Extracorporeal blood purification with Oxiris® filter in critically ill patients with COVID-19 requiring continuous renal replacement therapy.

INTRODUCTION: Severe COVID-19 is associated with a dysregulated immune response that usually leads to cytokine release syndrome. This study aimed to compare the use of extracorporeal blood purification therapy (Oxiris®) versus standard continuous renal replacement therapy (CRRT) in critically-ill patients with severe COVID-19. METHODS: This was a national, multicenter, retrospective study of patients with COVID-19 admitted to the intensive care unit (ICU) between March and October 2020 who required CRRT. Patients were categorized into two groups: Oxiris® CRRT and standard CRRT. The primary outcome was the number of patients alive and ventilator-free at 30-days post-CRRT treatment. Key secondary endpoints included change in inflammatory markers, Sequential Organ Failure Assessment (SOFA) scores, and PaO2/FiO2 ratio at 24- and 72-h post Oxiris® initiation. RESULTS: Thirty-five patients received Oxiris® CRRT and 23 patients received standard CRRT. The primary outcome was 31.4% in the Oxiris® group versus 4.3% in the standard CRRT group (adjusted odds ratio 5.97, 95% confidence interval [CI], 0.64-55.6; p = 0.117). In the Oxiris® group, interleukin-6 (IL-6) concentrations significantly decreased at 24 and 72-h (p = 0.033) and PaO2/FiO2 ratio significantly increased at 24 and 72 h after Oxiris® initiation (p = 0.001). There was no significant change in SOFA scores at 24- and 72-h after Oxiris® initiation. CONCLUSION: The number of patients alive and ventilator-free at 30-days was higher in the Oxiris® group than that in the standard CRRT group; however, the difference did not reach statistical significance after adjusting for the baseline severity of illness. There was a significant reduction in IL-6 and significant improvement in PaO2/FiO2 ratio after Oxiris® CRRT initiation.

EVALUATION OF HYDROCORTISONE, VITAMIN C, AND THIAMINE FOR THE TREATMENT OF SEPTIC SHOCK: A RANDOMIZED CONTROLLED TRIAL (THE HYVITS TRIAL).

ABSTRACT: Purpose: The aim of the study is to evaluate the effect of combined hydrocortisone, vitamin C, and thiamine (triple therapy) on the mortality of patients with septic shock. Methods : This multicenter, open-label, two-arm parallel-group, randomized controlled trial was conducted in four intensive care units in Qatar. Adult patients diagnosed with septic shock requiring norepinephrine at a rate of ≥0.1 µg/kg/min for ≥6 h were randomized to a triple therapy group or a control group. The primary outcome was in-hospital mortality at 60 days or at discharge, whichever occurred first. Secondary outcomes included time to death, change in Sequential Organ Failure Assessment (SOFA) score at 72 h of randomization, intensive care unit length of stay, hospital length of stay, and vasopressor duration. Results: A total of 106 patients (53 in each group) were enrolled in this study. The study was terminated early because of a lack of funding. The median baseline SOFA score was 10 (interquartile range, 8-12). The primary outcomes were similar between the two groups (triple therapy, 28.3% vs. control, 35.8%; P = 0.41). Vasopressor duration among the survivors was similar between the two groups (triple therapy, 50 h vs. control, 58 h; P = 0.44). Other secondary and safety endpoints were similar between the two groups. Conclusion: Triple therapy did not improve in-hospital mortality at 60 days in critically ill patients with septic shock or reduce the vasopressor duration or SOFA score at 72 h. Trial Registration:ClinicalTrials.gov identifier: NCT03380507. Registered on December 21, 2017.

Impact of Early Tracheostomy on Weaning From Ventilation and Sedation in COVID-19 Pregnant and Early Postpartum Patient: Two Case Reports.

Pregnant women are at high risk of coronavirus disease 2019 (COVID-19) complications, including acute respiratory distress syndrome (ARDS) and the need for mechanical ventilation. There is no literature on the optimal strategy for the management of difficult-to-wean pregnant and early postpartum patients. We report two cases of pregnant women with COVID-19 pneumonia and ARDS, who required mechanical ventilation and high doses of analgesia, and sedation with neuromuscular blocking agents to facilitate ventilation and oxygenation. Both patients had a tracheostomy procedure to facilitate weaning from mechanical ventilation and sedation. Shortly after tracheostomy, sedation and analgesia, along with ventilatory support were weaned off. Both patients were discharged home. These cases propose early tracheostomy as a strategy to facilitate weaning from mechanical ventilation and sedation in pregnant and early postpartum patients.

Anti-Xa Directed Thromboprophylaxis in Critically Ill Patients with Coronavirus Disease 2019.

