ANALGESIA AND SEDATION OF MECHANICALLY VENTILATED PATIENTS IN THE INTENSIVE CARE - CURRENT APPROACH.

Analgesia and sedation are basic parts of the treatment in the intensive care. Nevertheless, deep sedation during mechanical ventilation has many adverse effects. In last decades the trend towards mild titrated sedation is seen. It enables early weaning from mechanical ventilation and shortening the stay in the intensive care setting and hospital. In this article pharmacology of main drugs used for analgesia/sedation nad strategy of sedation in mechanically ventilated patients are described. The last section of this article is dedicated to sedation of patients with acute respiratory distress syndrome of common"and COVID -19 etiology. These patients usually suffer from critical respiratory failure and agressive ventilatory support, prone positioning and other invasive techniques are needed. That is why deep sedation or even paralysis is sometimes necessary, but also in these patients lower sedation and weaning attempts should be tried as soon as possible.Copyright © 2022 TIGIS Spol. s.r.o.. All rights reserved.

Re-humanisation, Recognising the person behind the patient

Submission content Introduction: At the end of a particularly hectic night shift on the intensive care unit (ICU) I found myself sitting in the relatives' room with the mother and aunt of a young patient, listening to their stories of her hopes and aspirations as she grew up. She had been diagnosed with lymphoma aged 14 and received a bone marrow transplant from her younger sister. Fighting through treatment cycles interposed with school studies, she eventually achieved remission and a portfolio of A-levels. Acceptance into university marked the start of a new era, away from her cancer label, where she studied forensic science and took up netball. Halfway through her first year she relapsed. Main body: When I met this bright, ambitious 20-year-old, none of this history was conveyed. She had been admitted to ICU overnight and rapidly intubated for type-1 respiratory failure. The notes contained a clinical list of her various diagnoses and treatments, with dates but no sense of the context. Rules regarding visitation meant her family were not allowed onto the unit, with next-of-kin updates carried out by designated non-ICU consultants to reduce pressures on ICU staff. No photos or personal items surrounded her bedside, nothing to signify a life outside of hospital. She remained in a medically-induced coma from admission onwards, while various organ systems faltered and failed in turn. Sitting in that relatives' room I had the uncomfortable realisation that I barely saw this girl as a person. Having looked after her for some weeks, I could list the positive microbiology samples and antibiotic choices, the trends in noradrenaline requirements and ventilatory settings. I had recognised the appropriate point in her clinical decline to call the family in before it was too late, without recognising anything about the person they knew and loved. She died hours later, with her mother singing 'Somewhere Over the Rainbow' at her bedside. Poignant as this was, the concept of this patient as more than her unfortunate diagnosis and level of organ failure had not entered my consciousness. Perhaps a coping mechanism, but dehumanisation none-the-less. Conclusion(s): Striking a balance between emotional investment and detachment is of course vital when working in a clinical environment like the ICU, where trauma is commonplace and worst-case-scenarios have a habit of playing out. At the start of my medical career, I assumed I would need to consciously take a step back, that I would struggle to switch off from the emotional aspects of Medicine. However, forgetting the person behind the patient became all too easy during the peaks of Covid-19, where relatives were barred and communication out-sourced. While this level of detachment may be understandable and necessary to an extent, the potential for this attitude to contribute to the already dehumanising experience of ICU patients should not be ignored. I always thought I was more interested in people and their stories than I was in medical science;this experience reminded me of that, and of the richness you lose out on when those stories are forgotten.

Variation in Demographic Characteristics, Socioeconomic Status, Clinical Presentation and Selected Treatments in Mortality Among Patients with a Diagnosis of COVID-19 in the United States

