Influence of SARS-COV-2 Infection on Cytokine Production by Mitogen-Stimulated Peripheral Blood Mononuclear Cells and Neutrophils in COVID-19 Intensive Care Unit Patients.

We sought to investigate the influence of SARS-CoV-2 infection on the cytokine profiles of peripheral blood mononuclear cells (PBMCs) and neutrophils from coronavirus disease 2019 (COVID-19) intensive care unit (ICU) patients. Neutrophils and PBMCs were separated and stimulated with the mitogen phytohemagglutinin. Culture supernatants of mitogen-stimulated PBMCs and neutrophils from 88 COVID-19 ICU patients and 88 healthy controls were evaluated for levels of granulocyte-macrophage colony-stimulating factor (GM-CSF), interferon (IFN)-α, IFN-γ, interleukin (IL)-2, -4, -5, -6, -9, -10, -12, -17A, and tumor necrosis factor (TNF)-α using anti-cytokine antibody MACSPlex capture beads. Cytokine profiles of PBMCs showed significantly lower levels of GM-CSF, IFN-γ, IL-6, IL-9, IL-10, IL-17A, and TNF-α (p < 0.0001) in COVID-19 ICU patients. In contrast, COVID-19 ICU patients showed higher median levels of IL-2 (p < 0.001) and IL-5 (p < 0.01) by PBMCs. As for neutrophils, COVID-19 ICU patients showed significantly lower levels of GM-CSF, IFN-γ, IL-2, IL-4, IL-5, IL-6, IL-9, IL-10, IL-17A, IL-12, TNF-α (p < 0.0001), and IFN-α (p < 0.01). T-helper (Th)1:Th2 cytokine ratios revealed lower inflammatory cytokine for PBMCs and neutrophils in COVID-19 ICU patients. Cytokine production profiles and Th1:Th2 cytokine ratios suggest that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has an immunomodulatory effect on PBMCs and neutrophils. This study also suggests that the increased levels of several cytokines in the serum are not sourced from PBMCs and neutrophils.

Extracorporeal Membrane Oxygenation in Pregnant Women With COVID-19.

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and lung involvement is common. Patients with COVID-19 may progress to acute respiratory distress syndrome (ARDS) for which they may require mechanical ventilation. When conventional ventilation strategies are unable to achieve the desired oxygenation and gas exchange, extracorporeal membrane oxygenation (ECMO) might be an option in selected patients. The literature on the use of ECMO in peripartum women with COVID-19 is limited. We present a series of ten cases involving pregnant and recently pregnant women who rapidly developed ARDS after the onset of COVID-19 for which they received ECMO. Nine of the 10 patients survived intensive care unit discharge after a gradual recovery of their pulmonary function and weaning from mechanical ventilation and ECMO. In addition, 9 out of the 10 delivered neonates survived neonatal intensive care unit discharge.

Appropriateness of lung ultrasound for the diagnosis of COVID-19 pneumonia.

BACKGROUND: Chest radiography (CXR) and computerized tomography (CT) are the standard methods for lung imaging in diagnosing COVID-19 pneumonia in the intensive care unit (ICU), despite their limitations. This study aimed to assess the performance of bedside lung ultrasound examination by a critical care physician for the diagnosis of COVID-19 pneumonia during acute admission to the ICU. METHOD: This was an observational, prospective, single-center study conducted in the intensive care unit of Adan General Hospital from April 10, 2020, to May 26, 2020. The study included adults with suspicion of COVID-19 Infection who were transferred to the ICU. Patients were admitted to the ICU directly from the ED after reverse transcriptase-polymerase chain reaction (RT-PCR) swabs were sent to the central virology laboratory in Kuwait, and the results were released 16 to 24 hours after the time of admission. A certified intensivist in critical care ultrasound performed the lung ultrasound within 12 hours of the patient's admission to the ICU.The treating physician confirmed the diagnosis of COVID-19 pneumonia based on a set of clinical features, inflammatory markers, biochemical profile studies, RT-PCR test results, and CXR. RESULTS: Of 77 patients with suspected COVID-19 pneumonia, 65 (84.4%) were confirmed. The median age of the patients was 48 (31-68) years, and 51 (71%) were men.In the group of patients with confirmed COVID-19 pneumonia, LUS revealed four signs suggestive of COVID-19 pneumonia in 63 patients (96.9%) (sensitivity 96.9%, CI 85%-99.5%). Two patients presented with unilateral lobar pneumonia without other ultrasonic signs of COVID-19 pneumonia but with positive RT-PCR results. Among patients in the group without COVID-19 pneumonia who had negative RT-PCR results, 11 (91.7%) were LUS negative for COVID-19 pneumonia (specificity 91.7%, 95% CI 58.72%-99.77%). CONCLUSIONS: During the COVID-19 outbreak, LUS allows the identification of early signs of interstitial pneumonia. LUS patterns that show a combination of the four major signs offer high sensitivity and specificity compared to nasopharyngeal RT-PCR.

