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BACKGROUND: Few studies detail the evolution of COVID-19 associated coagulopathy. We performed serial thromboelastography (TEG) and laboratory coagulation studies in 40 critically-ill, mechanically ventilated COVID-19 patients over a 14-day period and analysed differences between 30-day survivors and non-survivors. METHODS: Single-center prospective, observational study including 40 patients with severe COVID-19 pneumonia admitted to the intensive care unit (ICU) for mechanical ventilation. TEG analysis was performed on days 1, 7 and 14 of ICU admission and laboratory coagulation studies were performed on days 1 and 14. Coagulation variables were evaluated for change over the 14-day observation period. Differences between survivors and non-survivors at 30-days were analysed and compared. RESULTS: On admission, TEG maximum amplitude (MA) with heparinase correction was above the upper limit of the reference range in 32 (80%) patients while 33 (82.5%) presented with absent clot lysis at 30 min. The functional fibrinogen MA was also elevated above the upper limit of the reference range in 37 (92.5%) patients. All patients had elevated D-dimer and fibrinogen levels, mildly prolonged prothrombin times (PT), normal platelet counts and normal activated partial thromboplastin times (aPTT). The heparinase MA decreased significantly with time and normalised after 14 days (p = < 0.001) while the increased fibrin contribution to clot strength persisted with time (p = 0.113). No significant differences in TEG analysis were noted between 30-day survivors and non-survivors at all time points. No patients developed disseminated intravascular coagulopathy (DIC) after 14-days, however thrombosis and bleeding were each reported in 3 (7.5%) patients. CONCLUSION: Critically-ill patients with COVID-19 present in a hypercoagulable state characterised by an increased clot strength. This state normalises after 14 days despite a persistently increased fibrin contribution to clot strength. We were unable to demonstrate any significant differences in TEG parameters between 30-day survivors and non-survivors at all time points.
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Whilst Covid prevented so many of the year's promised commemorative activities, one positive outcome was the delay of the original ‘live’ Lucca event scheduled for March and its transformation into an online event in Beethoven's birth month. (Edited by his daughter Margaret O'Sullivan, this was part of his project ‘Beethoven's Irish Songs Revisited’, which sought to reconstruct those folksongs for which George Thomson never got around to supplying texts.) In his stimulating address, ‘Beethoven's Ninth Symphony as a Disputed Symbol of Community: From Thomas Mann's Doctor Faustus to the Brexiteers of 2019’, William Kinderman cast a wide intellectual net, developing themes from the final chapter of his most recent book, Beethoven: A Political Artist in Revolutionary Times (Chicago: University of Chicago Press, 2020). After this ingenious analysis we were then taken on a whirlwind video tour of performances of the ‘Ode to Joy’ in political events spanning almost a century, showing how – despite the movement's misappropriation by the Nazi regime and racist Rhodesia, and the way it is associated with aggression in Kubrick's A Clockwork Orange – Schiller's text was reinterpreted to suit each different historical context, whilst remaining ‘an untainted symbol’ of affirmation and resistance. The examples of performances included those given by Germans held in a Japanese prisoner-of-war camp in June 1918, the annual December ritual of massed choirs and orchestras in Japan, the Occupy Wall Street protests in New York in 2011, the struggle of Chilean opponents of Pinochet, the playing of cassette recordings with makeshift amplification by students protesting against martial law in China at Tiananmen Square in 1989, right up to Tan Dun's 2021 work Sound Pagoda – composed to be performed alongside the ‘Ode to Joy’ – for a concert dedicated to Wuhan's Covid victims.
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BACKGROUND: The utility of heated and humidified high-flow nasal oxygen (HFNO) for severe COVID-19-related hypoxaemic respiratory failure (HRF), particularly in settings with limited access to intensive care unit (ICU) resources, remains unclear, and predictors of outcome have been poorly studied. METHODS: We included consecutive patients with COVID-19-related HRF treated with HFNO at two tertiary hospitals in Cape Town, South Africa. The primary outcome was the proportion of patients who were successfully weaned from HFNO, whilst failure comprised intubation or death on HFNO. FINDINGS: The median (IQR) arterial oxygen partial pressure to fraction inspired oxygen ratio (PaO2/FiO2) was 68 (54-92) in 293 enroled patients. Of these, 137/293 (47%) of patients [PaO2/FiO2 76 (63-93)] were successfully weaned from HFNO. The median duration of HFNO was 6 (3-9) in those successfully treated versus 2 (1-5) days in those who failed (p<0.001). A higher ratio of oxygen saturation/FiO2 to respiratory rate within 6 h (ROX-6 score) after HFNO commencement was associated with HFNO success (ROX-6; AHR 0.43, 0.31-0.60), as was use of steroids (AHR 0.35, 95%CI 0.19-0.64). A ROX-6 score of ≥3.7 was 80% predictive of successful weaning whilst ROX-6 ≤ 2.2 was 74% predictive of failure. In total, 139 patents (52%) survived to hospital discharge, whilst mortality amongst HFNO failures with outcomes was 129/140 (92%). INTERPRETATION: In a resource-constrained setting, HFNO for severe COVID-19 HRF is feasible and more almost half of those who receive it can be successfully weaned without the need for mechanical ventilation.