Lung ultrasound as a predictor of mortality of patients with COVID-19.

OBJECTIVE: To evaluate the performance of lung ultrasound to determine short-term outcomes of patients with COVID-19 admitted to the intensive care unit. METHODS: This is a Prospective, observational study. Between July and November 2020, 59 patients were included and underwent at least two LUS assessments using LUS score (range 0-42) on day of admission, day 5th, and 10th of admission. RESULTS: Age was 66.5±15 years, APACHE II was 8.3±3.9, 12 (20%) patients had malignancy, 46 (78%) patients had a non-invasive ventilation/high-flow nasal cannula and 38 (64%) patients required mechanical ventilation. The median stay in ICU was 12 days (IQR 8.5-20.5 days). ICU or hospital mortality was 54%. On admission, the LUS score was 20.8±6.1; on day 5th and day 10th of admission, scores were 27.6±5.5 and 29.4±5.3, respectively (P=0.007). As clinical condition deteriorated the LUS score increased, with a positive correlation of 0.52, P <0.001. Patients with worse LUS on day 5th versus better score had a mortality of 76% versus 33% (OR 6.29, 95%CI 2.01-19.65, p. 0.003); a similar difference was observed on day 10. LUS score of 5th day of admission had an area under the curve of 0.80, best cut-point of 27, sensitivity and specificity of 0.75 and 0.78 respectively. CONCLUSION: These findings position LUS as a simple and reproducible method to predict the course of COVID-19 patients.

Taponamiento cardíaco y miocarditis en paciente con infección aguda por SARS-CoV-2 / Cardiac tamponade and myocarditis in a patient with acute SARS-CoV-2 infection

Resumen Describimos una paciente con COVID-19, con derrame pericárdico, taponamiento cardíaco y depresión miocárdica grave. Mujer de 51 años, sin enfermedad previa, COVID-19 leve que presentó tres episodios de síncope en domicilio. El electrocardiograma mostró ritmo sinusal, ST de concavidad superior difuso 2 mv; en la tomografía se observó derrame pericárdico y parénquima pulmonar normal. Ingresó a terapia intensiva con shock y requerimiento de asistencia ventilatoria mecánica (AVM). En el ecocardiograma se obser vó derrame pericárdico y taponamiento; se realizó drenaje. El ecocardiograma transesofágico mostró deterioro moderado de función sistólica biventricular; strain longitudinal global -14.2%, Fey estimada: 43%; deformación global circunferencial: -10.1%. A los 7 días del ingreso, la tomografía reveló infiltrados bilaterales y engrosamiento pericárdico con realce post-contraste y derrame pericárdico leve. El día 12 posterior al ingreso, se suspendió el soporte inotrópico; y la paciente, hemodinámicamente estable, se desvinculó de la AVM.

Abstract We describe a patient with COVID-19, with pericardial effusion, cardiac tamponade and severe myocar dial depression. A 51-year-old woman, previously healthy, with mild COVID-19 presented with three episodes of syncope. She was admitted to the emergency room. An electrocardiogram showed sinus rhythm, diffuse superior concavity ST 2 mv; a CT scan showed pericardial effusion, without lung pathological findings. Due to shock, dyspnoea and encephalopathy, the patient was admitted to intensive care, where she received vasopressor support and mechanical ventilation. A bedside ultrasound showed pericardial effusion and tamponade; drainage was performed; transoesophageal ultrasound showed moderate deterioration of biventricular systolic function; global longitudinal strain -14.2%, estimated Fey 43%; global circumferential strain -10.1%. Seven days after admission, CT scan revealed bilateral infiltrates and pericardial thickening with post-contrast enhancement and mild pericardial effusion. On day 12 post admission, inotropic support was discontinued; patient on mechanical ventilation weaning and haemodynamically stable.

Lung ultrasound as a predictor of mortality of patients with COVID-19 / Ultrassonografia pulmonar como preditor de mortalidade em pacientes com COVID-19