Lung Ultrasound and Sonographic Subpleural Consolidation in COVID-19 Pneumonia Correlate with Disease Severity.

INTRODUCTION: One of the ultrasonic features of COVID-19 pneumonia is the presence of subpleural consolidation (SPC), and the number of SPCs varies among patients with COVID-19 pneumonia. AIM: To examine the relationship between disease severity and the number of SPCs on admission. Methodology. This observational, prospective, single-center study included patients with suspected COVID-19 infection who had been transferred to the ICU. A specialized intensivist in critical care ultrasound performed lung ultrasound (LUS) and echocardiography within 12 hours of a patient's admission to the ICU. The aeration score was calculated, and the total number of SPCs was quantified in 12 zones of the LUS. RESULTS: Of 109 patients with suspected COVID-19 pneumonia, 77 (71%) were confirmed. The median patient age was 53 (82-36) years, and 81 of the patients (73.7%) were men. The aeration score and the counts of subpleural consolidation in each zone were significantly higher in patients with COVID-19 pneumonia (P=0.018 and P < 0.0001, respectively). There was an inverse relationship between PO2/FiO2, the aeration score, and the number of subpleural consolidations. The higher the number of SPCs, the worse the PO2/FiO2 will be. CONCLUSIONS: Sonographic SPC counts correlate well with the severity of COVID-19 pneumonia and PO2/FiO2. The number of SPCs should be considered when using LUS to assess disease severity.

Point-of-Care Ultrasound for COVID-19 Pneumonia Patients in the ICU.

BACKGROUND: There is scarce literature on point-of-care ultrasound (POCUS) assessment characteristics in coronavirus disease 2019 (COVID-19) pneumonia with hypoxic respiratory failure. METHODS: This study was an observational, prospective, single-center study, including adults suspected to have COVID-19 who were transferred to the intensive care unit (ICU). An intensivist in critical care ultrasound performed lung ultrasound (LUS) and echocardiology within 12 hours of patients' admission to the ICU. We calculated the trans mitral E/A ratio, E/e', left ventricular ejection fraction (EF), inferior vena cava (IVC) diameter, right ventricle (RV) size and systolic function. RESULTS: In the group of patients with confirmed COVID-19 pneumonia, echocardiographic findings revealed normal E/e', deceleration time (DT), and transmittal E/A ratio compared to those in the non-COVID-19 patients (p = 0.001, 0.0001, and 0.0001, respectively). IVC diameter was < 2 cm with > 50% collapsibility in 62 (81%) patients with COVID-19 pneumonia; a diameter of > 2 cm and < 50% collapsibility was detected among those with non-COVID-19 pneumonia (p-value of 0.001). In patients with COVID-19 pneumonia, there were 3 cases of myocarditis (3.9%) with poor EF, severe RV systolic dysfunction was seen in 9 cases (11.6%), and 3 cases exhibited RV thrombus. Lung US revealed 4 signs suggestive of COVID-19 pneumonia in 77 patients (98.6%) (sensitivity 96.9%; confidence interval, 85%-99.5%) when compared with reverse transcriptase-polymerase chain reaction results. CONCLUSIONS: POCUS plays an important role in the bedside diagnosis, hemodynamic assessment and management of patients with acute hypoxic respiratory and circulatory failure with COVID-19 pneumonia.

Improving management of hospitalised patients with COVID-19: algorithms and tools for implementation and measurement.

BACKGROUND: The COVID-19 pandemic represents an unprecedented challenge to healthcare systems and nations across the world. Particularly challenging are the lack of agreed-upon management guidelines and variations in practice. Our hospital is a large, secondary-care government hospital in Kuwait, which has increased its capacity by approximately 28% to manage the care of patients with COVID-19. The surge in capacity has necessitated the redeployment of staff who are not well-trained to manage such conditions. There was a great need to develop a tool to help redeployed staff in decision-making for patients with COVID-19, a tool which could also be used for training. METHODS: Based on the best available clinical knowledge and best practices, an eight member multidisciplinary group of clinical and quality experts undertook the development of a clinical algorithm-based toolkit to guide training and practice for the management of patients with COVID-19. The team followed Horabin and Lewis' seven-step approach in developing the algorithms and a five-step method in writing them. Moreover, we applied Rosenfeld et al's five points to each algorithm. RESULTS: A set of seven clinical algorithms and one illustrative layout diagram were developed. The algorithms were augmented with documentation forms, data-collection online forms and spreadsheets and an indicators' reference sheet to guide implementation and performance measurement. The final version underwent several revisions and amendments prior to approval. CONCLUSIONS: A large volume of published literature on the topic of COVID-19 pandemic was translated into a user-friendly, algorithm-based toolkit for the management of patients with COVID-19. This toolkit can be used for training and decision-making to improve the quality of care provided to patients with COVID-19.

