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PURPOSE: Although the decision of which ventilation strategy to adopt in COVID-19 patients is crucial, yet the most appropriate means of carrying out this undertaking is not supported by strong evidence. We therefore described the organization of a province-level healthcare system during the occurrence of the COVID-19 epidemic and the 60-day outcomes of the hospitalized COVID-19 patients according to the respiratory strategy adopted given the limited available resources. PATIENTS AND METHODS: All COVID-19 patients (26/02/2020-18/04/2020) in the Rimini Province of Italy were included in this population-based cohort study. The hospitalized patients were classified according to the maximum level of respiratory support: oxygen supplementation (Oxygen group), non-invasive ventilation (NIV-only group), invasive mechanical ventilation (IMV-only group), and IMV after an NIV trial (IMV-after-NIV group). Sixty-day mortality risk was estimated with a Cox proportional hazard analysis adjusted by age, sex, and administration of steroids, canakinumab, and tocilizumab. RESULTS: We identified a total of 1,424 symptomatic patients: 520 (36.5%) were hospitalized, while 904 (63.5%) were treated at home with no 60-day deaths. Based on the respiratory support, 408 (78.5%) were assigned to the Oxygen group, 46 (8.8%) to the NIV-only group, 25 (4.8%) to the IMV-after-NIV group, and 41 (7.9%) to the IMV-only group. There was no significant difference in the PaO2/FiO2 at IMV inception in the IMV-after-NIV and IMV-only groups (p=0.9). Overall 60-day mortality was 24.2% (Oxygen: 23.0%; NIV-only: 19.6%; IMV-after-NIV: 32.0%; IMV-only: 36.6%; p=0.165). Compared with the Oxygen group, the adjusted 60-day mortality risk significantly increased in the IMV-after-NIV (HR 2.776; p=0.024) and IMV-only groups (HR 2.966; p=0.001). CONCLUSION: This study provided a population-based estimate of the impact of the COVID-19 outbreak in a severely affected Italian province. A similar 60-day mortality risk was found for patients undergoing immediate IMV and those intubated after an NIV trial with favorable outcomes after prolonged IMV.
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BACKGROUND: To treat permanent hemodialysis (HD) catheter dysfunctions due to thrombosis, as an alternative to pre- and intradialytic instillations/infusions of fibrinolytic agents, for practical reasons, a post-dialysis urokinase lock is often preferred. This study aimed to analyze the consequences on catheter function and the cost/effectiveness of an intermittent post-dialysis urokinase lock. METHODS: A prospective open experimental study enrolling 10 dialysis patients with a Tesio twin catheter locked with either heparin 5,000 IU/mL or escalating urokinase doses. Catheter function was monitored measuring the blood flow obtained with an aspiration pressure of -180 mmHg for 28 consecutive HD sessions. RESULTS: No differences were noticed between the blood flow obtained before and after the lock of the catheter with 5000 U/lumen of urokinase (phase 1), but also with 10,000 U/lumen (phase 2) of urokinase. The incidence of catheter dysfunction episodes in the wash-out in the 1st and in the 2nd urokinase phases were, respectively: 13, 6 and 3% (p<0.05 for both 13 vs. 6% and 13 vs. 3%). 47,000 U of urokinase were necessary to avoid one dysfunction episode potentially treatable with an intradialytic urokinase lock of 10,000 U. Between the average blood flow measured in the initial wash out (230 +/- 27 ml/min) and in the 1st (236 +/- 32 ml/min) and also in the 2nd (247 +/- 34 ml/min) urokinase phases significant differences were noticed (p<0.01 and p<0.05, respectively). CONCLUSIONS: The post-dialysis lock with urokinase is associated with an increase in the catheter blood flow and a re-duction in the occurrence of dysfunction episodes. However, the modest impact on dialysis quality and the apparent unfavorable cost/effectiveness of the prophylactic treatment, call for an investigation of its potential advantages in a larger study.