Objectives: COVID-19 infected over 150 million people and caused over 1 million deaths in the US. This study evaluates several variables thought to be associated with mortality risk in the COVID-19 population. Method(s): The IQVIA longitudinal medical and pharmacy claims databases identified 17,682,111 patients with a COVID-19 diagnosis between 4/1/2020-4/30/2022 from a population of >277 million patients in the US. Patients were linked to Veritas Data Research fact-of-death records (90% complete compared to CDC reporting) and confirmed deaths were flagged. Confirmed mortality rates (CMR) were evaluated by age group, socioeconomic status (SES) using the Area Deprivation Index (v2.0, University of Wisconsin, 2015), co-morbidities and COVID-specific (approved and unapproved) treatments. Result(s): Of the 563,744 patients (3.2%) identified as dead (3.67% in men, 2.85% in women overall), CMR was lowest in patients aged 0-17 (0.08%), highest in age 65-75 (5.92%) and >75 (16.40%). Patients in the lowest 40% of SES had CMR of 4.43% while in the highest 20% was 1.56%. Respiratory failure, pneumonia and sepsis were the most common acute diagnoses accompanying COVID-19 deaths in all SES. In patients with comorbid dementia or Alzheimer's disease, CMR were 21.62% and 23.40% respectively. Additionally, congestive heart failure (15.79%), atrial fibrillation (15.50%), chronic kidney disease (15.30%) and COPD (12.19%) were associated with high CMR. Among patients receiving approved therapies, casirivimab/imdevimab and remdesivir had CMR of 1.41% and 12.63% respectively, while for those receiving unapproved therapies, ivermectin and hydroxychloroquine had CMR of 2.54% and 2.45%. Conclusion(s): Compared to the 1.1% case-mortality rate (Johns Hopkins 2023) among US COVID-19 patients, we found CMR exceeded 3% among those with a medical claim for COVID-19. Advanced age, dementia, and cardio-renal disease were associated with mortality. Patients with the lowest SES had approximately 3 times the confirmed mortality rate compared to those in the highest SES group.Copyright © 2023

Coronavirus disease (COVID-19) in patients with type 2 diabetes mellitus: clinical and laboratory peculiarities

This study aims to study the clinical-laboratory peculiarities of the coronavirus disease (COVID-19) course in patients with type 2 diabetes mellitus (DM). There were examined 60 patients with the coronavirus disease COVID-19. Patients were divided into two groups: group I - 30 patients with the coronavirus disease (COVID-19) with concomitant type 2 diabetes mellitus;group II - 30 patients with coronavirus disease (COVID-19) without diabetes mellitus;control group - 20 people. There were studied peculiarities of clinical-laboratory changes in patients with coronavirus disease with type 2 diabetes mellitus. General clinical laboratory tests, determination of biochemical parameters, coagulogram, ferritin, CRP, procalcitonin, D-dimer and endothelin-1 were performed. Blood saturation was measured. Out of the instrumental methods, an ultrasound examination of the lungs and RTG of thoracic organs was performed. Patients were admitted on the 5.46+/-0.87 day of the disease. The length of the hospital stay for patients of group I was 19.9+/-1.66 bed days and 14.7+/-0.91 bed days for the patients of group II. A severe course of the disease was observed in 83.3% of patients of group I and 33.3% of group II;a moderate severity course was observed in 16.7% of patients with concomitant DM and 66.7% of patients without concomitant DM. Respiratory failure (RF) of 1 degree was observed in 30% of patients of group 1, RF of the 2 degree - in 16.7% of patients, and RF of the 3 degree - in 10% of patients. In patients without DM, RF of 1 degree - was in 30% of patients, and RF of the 2 degree - was in 13.3% of patients. The laboratory diagnostic methods determined that the levels of leukocytes, D-dimer, endothelin-1, IL-6, procalcitonin, and ferritin were higher in patients with concomitant type 2 DM. In patients with type 2 DM, the course of the coronavirus disease is more severe and longer, with the development of pneumonia and respiratory failure. It is accompanied by leukocytosis, lymphopenia, increased ESR, prothrombin index, IL-6, CRP level, procalcitonin and endothelin-1. Copyright © 2023 The Authors.

IRF2BP2 mutation with autoimmune enteropathy, immune deficiency, and respiratory failure

Case history: We present the case of a 31-year-old Hispanic male with history of recurrent bronchiectasis, invasive aspergillosis, and severe persistent asthma, who is now status post lung transplant for end-stage lung disease. He initially presented at 7 years of age with diarrhea, failure to thrive, and nearly absent immunoglobulin levels (IgG < 33 mg/dL, IgA < 7 mg/dL, IgM = 11 mg/dL, IgE = 4 IU/dL) necessitating IVIG treatment. Small intestinal biopsy showed villous atrophy consistent with autoimmune enteropathy. Sweat chloride was reported as indeterminate (44 me/dL). Initial WBC, platelet, and T- and NK-cell counts were within normal range, and B-cell count and percentage were borderline low. Most recently, he was found to have increased immature B-cell count (CD21low), decreased memory B-cells, and poor pneumococcal vaccine antibody response. Patient has been hospitalized numerous times with increasingly severe bronchiectasis, pneumonitis, and COVID-19 infections twice despite vaccination, leading to respiratory failure and lung transplantation. Family history is negative for immune deficiency and lung diseases. Discussion(s): Of these 3 VUSs (see the table), the one in IRF2BP2 has the most pathogenic potential due to its autosomal dominant inheritance, its location in a conserved domain (Ring), and previous case reports of pathogenic variants at the same or adjacent alleles 1-3. Baxter et al reported a de novo truncating mutation in IRF2BP2 at codon 536 (c.1606CinsTTT), which is similar to our patient's mutation. This patient was noted to have an IPEX-like presentation, with chronic diarrhea, hypogammaglobulinemia, and recurrent infections. Variant Functional Prediction Score for our variant predicts a potentially high damage effect. There are 2 other case reports of heterozygous mutations in loci adjacent to this allele;one (c.1652G>A)2 with a similar clinical phenotype to our patient and the other (C.625-665 del)3 with primarily inflammatory features and few infections. Impact: This case highlights a variant in IRF2BP2 associated with severe hypogammaglobulinemia, recurrent pulmonary infections, and autoimmune enteropathy. [Table presented]Copyright © 2023 Elsevier Inc.