Right atrial thrombus in a patient with COVID-19 pneumonia: a case report.

BACKGROUND: Significant coagulopathy and hyperinflammation are found in patients with coronavirus disease 2019 (COVID-19). Expert consensus has recommended prophylactic anticoagulation in COVID-19 patients due to the risk of thrombo-embolism. However, the use of therapeutic anticoagulation in these patients is still a matter of debate. CASE SUMMARY: We describe a patient with COVID-19 pneumonia and a clinical hyperinflammatory state. He developed early respiratory depression and required ventilation, and he subsequently developed haemodynamic instability. Point-of-care echocardiography demonstrated a right atrial thrombus and right ventricular dysfunction suggestive of acute massive pulmonary embolism. He was managed with veno-arterial extracorporeal membrane oxygenation and local thrombolysis. DISCUSSION: Critical cases of COVID-19 pneumonia are associated with hypercoagulation, and these patients should be monitored closely for complications. Therapeutic anticoagulation may play a role in the management and prevention of thrombo-embolism.

Influence of injection rate of hyperbaric bupivacaine on spinal block in parturients: a randomized trial.

PURPOSE: A prospective, randomized, double-blind clinical trial was undertaken to determine whether a tenfold difference in the rate of intrathecal injection of bupivacaine would affect sensory block level in parturients. Secondary outcomes included onset of block and the incidence of hypotension and nausea. METHODS: Following Research Ethics Board approval, 90 ASA I and II term parturients scheduled for Cesarean delivery were randomized to receive either fast injection (over four seconds, Group F) or slow injection (over 40 sec, Group S) of 0.75% hyperbaric bupivacaine 12 mg plus morphine 200 microg. Sensory block, motor block, and blood pressure were assessed every minute for the first 15 min, then every five minutes for the next 20 min. All occurrences of nausea, hypotension (decrease in systolic blood pressure > 30%) and ephedrine requirements were recorded. RESULTS: Forty-three patients in Group F and 42 patients in Group S completed the study. No differences in maximum sensory block height (Group F = median T2, interquartile range [T2-T4], Group S = T3 [T2-T4], P = 0.077) or time to achieve block height (F = 9.3 +/- 4.3 min, S = 9.7 +/- 4.7, P = 0.64) were observed. The frequencies of hypotension (Group F = 35/43, Group S = 32/42, P = 0.56), ephedrine utilization (Group F = 32/43, Group S = 26/42, P = 0.21) and nausea (Group F = 15/43, Group S = 16/42, P = 0.76) were similar. CONCLUSION: Rapid intrathecal injection of hyperbaric bupivacaine does not affect spread of spinal anesthesia or the incidence of hypotension and nausea in parturients.

The efficacy of a subhypnotic dose of propofol in preventing laryngospasm following tonsillectomy and adenoidectomy in children.

BACKGROUND: Laryngospasm is a well-known problem typically occurring immediately following tracheal extubation. Propofol is known to inhibit airway reflexes. In this study, we sought to assess whether the empiric use of a subhypnotic dose of propofol prior to emergence will decrease the occurrence of laryngospasm following extubation in children. METHODS: After approval from the Institutional Ethics Committee and informed parental consent, we enrolled 120 children ASA physical status I and II, aged 3-14 years who were scheduled to undergo elective tonsillectomy with or without adenoidectomy under standard general anesthesia. Before extubation, the patients were randomized and received in a blinded fashion either propofol 0.5 mg.kg(-1) or saline (control) intravenously. Tracheal extubation was performed 60 s after administration of study drug, when the child was breathing regularly and reacting to the tracheal tube. RESULTS: Laryngospasm was seen in 20% (n = 12) of the 60 children in the control group and in only 6.6% (n = 4) of 60 children in the propofol group (P < 0.05). CONCLUSIONS: During emergence from inhalational anesthesia, propofol in a subhypnotic dose (0.5 mg.kg(-1)) decreases the likelihood of laryngospasm upon tracheal extubation in children undergoing tonsillectomy with or without adenoidectomy.