The Impact of CoronaVac Vaccination on 28-day Mortality Rate of Critically Ill Patients with COVID-19 in Türkiye.

Background: Vaccines against coronavirus disease-19 (COVID-19) have been effective in preventing symptomatic diseases, hospitalizations, and intensive care unit (ICU) admissions. However, data regarding the effectiveness of COVID-19 vaccines in reducing mortality among critically ill patients with COVID-19 remains unclear. Aims: To determine the vaccination status and investigate the impact of the COVID-19 vaccine on the 28-day mortality in critically ill patients with COVID-19. Study Design: Multicenter prospective observational clinical study. Methods: This study was conducted in 60 hospitals with ICUs managing critically ill patients with COVID-19. Patients aged ≥ 18 years with confirmed COVID-19 who were admitted to the ICU were included. The present study had two phases. The first phase was designed as a one-day point prevalence study, and demographic and clinical findings were evaluated. In the second phase, the 28-day mortality was evaluated. Results: As of August 11, 2021, 921 patients were enrolled in the study. The mean age of the patients was 65.42 ± 16.74 years, and 48.6% (n = 448) were female. Among the critically ill patients with COVID-19, 52.6% (n = 484) were unvaccinated, 7.7% (n = 71) were incompletely vaccinated, and 39.8% (n = 366) were fully vaccinated. A subgroup analysis of 817 patients who were unvaccinated (n = 484) or who had received two doses of the CoronaVac vaccine (n = 333) was performed. The 28-day mortality rate was 56.8% (n = 275) and 57.4% (n = 191) in the unvaccinated and two-dose CoronaVac groups, respectively. The 28-day mortality was associated with age, hypertension, the number of comorbidities, type of respiratory support, and APACHE II and sequential organ failure assessment scores (p < 0.05). The odds ratio for the 28-day mortality among those who had received two doses of CoronaVac was 0.591 (95% confidence interval: 0.413-0.848) (p = 0.004). Conclusion: Vaccination with at least two doses of CoronaVac within six months significantly decreased mortality in vaccinated patients than in unvaccinated patients.

Evaluation of IntelliVent-ASV® and PS-SIMV Mode Using Ultrasound (US) Measurements in Terms of Diaphragm Atrophy.

BACKGROUND:  Mechanical ventilation is a life-saving intervention for critically ill patients, but it can also lead to diaphragm atrophy, which may prolong the duration of mechanical ventilation and the length of stay in the intensive care unit. IntelliVent-ASV® (Hamilton Medical, Rhäzüns, Switzerland) is a new mode of ventilation that has been developed to reduce diaphragm atrophy by promoting spontaneous breathing efforts. In this study, we aimed to evaluate the effectiveness of IntelliVent-ASV® and pressure support-synchronized intermittent mandatory ventilation (PS-SIMV) mode in reducing diaphragm atrophy by measuring diaphragm thickness using ultrasound (US) imaging. METHODS:  We enrolled 60 patients who required mechanical ventilation due to respiratory failure and were randomized into two groups: IntelliVent-ASV® and PS-SIMV. We measured the diaphragm thickness using US imaging at admission and on the seventh day of mechanical ventilation. RESULTS: Our results showed that diaphragm thickness decreased significantly in the PS-SIMV group but remained unchanged in the IntelliVent-ASV® group. The difference in diaphragm thickness between the two groups was statistically significant on the seventh day of mechanical ventilation. CONCLUSIONS: IntelliVent-ASV® may reduce diaphragm atrophy by promoting spontaneous breathing efforts. Our study suggests that this new mode of ventilation may be a promising approach to preventing diaphragm atrophy in mechanically ventilated patients. Further studies using invasive measures of diaphragm function are warranted to confirm these findings.

Is there a relationship between the intensive care scores of patients with COVID-19 and depression and anxiety?