Two-year outcome of extracorporeal membrane oxygenation in COVID-19 related severe respiratory failure

Objectives: We sought to evaluate 2-year outcome of V-V ECMO support for COVID-19 related severe respiratory failure in our center. Method(s): Retrospective analysis of 41 consecutive patients (73% male, mean age 51.6+/-14.2 years, mean BMI 35.1+/-12.5 kg/m2) with critical hypoxemic and/or hypercapnic refractory respiratory failure (mean P/F ratio 67.9+/-14.3 mmHg, mean pCO2 77.6.0+/-185.7 mmHg, Murray Score 3.71+/-0.4) on V-V ECMO support from October 2020 to January 2022 Results: With mean support duration of 234.4+/-63.2 hours, 29 patients (70.7%) were successfully weaned off. Finally, 19 of them (46.3%) were discharged home with good neurological outcome (CPC 1,2). During followup, 30-day, 6-, 12-, and 24 -month survival rate was 61.3%, 46.2%, 41.9%, and 41,9% respectively. In survivor group shorter symptoms onset to respiratory failure time (4+/-4.7 vs. 7+/-6.7 days, p=0.04), higher P/F ration (86+/-41.5 vs. 65+/-37.5 mmHg, p=0.04) and norepinephrine support (0.03+/-0.06 vs. 0.09+/-0.12 ug/kg/min, p=0.04), and lower IL-6 level (12.3+/-7.5 vs. 25.9+/-8.8 ng/l, p=0.03) p=0.01) were analysed before cannulation. Mean in-ICU stay and in-hospital stay in survivors;groups reached 32.5+/-27.7 days and 42.6+/-35.8 days, respectively. All long-term survivors (17 patients) complained about slight functional health limitation only with normal 6MWT (542.6+/- 89.2 min), near to normal spirometry parameters (FEV/VC 87+/-7.4%, DLCO 63.1+/-13.7%, KCO 82.,1+/-19.4%) and minimal neurological disability (CPC 1-2) Conclusion(s): 2-year outcome of V-V ECMO support in COVID-19 severe respiratory failure is acceptable even in the scope of low-volume ECMO centre. Reported functional status of long-term survivors was good despite the complicated and prolonged in-hospital stay. (Table Presented).

Invasive aspergillosis in patients with COVID-19 in intensive care units: results of a multicenter study.

Objective. To study risk factors, clinical and radiological features and effectiveness of the treatment of invasive aspergillosis (IA) in adult patients with COVID-19 (COVID-IA) in intensive care units (ICU). Materials and methods. A total of 60 patients with COVID-IA treated in ICU (median age 62 years, male - 58%) were included in this multicenter prospective study. The comparison group included 34 patients with COVID-IA outside the ICU (median age 62 years, male - 68%). ECMM/ISHAM 2020 criteria were used for diagnosis of CAPA, and EORTC/MSGERC 2020 criteria were used for evaluation of the treatment efficacy. A case-control study (one patient of the main group per two patients of the control group) was conducted to study risk factors for the development and features of CAPA. The control group included 120 adult COVID-19 patients without IA in the ICU, similar in demographic characteristics and background conditions. The median age of patients in the control group was 63 years, male - 67%. Results. 64% of patients with COVID-IA stayed in the ICU. Risk factors for the COVID-IA development in the ICU: chronic obstructive pulmonary disease (OR = 3.538 [1.104-11.337], p = 0.02), and prolonged (> 10 days) lymphopenia (OR = 8.770 [4.177-18.415], p = 0.00001). The main location of COVID-IA in the ICU was lungs (98%). Typical clinical signs were fever (97%), cough (92%), severe respiratory failure (72%), ARDS (64%) and haemoptysis (23%). Typical CT features were areas of consolidation (97%), hydrothorax (63%), and foci of destruction (53%). The effective methods of laboratory diagnosis of COVID-IA were test for galactomannan in BAL (62%), culture (33%) and microscopy (22%) of BAL. The main causative agents of COVID-IA are A. fumigatus (61%), A. niger (26%) and A. flavus (4%). The overall 12-week survival rate of patients with COVID-IA in the ICU was 42%, negative predictive factors were severe respiratory failure (27.5% vs 81%, p = 0.003), ARDS (14% vs 69%, p = 0.001), mechanical ventilation (25% vs 60%, p = 0.01), and foci of destruction in the lung tissue on CT scan (23% vs 59%, p = 0.01). Conclusions. IA affects predominantly ICU patients with COVID-19 who have concomitant medical conditions, such as diabetes mellitus, hematological malignancies, cancer, and COPD. Risk factors for COVID-IA in ICU patients are prolonged lymphopenia and COPD. The majority of patients with COVID-IA have their lungs affected, but clinical signs of IA are non-specific (fever, cough, progressive respiratory failure). The overall 12-week survival in ICU patients with COVID-IA is low. Prognostic factors of poor outcome in adult ICU patients are severe respiratory failure, ARDS, mechanical ventilation as well as CT signs of lung tissue destruction.Copyright © 2022, Interregional Association for Clinical Microbiology and Antimicrobial Chemotherapy. All rights reserved.

