Effect of prone positioning on survival in adult patients receiving venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a prospective multicenter randomized controlled study.

Background: Current data supporting the use of prone positioning (PP) during venovenous extracorporeal membrane oxygenation (VV-ECMO) in patients with acute respiratory distress syndrome (ARDS) are limited. This prospective randomized controlled study aimed to determine whether PP implemented within 24 hours of ECMO can improve survival in these patients. Methods: From June 2021 to July 2023, 97 adult patients receiving VV-ECMO for ARDS in three centers were enrolled and 1:1 randomized into PP (n=49) and control groups (n=48). Patients in the PP group receiving prone positioning, while the control group were maintained in the supine position. The primary outcome was 30-day survival, and secondary outcomes included in-hospital survival and other clinical outcomes. Results: All 97 patients were included for analysis. Patient characteristics did not significantly differ between the two groups. The median duration of PP was 81 hours, and the median number of PP sessions was 5 times. PP improved oxygenation and ventilator parameters. The incidence of complications during PP was low, with pressure sores being the most frequent (10.2%). The 30-day survival was significantly higher in the PP group (67.3% vs. 45.8%; P=0.033), as was in-hospital survival (61.2% vs. 39.6%; P=0.033). In the PP group, the successful ECMO weaning rate was significantly higher (77.5% vs. 50.0%; P=0.005), and the duration of ECMO support was significantly shorter {10 [8-11] vs. 10 [8-14] days; P=0.038}. However, in subgroup analysis of COVID patients the 30-day survival, in-hospital survival, successful ECMO weaning rate and the duration of ECMO support did not differ between the groups. The duration of mechanical ventilation, length of intensive care unit stay, and length of hospital stay did not significantly differ between the groups. Conclusions: When initiated within 24 hours of ECMO, PP can improve 30-day survival in patients with ARDS receiving VV-ECMO. In addition, it may improve the successful ECMO weaning rate and reduce the duration of ECMO support. However, considering the limitations, more strictly designed, large sample prospective randomized controlled trials are proposed. Trial Registration: Chinese Clinical Trial Registry ChiCTR2300075326.

Evaluation and management of shock in patients with COVID-19.

Shock is common in critically ill patients with COVID-19, developing in up to 67% of patients in intensive care (5% to 10% overall) and is associated with high mortality. Optimal management requires prompt recognition with precise evaluation and differentiation. Correcting hypoperfusion and treating the underlying process are fundamental aspects of treatment. Undifferentiated shock may be treated initially with norepinephrine to optimize perfusion while additional evaluation is performed to categorize the shock pathophysiology. Physical examination, bedside echocardiography, hemodynamic monitoring, lactate and venous oxygen saturation are important components of the patient evaluation.

Adenovirus-associated Acute Respiratory Distress Syndrome: Need for a Protocol-based Approach.

AIM: Viral causes of acute respiratory distress syndrome (ARDS) are mostly limited to influenza A; however, adenovirus has been emerging as a cause of fulminant ARDS with a high mortality rate and no consensus on its management. Here we present a series of five patients with confirmed adenovirus infection treated for ARDS at our quaternary referral institution. MATERIALS AND METHODS: All patients were above 18 years old, had confirmed adenovirus infection, and were treated for acute hypoxic respiratory failure requiring mechanical ventilation in our medical intensive care unit (MICU). Demographic and clinical data were collected and analyzed. RESULTS: Among these patients, the median age was 28 years, median BMI 28 kg/m2 median sequential organ failure assessment (SOFA) score 9, and median acute physiology and chronic health evaluation (APACHE) III score 74. All patients received lung-protective mechanical ventilation with high positive end-expiratory pressure and low plateau pressures. Three patients developed severe ARDS, two received prone position ventilation, and one was placed on extracorporeal membrane oxygenation. The median duration of mechanical ventilation, MICU length of stay, and hospital length of stay were 24, 19, and 27 days, respectively. One out of five patients died in our study. CONCLUSION: The mortality rate for adenovirus-associated pneumonia in the literature is estimated to be 40% in those requiring mechanical ventilation. The lower mortality at our institution could be attributed to the use of standardized protocols, which include low tidal volume ventilation, early use of neuromuscular blockade, targeting low plateau pressures, conservative fluid management, and comfort and familiarity with the use of adjunctive and rescue therapies. We recommend testing for adenovirus as part of a routine respiratory viral panel in ARDS patients, and if tested positive, transfer to tertiary or quaternary centers with the experience and rescue modalities needed to manage complicated ARDS patients. HOW TO CITE THIS ARTICLE: Vashisht R, Mirzai S, Koval C, Duggal A. Adenovirus-associated Acute Respiratory Distress Syndrome: Need for a Protocol-based Approach. Indian J Crit Care Med 2020;24(5):367-368.

Respiratory failure in patients infected with SARS-CoV-2.

The management of patients with COVID-19-induced acute respiratory distress syndrome focuses on identifying the causes for respiratory failure and on following best practices for supportive care with oxygen supplementation and mechanical ventilation. In this patient population, appropriate measures need to be taken to prevent the spread of the coronavirus. Nearly 90% of COVID-19 patients admitted to the ICU need mechanical ventilation and most of these develop severe ARDS, which causes high morbidity and mortality. These patients need to be managed according to guidelines for the low-tidal-volume lung-protective ventilation. Practitioners also need to evaluate for other potential causes of respiratory failure.

A narrative review of non-pharmacological management of SARS-CoV-2 respiratory failure: a call for an evidence based approach.

A novel severe acute respiratory syndrome coronavirus (SARS-CoV-2) belonging to genus beta-coronavirus has been associated with an acute respiratory disease termed coronavirus disease 2019 (COVID-19). As of September 3, 2020, SARS-CoV-2 had caused 867,219 fatalities in 188 nations across the globe. Rapid progression to bronchopneumonia manifesting with severe hypoxemia and eventual evolution into acute respiratory distress syndrome (ARDS) necessitating mechanical ventilation is the hallmark of this disease. The novel nature of COVID-19 pneumonia and the high morbidity and mortality associated with the same has vexed the critical care community. A cultural shift away from evidence-based medicine, and the impetus to attempt newer unproven therapies like awake proning, interleukin receptor 6 antagonists, inhaled nitric oxide, empiric anticoagulation etc. over modalities that have been tested over the decades is slowly gaining ground. The suggestions to delay intubations and liberalize tidal volumes have polarized the medical field like never before. The lack of consistency in management practices and establishing practices based on anecdotes and experiences can lead to devastating outcomes in the patients affected by this deadly virus. In this narrative review, we attempt to re-emphasize the need for an evidence-based approach to the management of COVID-19 related ARDS and review treatment strategies that have been established after rigorous trials and have stood the test of time.

A Case of Severe Seronegative Inflammatory Arthritis due to Nivolumab and Review of the Literature.

Immune-checkpoint inhibitors (ICIs) have revolutionized the treatment of cancer, yet therapy is often hampered by immune-related adverse events (irAEs) which range from mild to severe life-threatening events. Musculoskeletal (MSK) irAEs leading to discontinuation of ICIs are uncommon but increasingly recognized. We report a challenging case of severe immune-related seronegative inflammatory arthritis due to nivolumab in a patient with stage IV metastatic adenocarcinoma.