Objective: Coronaviruses that cause respiratory infections in humans are known to be neuropathogenic. The purpose of this study is to determine whether there is an association between the severity of viral pneumonia and anxiety and depression levels in patients admitted to an intensive care unit (ICU) with coronavirus disease 2019 (COVID-19). Methods: Prospective study of 165 patients, patients were divided into two groups (intubated and non-intubated) according to whether they were intubated during follow-up. Results: Of 165 patients included, 70 were intubated after the first 7 days of follow-up. The Generalized Anxiety Disorder-7 (GAD-7) score was 10.37±3.75 (p < 0.001) in these patients. The length of ICU stay was 25±22.3 days (p < 0.001), and the length of overall hospital stay was 28.28±23.37 days, significantly longer than in patients who were not intubated (p < 0.001). The Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment Score scores, as well as GAD-7 and Patient Health Questionnaire-9, were positively associated with length of ICU stay and length of hospital stay (p < 0.01). Conclusion: The presence and exacerbation of anxiety and depression symptoms can provide information about the aggravation and progression of the underlying disease.

Is there a relationship between the intensive care scores of patients with COVID-19 and depression and anxiety?

OBJECTIVE: Coronaviruses that cause respiratory infections in humans are known to be neuropathogenic. The purpose of this study is to determine whether there is an association between the severity of viral pneumonia and anxiety and depression levels in patients admitted to an intensive care unit (ICU) with coronavirus disease 2019 (COVID-19). METHODS: Prospective study of 165 patients, patients were divided into two groups (intubated and non-intubated) according to whether they were intubated during follow-up. RESULTS: Of 165 patients included, 70 were intubated after the first 7 days of follow-up. The Generalized Anxiety Disorder-7 (GAD-7) score was 10.37±3.75 (p < 0.001) in these patients. The length of ICU stay was 25±22.3 days (p < 0.001), and the length of overall hospital stay was 28.28±23.37 days, significantly longer than in patients who were not intubated (p < 0.001). The Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment Score scores, as well as GAD-7 and Patient Health Questionnaire-9, were positively associated with length of ICU stay and length of hospital stay (p < 0.01). CONCLUSION: The presence and exacerbation of anxiety and depression symptoms can provide information about the aggravation and progression of the underlying disease.

Encephalitis due to COVID-19 in a Patient Who Has Undergone Transsphenoidal Pituitary Surgery.

Central and peripheral nervous system involvement of COVID-19 has been reported in 25% of cases. COVID-19 is associated with encephalitis and most often presenting with confusion and disorientation, and mortality decreases with early diagnosis and treatment.The patient who was admitted with confusion and fever and found COVID-19 PCR positivity in both cerebrospinal fluid (CSF) and the nasopharyngeal swab is presented here. A 71-year-old female patient who underwent transsphenoidal pituitary tumor surgery 4 months ago, was in an acute confusional state with fluctuations in consciousness and agitation. It was suggested that bilateral temporal areas of the brain and paramedian region of the pons compatible with encephalitis in the T2 and FLAIR axial sections of magnetic resonance imaging (MRI). Nasopharyngeal and CSF SARS-CoV-2 RNA PCR was studied since thorax CT was compatible with COVID-19 pneumonia and in both samples, PCR was found positive. Encephalitis for toxic and metabolic causes was excluded. In this case, COVID-19 encephalitis was treated with dual antiviral (favipiravir and acyclovir) and steroid therapy. The uniqueness of this case is not only the presence of a very few reported cases of both Nasopharyngeal and CSF SARS-CoV-2 RNA PCR positivity but also previous history of transsphenoidal pituitary surgery 4 months ago.