Concomitant hemorrhagic fever with renal syndrome and COVID-19.

Udmurt Republic is an endemic region for hemorrhagic fever with renal syndrome (HFRS). An extremely high incidence of COVID-19 in 2020-2021 worldwide and in Udmurt Republic in particular suggests that patients might bear these two infections simultaneously. In this article, we report a case of mixed COVID-19 plus HFRS infection. Specific clinical manifestations of HFRS in a COVID-19-coinfected patient included long-term fatigue, thrombocytopenia, iso(hypo)sthenuria, polyuria, episodes of sinus tachycardia and hypertension. On the other hand, the main clinical characteristics of COVID-19 in a HFRS-coinfected patient included no clinical signs of respiratory failure and relatively high saturation despite a substantial lung damage. In general, mixed infection is a risk factor that aggravates the disease and can worsen outcome. However, simultaneous infection of a cell with more than one virus probably causes viral interference, which results in suppression of one or both viruses.Copyright © 2023, Dynasty Publishing House. All rights reserved.

Omicron driven ECMO in a vaccinated critically ill patient

Objectives: Reporting a case of a COVID-19 vaccinated patient admitted to our intensive care unit with severe acute respiratory failure due to SARSCoV2 - Omicron variant, rapidly deteriorating requiring intubation, prone ventilation, and ECMO support. Method(s): A 62 years old Caucasian male was admitted in ICU for rapidly deranging respiratory failure and fever which occurred over the previous 24h. The patient received two doses of SARS-CoV2 vaccine (Oxford, AstraZeneca), the last one over five months before onset of symptoms. The patient was admitted to the intensive care unit (ICU) with tachypnea, low peripheral saturation (80%), elevated serum creatinine (2.4 mg/dl), and mild obesity (BMI 34,6). Pressure support ventilation trial (2 hours) failed carryng out to orotracheal intubation and protective ventilation. Worsening of respiratory exchanges (5 th day from the admission) required a rescue prone ventilation cycle, in the meantime an indication was given to the placement of veno-venous ECMO. The cannulation site was femoro-femoral and the configuration used was Vivc25- Va21, according to the current ELSO nomenclature;ECMO flow was progressively increased until a peripheral saturation of 95% was obtained. Result(s): The patient passed out after 2 month of extracorporeal support with no sign of recovery of pulmonary and renal function. Conclusion(s): Unlike evidences showing a lower symptomatic engagement of the Omicron variant SARSCoV2 positive patients, we have witnessed a rapid and massive pulmonary involvement. The short time that passed from the onset of symptoms and the rapid decay of respiratory function required rapid escalation of the intensity of care up to extracorporeal support. The patient showed previous pathologies that can lead to suspicion of a loss of immune coverage given by the vaccine, in addition to the long time elapsed since the last dose. (Figure Presented).

Reclassification of COVID-19 Related ICD-10 Codes in Mexico: A Real-World Data Analysis of 1,937,360 Hospital Discharges from the Ministry of Health

