detailed, it was learned that in order to mobilize the patient, she separated the TPN from the catheter and left the catheter tip open.

Does Interval between Breastfeeding and Heel Lance Affect the Perception of Pain in Newborns?

OBJECTIVE: To investigate whether the duration between breastfeeding and heel lance has an effect on babies' pain perception. STUDY DESIGN: A randomised trial. PLACE AND DURATION OF STUDY: Obstetrics & Gynecology Unit, Yenimahalle Training and Research Hospital, Ankara, Turkey between August 2019 and February 2020. METHODOLOGY: Healthy term newborns who were scheduled for a heel lance blood collection for newborn screening were included in the study. Healthy term babies were randomised into three groups, according to their heel lance time. The procedure was performed immediately after breastfeeding (group 1), one hour after breastfeeding (group 2), and two hours after breastfeeding (group 3). The magnitude of pain was measured by the neonatal pain, agitation and sedation scale (N-PASS) one minute before intervention, at the time of intervention, and at 1, 2 and 5 minutes after the intervention. Total crying times of the babies was recorded as well. RESULTS: Ninety-one babies were included in the study. The pain scores during heel lance and one and two minutes after heel lance were significantly higher in group 3 than in group 1 and group 2. Total crying time of the babies in group 3 was also significantly longer than the total crying time of the babies in group 1 and group 2. However, there was no significant difference between group 1 and 2 in terms of pain scores. CONCLUSION: The duration between breastfeeding and heel lance may influence the perception of pain in newborns. Keeping this period short, may reduce the perception of pain. Key Words: Breastfeeding, Breast milk, Newborn, Pain.

Role Of Il-6 In The Adjustment Of The Medical Treatment Of Patients With Covid-19 Associated Acute Respiratory Distress Syndrome.

BACKGROUND: Many cytokines propose to play a role in the pathogenesis of Severe Acute Respiratory Syndrome Coronavirus type 2 (SARS-CoV-2) associated COVID-19 disease. High interleukin-6 (IL-6) levels are associated with mortality and other poor clinical outcomes in COVID-19. METHODS: In this retrospective study, the correlation of IL-6 level with clinical and other inflammatory parameters, its role in treatment change and its relationship with mortality in COVID-19 patients developing acute respiratory distress syndrome (ARDS) were investigated. RESULTS: Totally 76 patients were included in the study; Thirty-four (44.7%) patients were female and 42 (55.3%) patients were male. All patients had IL-6 levels above the upper reference value (>5.9 pg/mL). Overall, 48 patients (63.1%) had a severe clinical presentation (tachypnoea, tachycardia, fever) that was clinically compatible with IL-6 values, and medical treatment was changed for COVID-19 in this group. A positive correlation was detected between IL-6 and CRP on the day of the change in treatment (p=0.035, r=0.76). There was no decrement observed in IL-6 level on the 3rd day in patients that was clinically thought to have cytokine storm and whose treatment was changed. Mortality was higher in the group whose treatment was changed. CONCLUSIONS: We believe that IL-6 level alone is insufficient to decide on a change in treatment, and correlation of IL-6 with the patient's clinical status is more significant in such decision.

Association of baseline diaphragm, rectus femoris and vastus intermedius muscle thickness with weaning from mechanical ventilation.

BACKGROUND: To determine whether baseline diaphragm (Tdi), rectus femoris (RF) and vastus intermedius (VI) muscle thickness (TRF and TRF + VI) are associated with weaning success. MATERIAL AND METHODS: Right Tdi, TRF and TRF + VI were measured by ultrasonography within 36 h of intubation and diaphragmatic excursion (DE) was evaluated at the first spontaneous breathing trial in adult critically-ill patients. Reintubation or death within 7 days after extubation was defined as weaning failure. Weaning failure and success groups were compared in terms of ultrasonographic measurements and clinical features. RESULTS: Thirty-eight patients were assessed for weaning, 15 (39.4%) being in the weaning failure group. The median body mass index (BMI) was lower while the median clinical frailty scale (CFS), vasopressor use, duration of mechanical ventilation, intensive care and hospital mortality rate were higher in the weaning failure group, and the median TRF + VI (14.0 [12.3-26.2] vs 23.6 [21.3-27.1] mm, p = 0.03) and median DE (19.4 [14.6-24.0] vs 25.9 [19.3-38.5] mm, p = 0.045) were lower. The median Tdi was similar in two groups (1.9 [1.5-2.3] vs 2.0 [1.7-2.4] mm, p = 0.26). In ROC analysis, area under the curve for TRF + VI was 0.71 (95% CI: 0.51-0.90; p = 0.035), with 21 mm cut-off having sensitivity of 82% and specificity of 57%. Binary logistic regression analysis revealed TRF + VI < 21 mm as the only predictor of weaning failure with an odds ratio of 10.5 (95% CI: 1.1-97.8, p = 0.038) after adjusting for age, sex, BMI and CFS. CONCLUSIONS: TRF + VI lower than 21 mm, measured by ultrasonography within 36 h of intubation, was associated with weaning failure among critically-ill patients.