Prognostic Value of Antithrombin Levels in COVID-19 Patients and Impact of Fresh Frozen Plasma Treatment: A Retrospective Study

Objective: The defective interplay between coagulation and inflammation may be the leading cause of intravascular coagulation and organ dysfunction in coronavirus disease-19 (COVID-19) patients. Abnormal coagulation profiles were reported to be associated with poor outcomes. In this study, we assessed the prognostic values of antithrombin (AT) activity levels and the impact of fresh frozen plasma (FFP) treatment on outcome. Materials and Methods: Conventional coagulation parameters as well as AT activity levels and outcomes of 104 consecutive critically ill acute respiratory distress syndrome (ARDS) patients with laboratory-confirmed COVID-19 disease were retrospectively analyzed. Patients with AT activity below 75% were treated with FFP. Maximum AT activity levels achieved in those patients were recorded. Results: AT activity levels at admission were significantly lower in nonsurvivors than survivors (73% vs. 81%). The cutoff level for admission AT activity was 79% and 58% was the lowest AT for survival. The outcome in those patients who had AT activity levels above 75% after FFP treatment was better than that of the nonresponding group. As well as AT, admission values of D-dimer, C-reactive protein, and procalcitonin were coagulation and inflammatory parameters among the mortality risk factors. Conclusion: AT activity could be used as a prognostic marker for survival and organ failure in COVID-19-associated ARDS patients. AT supplementation therapy with FFP in patients with COVID-19-induced hypercoagulopathy may improve thrombosis prophylaxis and thus have an impact on survival.

A Different Approach to Toxic Epidermal Necrolysis: Cytokine Filter.

Toxic epidermal necrolysis (TEN) is a potentially life-threatening dermatologic disorder that erythema and exfoliation of the skin involve more than 30% of the body surface and usually drug related. A 68-year-old male patient who was admitted to the emergency department with the complaint of extensive bullous lesions on his skin was followed up in the intensive care unit (ICU) with the diagnosis of TEN. He had been on multiple anti-inflammatory, antibiotic and analgesic treatment for approximately 20 days due to respiratory tract infection and gout. Methylprednisolone 1 g day 1 was started after the patient's previous treatments were discontinued. The patient was connected to the mechanical ventilator on 11th day due to sepsis and respiratory mucosal involvement. Regression and epithelialisation of skin lesions started after starting cytokine filter treatment on 14th day. The cytokine filter was applied with a renal replacement therapy machine in our patient. Withdrawal of suspected drugs, maintaining an optimal electrolyte balance, sterile care of skin lesions and management in the ICU of specialised centres are essential. Although agents, such as corticosteroids, intravenous immunoglobulins and cyclosporine, are used in the treatment, we think that the use of cytokine filters will contribute to recovery by stopping the cytokine storm in these cases.

Survey of postoperative residual curarization, acute respiratory events and approach of anesthesiologists / Pesquisa de curarização residual no pós-operatório, eventos respiratórios agudos e abordagem de anestesiologistas

BACKGROUND AND OBJECTIVES: residual paralysis following the use of neuromuscular blocking drugs (NMBDs) without neuromuscular monitoring remains a clinical problem, even when NMBDs are used. This study surveys postoperative residual curarization and critical respiratory events in the recovery room, as well as the clinical approach to PORC of anesthesiologists in our institution. METHODS: This observational study included 415 patients who received general anesthesia with intermediate-acting NMBDs. Anesthesia was maintained by non-participating anesthesiologists who were blinded to the study. Neuromuscular monitoring was performed upon arrival in the recovery room. A CRE was defined as requiring airway support, peripheral oxygen saturation <90% and 90-93% despite receiving 3 L/min nasal O2, respiratory rate >20 breaths/min, accessory muscle usage, difficulty with swallowing or speaking, and requiring reintubation. The clinical approach of our anesthesiologists toward reversal agents was examined using an 8-question mini-survey shortly after the study. RESULTS: The incidence of PORC was 43% (n = 179) for TOFR <0.9, and 15% (n = 61) for TOFR <0.7. The incidence of TOFR <0.9 was significantly higher in women, in those with ASA physical status 3, and with anesthesia of short duration (p < 0.05). In addition, 66% (n = 272) of the 415 patients arriving at the recovery room had received neostigmine. A TOFR <0.9 was found in 46% (n = 126) of the patients receiving neostigmine. CONCLUSIONS: When routine objective neuromuscular monitoring is not available, PORC remains a clinical problem despite the use of NMBDs. The timing and optimal antagonism of the neuromuscular blockade, and routine objective neuromuscular monitoring is recommended to enhance patient safety.