Objectives: To estimate the reclassification of COVID-19 related ICD-10 codes from admission to discharge using Real-World Data (RWD) from the 2020 Mexican Ministry of Health (MoH) hospitals discharge dataset. Method(s): In this retrospective study, we analyzed all COVID-19 related discharges in the 2020 MoH open database, according to ten ICD-10 codes that the WHO associated with COVID-19. Reclassification was defined as those COVID-19 related cases who were discharged with a different ICD-10 code compared to their ICD-10 admission code. Result(s): From a total of 1,937,360 discharges reported in the MoH's 2020 database 63,740 (3.3%), mostly men (60.8%), with a median age of 56 years, were discharged with a COVID-19 related ICD-10 code and 12,945 of these were reclassified (20.3%). Although "2019-nCoV acute respiratory disease" (U071) had the greatest frequency of reclassified discharges (12,013, 22.3%), the "other coronavirus as the cause of diseases classified elsewhere" (B972) was associated with the greatest reclassification proportion (68, 74.7%) followed by "pneumonia case confirmed as due to COVID-19" (J128) (26.0%). Codes with lower percentages were "acute respiratory distress syndrome due to COVID-19" (J80X) and "acute respiratory failure due to COVID-19" (J960) with 6.3% and 3.8%, respectively. From 63,740 discharges, 50.7% were due to clinical improvement, followed by death (38.2%), transfer to another unit (5.2%) and voluntary discharge (3.3%). The J960 code had the highest mortality (67%) followed by codes J80X (59.7%) and U071 (35.5%). Conclusion(s): In our RWD analysis, we identified that 1 in 5 COVID-19 discharges were admitted with different diagnoses, highlighting the enormous challenges faced by the Mexican MoH during the global health crisis to establish an accurate COVID-19 diagnosis and coding. Given that this is the first reclassification analysis in Mexico, the conduction of future studies is essential to gain more insights on the consequences of reclassification at a health system level.Copyright © 2023

Hemoperfusion with CytoSorb as Adjuvant Therapy in Critically Ill Patients with SARS-CoV2 Pneumonia

Background: Several pro- and anti-inflammatory cytokines involved in COVID-19 and it is reasonable to speculate that their removal from blood might limit organ damage. Hemoperfusion with CytoSorb is a technique developed to adsorb molecules in the middle molecular weight range (up to 55 kDa). Studies in vitro and in vivo have shown that HP is highly effective in clearing blood from a number of cytokines. Method(s): We report a case series of 9 consecutive COVID-patients admitted to our COVID Intensive Care Unit (ICU). Five of them were treated with HP using CytoSorb (T), due to the heavy emergency overload it was impossible to deliver blood purification in the other 4 patients (C), who were also considered as potential candidates by the attending medical team. All patients had pneumonia and respiratory failure requiring continuous positive airway pressure. Different antibacterial prophylaxes, antiviral, and anti-inflammatory therapies including steroids were delivered. Result(s): Our results show a better clinical course of T compared to control patients (C), in fact all T except 1 survived, and only 2 of them were intubated, while all C required intubation and died. CRP decreased in both groups, but to a greater extent after HP. Lymphocytopenia worsened in control patient but not in treated patient after HP. Procalcitonin increased in 2 of the not treated patients. In all survived patients (n = 4) HP reduced pro-inflammatory cytokines, as IL-6, TNF-alpha, and IL-8. Notably, a striking effect was observed on IL-6 levels that at the end of the second session were decreased by a 40% than before the first treatment. Serum levels of IL-8 and TNF-alpha were lowered within normal range. In all patients the treatment was safe and there were no complications. Conclusion(s): Our study suggests a potential efficacy of HP in an early phase of viral infection not only for improving survival in the treated patients but also by the remodeling treatment-associated cytokine levels.

Extracorporeal membrane oxygenation instead of invasive ventilation in patients with COVID-19 acute respiratory distress syndrome (ARDS) and pneumomediastinum: A cohort trial

Objectives: In patients with severe respiratory failure, invasive ventilation may deteriorate the pneumomediastinum and hypoxia. This study aimed to compare the mortality and the complications of the patients with coronavirus disease 2019 (COVID-19) related severe ARDS treated with invasive ventilation or veno-venous ECMO (VV-ECMO) to avoid intubation. We hypothesized that VV-ECMO support without prior intubation is a feasible alternative strategy to invasive ventilation. Method(s): This retrospective study evaluated patients with COVID-19 related severe respiratory failure and radiological evidence of pneumomediastinum. The primary outcome was intensive care unit (ICU) survival at 90 days. Result(s): Out of 347 patients with COVID-19 disease treated in our unit, 22 patients developed spontaneous pneumomediastinum associated with deterioration of respiratory function. In 13 patients (59%), invasive ventilation was chosen as initial respiratory support;in 9 patients (41%), VV-ECMO was chosen as initial respiratory support. The median age of the patients in the invasive ventilation group was 62 years (IQR: 49-69) compared to 53 years (IQR: 46-62) in ECMO group (P=0.31). No statistically significant difference in SAPS II score between the groups was observed (39.7 (IQR: 33.2-45.3) vs. 28.9 (IQR:28.4-34.6), P=0.06). No elevated fluid balance within the first 4 days was observed in the ECMO group compared to the invasive ventilation group (162 mL (IQR: -366-2000) vs. 3905 mL (IQR: 2068-6192), P=0.07). VV-ECMO as the initial strategy for supporting patients with severe respiratory failure and pneumomediastinum, was associated with lower 90 days mortality (HR: 0.33 95%-CI: 0.11-0.97, P= 0.04) compared to patients treated with invasive ventilation (Figure). Conclusion(s): VV-ECMO can be an alternative strategy to invasive ventilation for treating patients with severe respiratory failure and spontaneous pneumomediastinum. (Figure Presented).

