Resources for dealing with ICU patients
The New England Journal of Medicine Group has developed a virtual simulation on the treatment and management of suspected or confirmed cases of COVID-19: There are different levels of cases, ranging from a mild case to an expert case. Several tasks can be performed, such as gathering data, developing a differential diagnosis, ordering diagnostic tests, […]
Based on pulmonary and cutaneous biopsy and autopsy samples, some critically ill patients present a generalized thrombotic microvascular injury. Cutaneous manifestation consistent with a thrombotic microvascular injury included retiform purpura or livedo racemose. Histological findings suggest that some of the severe cases of COVID-19 would have thrombotic injuries mediated by a systemic activation of the […]
According to the experience with other strains of coronavirus, antibodies from convalescent plasma would neutralize the virus. 3,4 Patients who received convalescent plasma transfusion had a clinical improvement as assessed by decreased body temperature, increased PaO2/FiO2, radiologic improvement and lower inflammation blood markers. (Caution: Other treatments (steroid and antiviral treatment) were administered at the same […]
Twice daily temperature report for all health care workers Have a provision of clean scrubs and showering facilities for the staff members Use of videoconference applications for team meetings Early transfer of deteriorating cases Checklists for preparation of drugs, pre-prepared trolleys with equipment to minimize staff movement Use walkie-talkies or preprinted message to relay information […]
Singapore intensive care unit used Modified Early Warning Score to guide patient assessment: Parameter 3 2 1 0 1 2 3 Age <65 >65 Respiratory frequency (/min) <9 9‒11 12‒20 21‒24 >25 Oxygen saturation under room air (%) <92 92‒93 94‒95 >95 Oxygen supply necessary Yes No Systolic blood pressure (mm Hg) <91 91‒100 101‒110 […]
Patients with COVID-19 induced ARDS had a low lung recruitability (measured by R/I ratio) with high PEEP, questionning the necessity of high peep in COVID-19 associated ARDS. R/I ratio is a simplified one-breath bedside way of measuring lung recruitability. Alternating body position (prone and supine) was associated with a better lung recruitability. ARDSnet Recommandations for […]
There is a significant difference in the ratio of severe symptoms between the RNA blood positive group (100%) and the RNA blood negative group (23,5%). There is a significant difference in the ratio of severe symptoms between the RNA anal swab positive group (72,7%) and the RNA blood negative group (23,5%). Both tests could be […]
In the 2009 H1N1 pandemic, obesity was identified as a risk factor for fatal and critical complications of influenza.1,3,4 Obesity appears to be an independent risk factor for severe COVID-19 infection: 5 The need for invasive mechanical ventilation increases with body mass categories, reaching nearly 90% in ICU patients with a BMI > 35 kg/m2. […]
Older age, neutrophilia, hepatic and coagulation dysfunction (eg, higher LDH, higher D-dimer) increase risk of developping ARDS and death. Diabetes and Hypertension increase risk of developping ARDS without any impact on death. High temperature (more than 39°C) increase risk of developping ARDS, but improve chance of survival Among ARDS patients, methylprednisolone seemed to reduce the risk […]
Investigational Drugs Results in favor of the use* Results not in favor of the use** Efficacy proven Antiviral agents Chloroquine∆,1-3 ✓ ✓ Hydroxychloroquine∆,4-11 ✓ ✓ Hydroxychloroquine + Azithromycin∆,5,7,8,10 ✓ ✓ Ivermectin12 N/A N/A Favipivir13,14 ✓ Lopinavir-Ritonavir15,16 ✓ Oseltamivir17 ✓ Remdesivir18,19 ✓ ✓ Convalescent plasma20 ✓ Supporting agents Anakinra (IL-1 receptor antagonist) N/A N/A Baricitinib (JAK […]
Mechanical ventilation strategy to COVID-19 is the one typically applied to severe ARDS: low tidal volume ventilation1 Some patients with COVID-19 pneumonia and «ARDS» present with an atypical form of the syndrome described by a high lung compliance A conceptual model, based on respiratory physiology, leads to the development of a time-related disease spectrum within […]
About coagulation and inflammation biochemical parameters: Markedly decreased fibrinogen, high FDP (fibrin degradation product), high D-dimers and increased PT/PTT are observed in COVID-19 non survivors.1,2,3,4,5,6 Rapidly rising FDP may be correlated with disease progression and may be a better surrogate marker than D-dimers.1,4,5 Plasminogen levels tend to be higher in severe disease and may play […]
CVD (cardiovascular disease): Pre-existing cardiovascular and metabolic disease are common in COVID-19 patients and they increase the risk of morbidity and mortality1. These comorbidities (hypertension, cardiovascular/cerebrovascular disease and diabetes) are associated with a greater risk of ICU hospitalisation2. Patients with CVD appear more susceptible to COVID-19–induced cardiac injury3. Acute cardiovascular complications: Acute cardiac injury is […]