JUSTIFICATIVA E OBJETIVOS: A paralisia residual após o uso de bloqueadores neuromusculares (BNMs) sem monitoração neuromuscular continua sendo um problema clínico, mesmo quando BNMs são usados. Este estudo pesquisou a curarização residual pós-operatória e os eventos respiratórios críticos em sala de recuperação, bem como a abordagem clínica da CRPO feita pelos anestesiologistas em nossa instituição. MÉTODOS: Este estudo observacional incluiu 415 pacientes que receberam anestesia geral com BNMs de ação intermediária. A manutenção da anestesia foi feita por anestesiologistas não participantes, "cegos" para o estudo. A monitoração neuromuscular foi realizada no momento da chegada à sala de recuperação. Um ERC foi definido como necessidade de suporte ventilatório; saturação periférica de oxigênio <90% e 90-93%, a despeito de receber 3 L/min de O2 via cânula nasal; frequência respiratória >20 bpm; uso de musculatura acessória; dificuldade de engolir ou falar e necessidade de reintubação. A abordagem clínica de nossos anestesiologistas, em relação aos agentes de reversão, foi avaliada usando um miniquestionário de oito perguntas logo após o estudo. RESULTADOS: A incidência de CRPO foi de 43% (n = 179) para a SQE <0 e 15% (n = 61) para a SQE <0,7. A incidência de SQE <0,9 foi significativamente maior em mulheres, pacientes com estado físico ASA III e com anestesia de curta duração (p < 0,05). Além disso, 66% (n = 272) dos 415 pacientes que chegam à sala de recuperação haviam recebido neostigmina. Uma SQE <0,9 foi encontrada em 46% (n = 126) dos pacientes que receberam neostigmina. CONCLUSÃO: Quando a monitoração neuromuscular objetiva de rotina não está disponível, a CRPO continua sendo um problema clínico, a despeito do uso de BNMs. O momento e o antagonismo ideais do bloqueio neuromuscular e a monitoração neuromuscular objetiva de rotina são recomendados para aumentar a segurança do paciente.

Survey of postoperative residual curarization, acute respiratory events and approach of anesthesiologists.

BACKGROUND AND OBJECTIVES: residual paralysis following the use of neuromuscular blocking drugs (NMBDs) without neuromuscular monitoring remains a clinical problem, even when NMBDs are used. This study surveys postoperative residual curarization and critical respiratory events in the recovery room, as well as the clinical approach to PORC of anesthesiologists in our institution. METHODS: This observational study included 415 patients who received general anesthesia with intermediate-acting NMBDs. Anesthesia was maintained by non-participating anesthesiologists who were blinded to the study. Neuromuscular monitoring was performed upon arrival in the recovery room. A CRE was defined as requiring airway support, peripheral oxygen saturation <90% and 90-93% despite receiving 3 L/min nasal O2, respiratory rate > 20 breaths/min, accessory muscle usage, difficulty with swallowing or speaking, and requiring reintubation. The clinical approach of our anesthesiologists toward reversal agents was examined using an 8-question mini-survey shortly after the study. RESULTS: The incidence of PORC was 43% (n = 179) for TOFR < 0.9, and 15% (n = 61) for TOFR < 0.7. The incidence of TOFR < 0.9 was significantly higher in women, in those with ASA physical status 3, and with anesthesia of short duration (p < 0.05). In addition, 66% (n = 272) of the 415 patients arriving at the recovery room had received neostigmine. A TOFR < 0.9 was found in 46% (n = 126) of the patients receiving neostigmine. CONCLUSIONS: When routine objective neuromuscular monitoring is not available, PORC remains a clinical problem despite the use of NMBDs. The timing and optimal antagonism of the neuromuscular blockade, and routine objective neuromuscular monitoring is recommended to enhance patient safety.