Cerebral microbleeds and Fazekas scale in brain magnetic resonance imaging after critical COVID-19: A prospective cohort study

Background: We aimed to report long-term brain magnetic resonance imaging (MRI) findings in survivors of ICU-treated COVID-19 compared to other groups. Material(s) and Method(s): In this prospective cohort study 70 ICU-treated, 46 ward-treated and 46 home-isolated patients, diagnosed with COVID-19 in 2020, underwent brain MRI 6 months after the acute phase to determine the presence of cerebral microbleeds (CMB) and Fazekas scale. Result(s): CMBs existed in 27 (38.6%) ICU-treated, 13 (28.3%) ward-treated, 8 (17.4%) home-isolated COVID-19 patients, and in 12 (22.6%) non-COVID controls (Figure 1). The number of CMBs in COVID-19 patients and controls was median 2 (IQR 1-4) and 1 (IQR 1-2), respectively. Patients with CMBs differed from those without, regarding age (median 62 vs. 52 years, p < 0.001), history of arterial hypertension (50% vs. 31%, p = 0.03), need of ICU (56% vs. 38%, p = 0.03) and ventilator treatment (42% vs. 22%, p = 0.01), length of hospital stay (median 21 vs. 12 days, p < 0.001), and supplementary oxygen therapy (median 18 vs. 10 days, p = 0.008), respectively. Within the ICU group, patients with and without CMBs differed regarding the duration of ICU stay (median 17 vs. 9 days, p = 0.006), and mechanical ventilation (median 14 vs. 6 days, p = 0.002). In multivariable analysis, only age was associated with CMBs (OR 1.06, 95% CI 1.02-1.09). The majority of subjects in all groups had Fazekas scale one for white matter hyperintensities (Figure 1). Conclusion(s): Although the severity of respiratory failure and history of arterial hypertension were associated with the presence of CMBs, only age was an independent predictor of CMBs.

The impact of deprivation on Respiratory Support Unit outcomes in COVID-19 patients, and highlights from wave 2 data in Portsmouth

Background: The second wave of the COVID-19 pandemic caused significant demand for beds capable of delivering enhanced respiratory support. NHS England recommended the use of CPAP for patients with COVID-19 respiratory failure, a treatment which can be offered outside of a critical care facility, and on a Respiratory High Care/ Support Unit (RSU). The enhancement of Portsmouth's RSU provided CPAP and NIV for patients with COVID-19 respiratory failure. With our intensive care facilities at 300% their normal capacity, this greatly alleviated bed pressures on critical care. Varied levels of deprivation exist in Portsmouth's dense population. Deprivation has an impact on overall health, however the effect of postcode on outcomes for people going onto support for COVID-19 respiratory failure, is unknown. Method(s): Retrospective cohort analysis of consecutive patients admitted to Respiratory Support Unit during the second wave of the COVID-19 pandemic, from 02/11/2020 to 31/01/2021. 227 patients were included in the study with 8 removed due to incomplete data, all of the patients received respiratory support in the form of CPAP or NIV. We collected multivariate data including biochemical markers, demographics, oxygenation status, co-morbidities and outcomes. Outcomes measured were: 1) Death in RSU, 2) Discharge from RSU or 3) Intubation and Ventilation. To measure deprivation, we linked a persons postcode to an area called an LSOA (Lower-layer Super Output Area). These are small areas of similar population size, each of which has a deprivation score (ie. top 10%, to the lowest 10% areas of deprivation in the UK). This is measured using an 'index of multiple deprivation'. An individual's outcome from the RSU was then analysed in relation to the deprivation score allocated to their postcode. Result(s): We observed a significant number of patients discharged from RSU, without needing invasive mechanical ventilation. 80/219 were discharged directly. 45/219 died in RSU, and 94 were eventually admitted to ITU. The average stay on CPAP or NIV before needing admission to ITU was 3 days. Some biochemical markers which stood out in relation to the outcomes described were as follows: average LDH, D-dimer and Troponin levels were higher in those who were admitted to intensive care. In patients who died, the PCT was significantly higher on average when compared to the other two groups. In the group who were discharged, mean lymphocyte count was >1, in the other two groups this was <1. From our observations in Portsmouth, there is a negative correlation between deprivation and lower aged individuals admitted for COVID-19 related respiratory support. Overall, we also saw disproportionate representation of those from the most deprived 50% of the UK in our respiratory support unit. Conclusion(s): CPAP and NIV can effectively be used in an RSU during a spike of COVID-19, to safely minimise demand on critical care services. Deprivation may have an impact on outcomes in patients needing respiratory support related to COVID-19. Deprivation levels may help predict risk of needing enhanced respiratory support in certain age groups. Multiple biochemical markers may be of prognostic value in COVID-19.