Management of the dedicated operating room(OR): The OR should be adequately ventilated, ideally with negative pressure. The same OR and the same anesthesia machine should be used for COVID-19 positive patients. The anesthetic drug trolley should be kept in the induction room and all the drugs and equipment required for the procedure should be placed […]
Canadian Society of Otolaryngology-Head and Neck Surgery strongly advise against performing a tracheotomy in still infectious COVID-19 patients. In positive patients, requests for tracheotomy should generally not be considered regardless of duration of endotracheal intubation. In emergency tracheotomy with unknown COVID-19 status: Manage patient as if COVID-19 positive. Intubation rather than tracheotomy is highly preferable. […]
DIC (Disseminated Intravascular Coagulation) is highly associated with death, as the majority of patients (71%) who died from NCP (novel coronavirus pneumoniae) met the criteria for DIC (with median time of four days after admission) compared to few survivor (0.6% developing DIC). Coagulation parameters (mainly D-dimers) should be done at baseline and followed throughout the […]
Lymphopenia is frequent1,2 and severe lymphopenia may be useful to identify patients that will need ICU care1,2,3. Patients requiring ICU tend to have higher LDH (lactate dehydrogenase) and higher ANC (absolute neutrophil count)1,2,3. Thrombocytopenia is frequent2,3, but does not seem to correlate the need of ICU care.1,2,3. Hemoglobin, monocyte, prothrombin time, activated partial thromboplastin time […]
LMWH (low molecular weight heparin) at a prophylactic dose may reduce mortality in patient with markedly elevated D-dimers (6 upper limit normal) or a SIC (sepsis-induced-coagulopathy criteria) ≥4, as 28-day mortality rates were statistically lower for patients meeting these criterias. Higher doses should be considered in patient with a high body mass index. Rationale of […]
Before COVID-19 Mesenchymal stem cells (MSCs) are multipotent, self-renewing stromal cells present mainly in the bone marrow and adipose tissue, that are able to differentiate into various cell types, including myocytes, adipocytes, osteoblasts and chondrocytes.2 MSCs have shown their effectiveness in immune-mediated inflammatory diseases2: They have been recognized to have immunomodulatory, immunosuppressive, and regenerative effects, […]
Before COVID-19 Cytokine storm, also known as secondary haemophagocytic lymphohistiocytosis (sHLH), refers to an hyperinflammation state of excessive and uncontrolled release of pro-inflammatory cytokine (interferons, interleukins, chemokines, colony-stimulating factors and tumor necrosis factors) which regulate immune and inflammatory responses sHLH can be caused by a variety of infectious agents, such as Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis, […]
Kidney injury in COVID-19 infection may results from two different mechanisms: Hypoperfusion of the renal tubules secondary to the cytokine storm and shock.1,2 Direct cytopathogenic effect of SARS-CoV-2. Reports suggest that ACE2 (essential for virus uptake by cells) is highly expressed on podocytes and renal tubular epithelial cells (RTEC). Hematuria and albuminuria along with viral […]
Using high-flow nasal oxygen for patients with moderately severe hypoxemia might reduce the need for intubation. For mechanically-ventilated patient: Tidal volume: 6mL/kg per predicted bodyweight Plateau airway pressure: Less than 30 cm H2O Respiratory rates: Increase to 35 bpm as needed In case of ventilator dyssynchrony, increased airway pressure and hypoxaemia, deep sedation should be […]
Cardiac tamponade may be a potential symptom of SARS-CoV2 infection This case report demonstrates the first case of COVID-19-related cardiac tamponade. The 47-year-old Afro-Caribbean patient was admitted in March 2020 at the King’s College Hospital, London, UK. Initial echocardiogram showed small to moderate pericardial effusion. Upon deteriotation of patient, repeat echocardiagram showed cardiac tamponade […]
Pro-inflammatory processes in ARDS disrupt ACE function in the pulmonary endothelium. Thus, Ang-1 (angiotensin I) cannot be hydrolyzed to Ang-2. Excess Ang-1 contributes to hypotension via 4 physiological mechanisms: (1) decrease in smooth muscle contraction, (2) metabolism into Ang-(1-7) to agonize vasodilatory MAS and AT2 receptors (3) Activation of NO production (4) Impairs hydrolysis of […]
Cardiac troponin I (cTnI) concentrations are greatly increased in patients with severe infections. Standard measurement of cTnI without suspicion of myocardial injury should be avoided This data comes from a meta-analysis encompassing four studies from China in which cardiac troponin I values in COVID-19 patients were reported as well as disease severity. Of the 341 […]