Objective: To compare Anti-Xa directed thromboprophylaxis using low molecular weight heparin (LMWH) (anti-Xa peak goal 0.2-0.5 IU/mL) to alternative anticoagulation strategies in critically ill COVID-19 patients. Methods: This was a retrospective, multicenter, single health-system study. Primary outcomes were thromboembolic events and clinically important bleeding events. Secondary outcomes included dosing comparisons between LMWH cohorts. Main Results: A total of 695 patients were included. No differences were found in the incidence of thrombotic events with any of the dosing strategies. The incidence of major bleeding was significantly higher in the standard dose thromboprophylaxis, intermediate dose subcutaneous heparin (SQH), and therapeutic anticoagulation cohorts. Forty-nine percent of patients within the anti-Xa directed group had their first anti-Xa peak at goal, while 43% were above goal. Patients who had levels above goal had dose modifications made, therefore anti-Xa directed LMWH resulted in significantly lower total daily doses compared to intermediate dose LMWH. Conclusions: Anti-Xa directed LMWH dosing provided comparable thromboprophylaxis with lower total daily doses of LMWH in critically ill COVID-19 patients. Further randomized controlled trials are needed to confirm our findings.

Predictors of mortality and morbidity in critically ill COVID-19 patients: An experience from a low mortality country.

Background and Aims: Clinical characteristics and factors associated with mortality in patients admitted to the intensive care unit (ICU) in countries with low case fatality rates (CFR) are unknown. We sought to determine these in a large cohort of critically ill COVID-19 patients in Qatar and explore the early mortality predictors. Methods: We retrospectively studied the clinical characteristics and outcomes in patients admitted to the ICU at the national referral hospital for COVID-19 patients in Qatar. Logistic regression analysis was used to determine factors associated with mortality. Results: Between March 7 and July 16, 2020, a total of 1079 patients with COVID-19 were admitted to the ICU. The median (IQR) age of patients was 50 (41-59) years. Diabetes (47.3%) and hypertension (42.6%) were the most common comorbidities. In-hospital mortality was 12.6% overall and 25.9% among those requiring mechanical ventilation. Factors independently associated with mortality included older age ([OR]; 2.3 [95% CI; 1.92-2.75] for each 10-year increase in age, p < 0.001), chronic kidney disease (OR; 1.9 [95% CI; 1.02-3.54], p = 0.04), active malignancy (OR; 6.15 [95% CI; 1.79-21.12], p = 0.004), lower platelet count at ICU admission (OR; 1.41 [95% CI; 1.13-1.75] for each 100 × 103/µl decrease, p = 0.002), higher neutrophil-to-lymphocyte ratio at admission (OR; 1.01 [95% CI; 1-1.02] for each 1- point increase, p = 0.016), higher serum ferritin level at admission (OR; 1.05 [(95% CI; 1.02-1.08] for each 500 µg/L increase, p = 0.002), and higher serum bilirubin level at admission (OR; 1.19 [95% CI; 1.04-1.36] for each 10 µmol/L increase, p = 0.01). Conclusions: The mortality rate among critically ill COVID-19 patients is low in Qatar compared to other countries. Older age, chronic kidney disease, active malignancy, higher neutrophil-to-lymphocyte ratios, lower platelet counts, higher serum ferritin levels, and higher serum bilirubin levels are independent predictors of in-hospital mortality.

Clinical outcomes of intravenous immunoglobulin therapy in COVID-19 related acute respiratory distress syndrome: a retrospective cohort study.

BACKGROUND: Intravenous immunoglobulin (IVIG) has been used as an immunomodulatory therapy to counteract severe systemic inflammation in coronavirus disease 2019 (COVID-19). But its use in COVID-19 related acute respiratory distress syndrome (ARDS) is not well established. METHODS: We conducted a retrospective analysis of electronic health records of COVID-19 patients admitted to intensive care units (ICUs) at Hazm Mebaireek General Hospital, Qatar, between March 7, 2020 and September 9, 2020. Patients receiving invasive mechanical ventilation for moderate-to-severe ARDS were divided into two groups based on whether they received IVIG therapy or not. The primary outcome was all-cause ICU mortality. Secondary outcomes studied were ventilator-free days and ICU-free days at day-28, and incidence of acute kidney injury (AKI). Propensity score matching was used to adjust for confounders, and the primary outcome was compared using competing-risks survival analysis. RESULTS: Among 590 patients included in the study, 400 received routine care, and 190 received IVIG therapy in addition to routine care. One hundred eighteen pairs were created after propensity score matching with no statistically significant differences between the groups. Overall ICU mortality in the study population was 27.1%, and in the matched cohort, it was 25.8%. Mortality was higher among IVIG-treated patients (36.4% vs. 15.3%; sHR 3.5; 95% CI 1.98-6.19; P < 0.001). Ventilator-free days and ICU-free days at day-28 were lower (P < 0.001 for both), and incidence of AKI was significantly higher (85.6% vs. 67.8%; P = 0.001) in the IVIG group. CONCLUSION: IVIG therapy in mechanically ventilated patients with COVID-19 related moderate-to-severe ARDS was associated with higher ICU mortality. A randomized clinical trial is needed to confirm this observation further.