Role of serological rapid antibody test in the management of possible COVID-19 cases.

BACKGROUND: Although the detection of viral particles by reverse transcription polymerase chain reaction (RT-PCR) is the gold standard diagnostic test for coronavirus disease 2019 (COVID-19), the false-negative results constitute a big challenge. AIM: To examine a group of patients diagnosed and treated as possible COVID-19 pneumonia whose multiple nasopharyngeal swab samples were negative for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by RT-PCR but then serological immunoglobulin M/immunoglobulin G (IgM/IgG) antibody against SARS-CoV-2 were detected by rapid antibody test. METHODS: Eighty possible COVID-19 patients who had at least two negative consecutive COVID-19 RT-PCR test and were subjected to serological rapid antibody test were evaluated in this study. RESULTS: The specific serological total IgM/IgG antibody against SARS-CoV-2 was detected in twenty-two patients. The mean age of this patient group was 63.2± 13.1-years-old with a male/female ratio of 11/11. Cough was the most common symptom (90.9%). The most common presenting chest computed tomography findings were bilateral ground glass opacities (77.2%) and alveolar consolidations (50.1%). The mean duration of time from appearance of first symptoms to hospital admission, to hospital admission, to treatment duration and to serological positivity were 8.6 d, 11.2 d, 7.9 d, and 24 d, respectively. Compared with reference laboratory values, serologically positive patients have shown increased levels of acute phase reactants, such as C-reactive protein, ferritin, and procalcitonin and higher inflammatory markers, such as erythrocyte sedimentation rate, lactate dehydrogenase enzyme, and fibrin end-products, such as D-dimer. A left shift on white blood cell differential was observed with increased neutrophil counts and decreased lymphocytes. CONCLUSION: Our study demonstrated the feasibility of a COVID-19 diagnosis based on rapid antibody test in the cases of patients whose RT-PCR samples were negative. Detection of antibodies against SARS-CoV-2 with rapid antibody test should be included in the diagnostic algorithm in patients with possible COVID-19 pneumonia.

Clinical Outcomes and Independent Risk Factors for 90-Day Mortality in Critically Ill Patients with Respiratory Failure Infected with SARS-CoV-2: A Multicenter Study in Turkish Intensive Care Units.

BACKGROUND: There are limited data on the long-term outcomes of COVID-19 from different parts of the world. AIMS: To determine risk factors of 90-day mortality in critically ill patients in Turkish intensive care units (ICUs), with respiratory failure. STUDY DESIGN: Retrospective, observational cohort. METHODS: Patients with laboratory-confirmed COVID-19 and who had been followed up in the ICUs with respiratory failure for more than 24 hours were included in the study. Their demographics, clinical characteristics, laboratory variables, treatment protocols, and survival data were recorded. RESULTS: A total of 421 patients were included. The median age was 67 (IQR: 57-76) years, and 251 patients (59.6%) were men. The 90-day mortality rate was 55.1%. The factors independently associated with 90-day mortality were invasive mechanical ventilation (IMV) (HR 4.09 [95% CI: [2.20-7.63], P < .001), lactate level >2 mmol/L (2.78 [1.93-4.01], P < .001), age ≥60 years (2.45 [1.48-4.06)], P < .001), cardiac arrhythmia during ICU stay (2.01 [1.27-3.20], P = .003), vasopressor treatment (1.94 [1.32-2.84], P = .001), positive fluid balance of ≥600 mL/day (1.68 [1.21-2.34], P = .002), PaO2/FiO2 ratio of ≤150 mmHg (1.66 [1.18-2.32], P = .003), and ECOG score ≥1 (1.42 [1.00-2.02], P = .050). CONCLUSION: Long-term mortality was high in critically ill patients with COVID-19 hospitalized in intensive care units in Turkey. Invasive mechanical ventilation, lactate level, age, cardiac arrhythmia, vasopressor therapy, positive fluid balance, severe hypoxemia and ECOG score were the independent risk factors for 90-day mortality.