ICU without walls = ICU without Data? the Covid-19 deficit

Introduction: Northern Ireland (NI) has 5.5 ICU beds/100 000 population,1 amongst the lowest in Western Europe.2 Alongside ICU bed expansion the Covid-19 response required delivery of advanced Respiratory support (Continuous Positive Airway Pressure (CPAP) and High Flow Nasal Oxygen (HFNO)) outside ICU. ICNARC provides robust data for patients within ICU but this is unavailable for those receiving 'critical care' elsewhere. Objective(s): To evaluate delivery of CPAP/HFNO outside of ICU to Covid-19 patients - focusing on demographics and outcomes including ICU admission and mortality. Method(s): Ward-CPAP for acute hypoxaemic respiratory failure (AHRF) was not previously utilised.3 It was introduced for Covid-19 to Medical wards. Data was analysed using the NI Electronic Care Record, ward electronic note system (EDAMS) and ICU system (ICCA, Koninklijke Philips N.V.). Data was compared between Wave 1 (01/03/2020 - 12/12/2020) and Wave 2 (13/12/2020 - 01/04/2021). Result(s): 215 patients received CPAP/HFNO/Invasive Mechanical Ventilation (IMV) for Covid-19: 103 in Wave 1 and 112 in Wave 2. 75 Covid-19 patients were admitted to the ICU itself (comprising 44 of the study cohort, 11 direct from ED and 20 transferred from other Trusts). Table 1 shows demographics. Fewer patients were female as seen elsewhere,4 there were more young patients in Wave 2. The majority of patients would likely have been ICU candidates pre-pandemic,3 but a subset of 25% were deemed for a ward ceiling-of-care on admission by a Consultant and the proportion of elderly patients was higher than described by ICNARC.4 Comorbidities and obesity were common. Outcomes are shown in Table 2 and Figures 1-3. Close co-operation with ICU saw 61% of patients with a documented ICU review. Overall 20% of patients were admitted to ICU, and 15% received IMV. Mortality was 37%, but 22% if patients with an admission ward ceiling-of-care decision were excluded. Mortality correlated with frailty and age (fig 2&3). Outcomes were generally better in Wave 2. Conclusion(s): This Evaluation documents the huge contribution to the critical care Covid-19 response made by our Medical teams, not captured by ICNARC. Most patients avoided ICU admission and IMV and outcomes were likely at least comparable which undoubtedly freed up vital ICU beds. We thank the teams involved and believe it is vital to evaluate the outcome of all critically ill Covid-19 patients irrespective of their location.

Characteristics of Patients Diagnosed with Long COVID: Early Findings from Real-World Data

Objectives: While persistent and relapsing symptoms of COVID-19 are increasingly documented, limited data exist on the post-acute population. The objective of this analysis is to identify the characteristics of patients diagnosed with long COVID using real-world data. Method(s): Children/adolescents (age 0-17) and adults (age 18-39, 40-64 and >=65) with >=2 primary diagnoses for U09.9 "Post COVID-19 condition" from 10/01/2021 (ICD-10 code introduction) until 03/31/2022 were selected from Optum's de-identified Clinformatics Data Mart Database, with the first diagnosis deemed index. Included patients had >=1 diagnosis for COVID-19 and continuous enrollment 12 months prior to index (baseline). To ensure alignment with most institutional definitions, >=4 weeks between initial COVID-19 infection and index was required. Diagnoses recorded +/-2 weeks from index that were not present prior to the initial COVID-19 diagnosis were summarized. Newly prescribed treatments and total medical costs were evaluated during the month following index (continuous enrollment required). Result(s): 3,587 patients met eligibility criteria (mean age 59.02, 57.56% female) with a median time from initial COVID-19 infection to long COVID diagnosis of 83 days (IQR: 46-201 days). The most common concurrent diagnoses included breathing complications such as dyspnea (20.38%) and respiratory failure (15.23%);malaise and fatigue (15.31%);symptoms related to cognitive functioning/anxiety (11.35%);and chest pain (7.67%). Children/adolescents had the highest prevalence of chest pain, while patients >=65 years of age had the highest prevalence of issues with coordination. The average total medical cost during the month following long COVID diagnosis was $4,267 (SD $14,662), with common prescriptions including albuterol (4.42%), prednisone (3.51%), and methylprednisolone (2.01%). Conclusion(s): This retrospective analysis confirms clinically documented symptoms of long COVID in a large, real-world population. Once more data become available, further research on the long term economic and clinical outcomes among patients diagnosed with post-acute COVID-19 syndrome are warranted.Copyright © 2023

