Role of Non-Invasive Respiratory Supports in COVID-19 Acute Respiratory Failure Patients with Do Not Intubate Orders.

The current gold-standard treatment for COVID-19-related hypoxemic respiratory failure is invasive mechanical ventilation. However, do not intubate orders (DNI), prevent the use of this treatment in some cases. The aim of this study was to evaluate if non-invasive ventilatory supports can provide a good therapeutic alternative to invasive ventilation in patients with severe COVID-19 infection and a DNI. Data were collected from four centres in three European countries. Patients with severe COVID-19 infection were included. We emulated a hypothetical target trial in which outcomes were compared in patients with a DNI order treated exclusively by non-invasive respiratory support with patients who could be intubated if necessary. We set up a propensity score and an inverse probability of treatment weighting to remove confounding by indication. Four-hundred patients were included: 270 were eligible for intubation and 130 had a DNI order. The adjusted risk ratio for death among patients eligible for intubation was 0.81 (95% CI 0.46 to 1.42). The median length of stay in acute care for survivors was similar between groups (18 (10-31) vs. (19 (13-23.5); p = 0.76). The use of non-invasive respiratory support is a good compromise for patients with severe COVID-19 and a do not intubate order.

Corticosteroid Responsive Encephalopathy: Prolonged Coma in Patients Late in the Course of Dreadful Severe Acute Respiratory Syndrome Coronavirus 2 Infection.

BACKGROUND: Responsible for the coronavirus disease 2019 pandemic that began in December 2019, severe acute respiratory syndrome coronavirus 2 mainly causes respiratory insult. Few cases were reported of extrapulmonary involvement, many of which were neurologic. CASE SUMMARY: In this case report, we present two cases of prolonged coma after weaning off sedation in severe acute respiratory syndrome coronavirus 2 patients with rapid neurologic improvement shortly after high-dose corticosteroid regimen. CONCLUSIONS: We thus hypothesize an inflammatory process being responsible for the prolonged coma. Inflammatory neurologic insult has been described with other coronaviruses. Further studies are needed to determinate the extent and underlying mechanism of neurologic involvement in severe acute respiratory syndrome coronavirus 2 infections.

[Hyperlactatemia and lactic acidosis in the critically ill patient]. / Hyperlactatémie et acidose lactique chez le patient critique.

Hyperlactatemia is associated with an ominous prognosis in critical illness and must be rapidly detected. Lactate is produced by glycolysis through reduction of pyruvate, itself oxidized in the mitochondria. It is transported to the liver and converted to glucose through gluconeogenesis (Cori's cycle). Hyperlactatemia can result from excessive production or reduced clearance. Excess production can occur in aerobic conditions, following an increase in pyruvate generation, or in anaerobic conditions, due to impaired pyruvate oxidation. Reduced lactate clearance occurs as a result of liver hypoperfusion or hepatic failure. Lactate/pyruvate ratio, as well as the concomitant existence of metabolic acidosis (lactic acidosis), help distinguish the different mechanisms leading to hyperlactatemia, which are reviewed in detail in this article.