Hyperglycemia Risk Evaluation of Hydrocortisone Intermittent Boluses vs Continuous Infusion in Septic Shock: A Retrospective Study.

INTRODUCTION: Hydrocortisone showed to be effective in reducing the time until reversal of shock when added to standard therapy in managing septic shock. Hyperglycemia is one of the common adverse effects associated with corticosteroid treatment. However, the difference in hyperglycemia risk with different methods of hydrocortisone administration is not clear. The objective of this study was to evaluate the risk of hyperglycemia of intermittent hydrocortisone boluses vs continuous infusion in septic shock patients. MATERIALS AND METHODS: This was a retrospective observational study. Data were collected from the electronic medical records of eligible patients admitted to intensive care units. All patients admitted with septic shock who received noradrenaline and hydrocortisone were included. Only patients who exceeded 200 mg/day of hydrocortisone were excluded. The primary outcome was mean blood glucose. RESULTS: A total of 108 patients (with 3,021 blood glucose readings) were included in the final analysis. Seventy-six patients received hydrocortisone as intermittent boluses (70.3%), and 32 patients (29.7%) received continuous infusion. For the primary outcome, no statistically or clinically significant difference was found in the blood glucose estimated marginal mean: 8.58 mmol/L (95% confidence interval [CI]; 8.01-9.16) in the bolus group and 8.9 mmol/L (95% CI; 7.99-9.82) in the infusion group with a mean difference of 0.32 mmol/L (95% CI; -0.77 to 1.41). For secondary outcomes, no difference was found between the two groups in mortality, length of stay, reversal of shock, or hypoglycemic events. CONCLUSION: Intermittent boluses of hydrocortisone were not associated with a higher risk of hyperglycemia than continuous infusion in septic shock patients. HOW TO CITE THIS ARTICLE: Mitwally H, Saad MO, Mahmoud S, Mohamed A. Hyperglycemia Risk Evaluation of Hydrocortisone Intermittent Boluses vs Continuous Infusion in Septic Shock: A Retrospective Study. Indian J Crit Care Med 2021;25(1):29-33.

Evaluation of the risk of acute kidney injury with the use of piperacillin/tazobactam among adult critically ill patients.

PURPOSE: Piperacillin/tazobactam (PT), when combined with vancomycin, is associated with an increased risk of acute kidney injury (AKI). It is not known whether PT alone is associated with a higher incidence of AKI compared to other ß-lactams among critically ill patients. The objective of this study was to compare the incidence of AKI associated with the use of PT to other ß-lactams among adult critically ill patients METHODS: This retrospective study was conducted in the surgical and the medical intensive care units at two hospitals within Hamad Medical Corporation (HMC) in Qatar and included adult critically ill patients who received at least one dose of anti-pseudomonal ß-lactams. The primary outcome was acute kidney injury, defined using the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Multiple logistic regression with adjustment for pre-specified potential confounders was used for the primary outcome analysis. RESULTS: A total of 669 patients were included in the analysis: 507 patients in the PT group and 162 patients in the control (meropenem/cefepime) group. AKI occurred in 136 (26.8%) members of the PT group and 38 (23.5%) members of the control group [odds ratio (OR) 1.2; 95% confidence interval (CI) 0.79-1.8]. The results were not significantly altered after adjusting for the pre-specified potential confounders (adjusted OR 1.38; 95% CI 0.88-2.15). CONCLUSION: In this study, PT was not associated with a higher risk of AKI compared to cefepime or meropenem among adult critically ill patients.

Effectivness of Clonidine in Treating Dexmedetomidine Withdrawal in a Patient with Co-Existing Psychiatric Illness: A Case Report.

BACKGROUND Dexmedetomidine is a sedating agent approved for use in non-intubated patients and procedural sedation due to its efficacy in conscious sedation and minimal risks of respiratory depression. Previous reports proved the effectiveness of clonidine in treatment of withdrawal symptoms, but none have discussed cases with co-existing non-controlled psychiatric illness and prolonged duration of dexmedetomidine exposure. CASE REPORT We report a case of a 40-year-old woman diagnosed with viral meningitis. Due to her complicated psychiatric illness and viral meningitis, she developed severe agitation unresponsive to standard therapy. The patient had to be placed on dexmedetomidine, to which she developed dependence. There were several attempts to gradually withdraw dexmedetomidine but these were unsuccessful despite adding multiple antipsychotic medications. Withdrawal was manifested in multiple symptoms, including severe agitation, sweating, and tachycardia. Clonidine was used and was an effective treatment option to successfully withdraw the patient from dexmedetomidine. A smaller initial dose was used due to low baseline systolic blood pressure, which was successful. CONCLUSIONS This report proves that clonidine is an effective option for treatment of dexmedetomidine dependence compared to other antipsychotic agents. The present report is the first to discuss severe psychiatric illness and prolonged dexmedetomidine duration (>7 days) in a non-intubated patient. Dexmedetomidine withdrawal must be considered in the differential diagnosis of patients with psychiatric illness, which can be easily treated with clonidine.