A clinical case of prolonged CPAP ventilation in a patient with COVID-19-associated pneumonia

Non-invasive ventilation (NIV) via a mask to maintain a constant positive airway pressure (CPAP mask) is the method of choice for the treatment of pulmonary disorders in severe COVID-19-associated pneumonia. Nowadays, there are no studies which had shown the effectiveness of the ROX-index in predicting the efficacy of NIV in patients with acute hypoxic respiratory failure (AHRF). This clinical case describes our experience of effective use of ROX-index in patients with AHRF because of coronavirus dis-ease, SARS-CoV-2-associated, who underwent non-invasive lung ventilation through CPAP mask. © 2022. The Authors.

Liver dysfunction as a respiratory prognostic factor in covid-19 patients.

Respiratory dysfunction is a main clinical symptom of COVID-19. Liver dysfunction is also frequently reported in patients with COVID-19 and considered to be related to a poor prognosis. However, the precise mechanisms behind these findings remain unclear. We investigated the clinical features and prognostic factors related to liver dysfunction in 26 COVID-19 pa-tients. The patients with liver dysfunction had markedly higher WBC, neutrophils, CRP, and frequency of oxygen administration and markedly lower PaO2/FIO2 ratios. The patients with liver dysfunction had longer mean hospital stays. In conclusion, liver dysfunction at hospital admission may be an important prognostic factor for respiratory failure in patients with COVID-19. We must administer intensive care to these patients earlier to inhibit severe disease progression.Copyright ©2021 The Japan Society of Hepatology.

Uptake of the Post COVID-19 Condition ICD-10-CM Diagnosis Code By Social Factors

Objectives: Post-COVID conditions (PCC) are increasingly reported in people who had COVID. Certain racial or socioeconomic groups may be at greater risk for PCC and less likely to seek care. We examined the uptake of the new ICD-10-CM diagnosis code for PCC in routine clinical practice in the United States and how it varied by race and payer group. Method(s): Using the Optum de-identified Electronic Health Record (EHR) dataset, we identified patients with an ICD-10-CM code for PCC (U09.9) between October 1, 2021, through March 31, 2022, with 6 months of prior EHR activity. The earliest diagnosis defined the index date. All concurrent diagnoses were measured on the index date. Prior COVID diagnosis was assessed using all available data before the index date. Result(s): There were 23,647 patients: 9.9% were African American, 12.1% had Medicaid, and 2.4% were uninsured. There was an overrepresentation of white patients among those with PCC (78.6% compared with 69.6% of the overall EHR in 2021). More African American (24.1%), Medicaid (23.1%), and uninsured (27.5%) patients were diagnosed in the inpatient setting or emergency department than whites (14.0%) and commercially insured patients (10.0%). Among racial groups, African Americans had the highest percentage of documented prior COVID diagnosis at 63.6%. Of concurrent diagnoses, shortness of breath and acute respiratory failure with hypoxia were higher among African Americans (13.9% and 6.1%, respectively) than whites (11.5% and 4.3%, respectively). The same pattern was seen when comparing Medicaid and uninsured to commercial payors. Conclusion(s): The PCC code was used differently across racial groups and payor types and captures varying manifestations of PCC. The differences in diagnosis locations underscore the importance of using data capturing all care settings when conducting studies using this code. Subgroup analyses are important for future studies using U09.9 due to variability in code application.Copyright © 2023

COVID-19: Intensive care management.

The SARS-coronavirus 2 disease initially reported in December 2019 in China (COVID-19) represents a major challenge for intensive care medicine, due to the high number of ICU admission and the prolonged stay for many patients. Up to 5% of COVID-19 infected patients develop severe acute hypoxemic respiratory failure requiring invasive mechanical ventilation as supportive treatment. Apart from early antiviral and anti-inflammatory treatment, the management of COVID-19 patients is mainly applying protective mechanical ventilation, to support the injured lungs. However recently acquired data and clinical experience suggest that COVID-19-related ARDS presents some specificities that will be summarized in the present article.Copyright © 2020 Editions Medecine et Hygiene. All rights reserved.