ABSTRACT Objective To evaluate the performance of lung ultrasound to determine short-term outcomes of patients with COVID-19 admitted to the intensive care unit. Methods This is a Prospective, observational study. Between July and November 2020, 59 patients were included and underwent at least two LUS assessments using LUS score (range 0-42) on day of admission, day 5th, and 10th of admission. Results Age was 66.5±15 years, APACHE II was 8.3±3.9, 12 (20%) patients had malignancy, 46 (78%) patients had a non-invasive ventilation/high-flow nasal cannula and 38 (64%) patients required mechanical ventilation. The median stay in ICU was 12 days (IQR 8.5-20.5 days). ICU or hospital mortality was 54%. On admission, the LUS score was 20.8±6.1; on day 5th and day 10th of admission, scores were 27.6±5.5 and 29.4±5.3, respectively (P=0.007). As clinical condition deteriorated the LUS score increased, with a positive correlation of 0.52, P <0.001. Patients with worse LUS on day 5th versus better score had a mortality of 76% versus 33% (OR 6.29, 95%CI 2.01-19.65, p. 0.003); a similar difference was observed on day 10. LUS score of 5th day of admission had an area under the curve of 0.80, best cut-point of 27, sensitivity and specificity of 0.75 and 0.78 respectively. Conclusion These findings position LUS as a simple and reproducible method to predict the course of COVID-19 patients.

RESUMO Objetivo Avaliar o desempenho da ultrassonografia pulmonar para determinar a evolução em curto prazo de pacientes com COVID-19 internados na unidade de terapia intensiva. Métodos Este é um estudo prospectivo e observacional. Entre julho e novembro de 2020, 59 pacientes foram incluídos e submetidos a pelo menos duas avaliações LUS usando o escore LUS (variação de 0-42) no dia da admissão, dia 5 e 10 de admissão. Resultados A idade foi de 66,5 ± 15 anos, APACHE II foi de 8,3 ± 3,9, 12 (20%) pacientes tinham malignidade, 46 (78%) pacientes tinham ventilação não invasiva / cânula nasal de alto fluxo e 38 (64%) pacientes ventilação mecânica necessária. A mediana de permanência na UTI foi de 12 dias (IQR 8,5-20,5 dias). A mortalidade na UTI ou hospitalar foi de 54%. Na admissão, o escore LUS era de 20,8 ± 6,1; no dia 5 e no dia 10 de admissão, os escores foram 27,6 ± 5,5 e 29,4 ± 5,3, respectivamente (P = 0,007). Com a deterioração do quadro clínico, o escore LUS aumentou, com correlação positiva de 0,52, P <0,001. Pacientes com pior LUS no dia 5 versus melhor pontuação tiveram mortalidade de 76% versus 33% (OR 6,29, IC 95% 2,01-19,65, p. 0,003); uma diferença semelhante foi observada no dia 10. O escore LUS do 5º dia de admissão teve uma área sob a curva de 0,80, melhor ponto de corte de 27, sensibilidade e especificidade de 0,75 e 0,78, respectivamente. Conclusão Esses achados posicionam o LUS como um método simples e reprodutível para predizer a evolução de pacientes com COVID-19.

Is a strategy based on routine endotracheal cultures the best way to prescribe antibiotics in ventilator-associated pneumonia?

OBJECTIVES: The objectives of this study were to evaluate if a strategy based on routine endotracheal aspirate (ETA) cultures is better than using the American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines to prescribe antimicrobials in ventilator-associated pneumonia (VAP). METHODS: This was a prospective, observational, cohort study conducted in a 15-bed ICU and comprising 283 patients who were mechanically ventilated for ≥48 h. Interventions included twice-weekly ETA; BAL culture was done if VAP was suspected. BAL (collected at the time of VAP) plus ETA cultures (collected≤7 days before VAP) (n=146 different pairs) were defined. We compared two models of 10 days of empirical antimicrobials (ETA-based vs ATS/IDSA guidelines-based strategies), analyzing their impact on appropriateness of therapy and total antimicrobial-days, using the BAL result as the standard for comparison. RESULTS: Complete ETA and BAL culture concordance (identical pathogens or negative result) occurred in 52 pairs; discordance (false positive or false negative) in 67, and partial concordance in two. ETA predicted the etiology in 62.4% of all pairs, in 74.0% of pairs if ETA was performed≤2 days before BAL, and in 46.2% of pairs if ETA was performed 3 to 7 days before BAL (P=.016). Strategies based on the ATS/IDSA guidelines and on ETA results led to appropriate therapy in 97.9% and 77.4% of pairs, respectively (P<.001). The numbers of antimicrobial-days were 1,942 and 1,557 for therapies based on ATS/IDSA guidelines and ETA results, respectively (P<.001). CONCLUSIONS: The ATS/IDSA guidelines-based approach was more accurate than the ETA-based strategy for prescribing appropriate, initial, empirical antibiotics in VAP, unless a sample was available≤2 days of the onset of VAP. The ETA-based strategy led to fewer days on prescribed antimicrobials.