Invasive mechanical ventilation during the first wave of COVID-19: Management and outcomes

Authors: Mafalda Aguiar Mourisco, Filipa Resende Brochado, Filipe Silva Machado, Diana Moreira Dias, Ricardo Pinho, Paulo Reis Rodrigues


Objective: To describe demographics, clinical, and respiratory mechanics (including ventilatory management details) of patients admitted to the Intensive Care Unit (ICU) with severe COVID-19 and to evaluate the effectiveness of gas exchange variables, ventilatory parameters, and ICU illness severity scores in predicting 28-day mortality.

Design: Single-center retrospective cohort study.

Setting: Portuguese medical-surgical ICU.

Patients: Adults sequentially admitted to the ICU, from March 18 to May 12, 2020, with critical COVID-19 requiring invasive mechanical ventilation (IMV) for over 48 hours.

Interventions: None, due to study design.

Measurements and results: Data regarding positioning, positive end-expiratory pressure (PEEP), driving pressure, static lung compliance, and lowest daily arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2) ratio throughout the first 5 days of ICU admission were collected from daily ventilatory assessment charts. The median ICU length of stay was 11.3 days and median IMV duration was 9.5 days. The 28-day mortality was 12.1%. When comparing non-survivors and survivors, significant differences were found regarding Simplified Acute Physiology Score (SAPS) II (48.5, IQR 14.0 vs. 32.0, IQR 11.0, p=0.004), PaO2/FiO2 ratio before endotracheal intubation (101.3, IQR 22.5 vs. 174.1, IQR 9.5, p=0.01) and throughout ICU stay. Over 90% of patients were submitted to prone positioning. Use of low PEEP levels and maintenance of low driving pressures in patients whose overall compliance was low as possible.

Conclusions: Significant differences were found regarding SAPS II and PaO2/FiO2 ratios between survivors and non-survivors, eliciting further investigation as potential mortality predictors. With the second wave of the pandemic taking shape, sharing previous experience is crucial to further coordinate efforts internationally.

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Restrictive fluid and fluid removal approach in diabetic ketoacidosis with septic AKI: A case report

Authors: Elvia AS, Mayang Indah Lestari, Yohannes WH George


Diabetic ketoacidosis is a life-threatening complication that requires a rapid restoration of intravascular volume usually with aggressive administration of intravenous fluid with 0.9% sodium chloride as recommended by the American Diabetes Association. We report a 50-year-old obese female patient with a history of diabetes mellitus (DM) since 20 years ago and routinely using insulin. She experienced dyspnea and presumably was caused by diabetic ketoacidosis. The patient was given fluid resuscitation with normal saline, but the dyspnea did not resolve and the work of breathing increased further, so the patient was intubated and admitted to the intensive care unit. Aggressive fluid resuscitation carries potential adverse effects such as hyperchloremic metabolic acidosis, interstitial multi-organ edema, and increased incidence of acute kidney injury. The first day of ICU treatment, positive cumulative fluid balance occurred and fluid removal was indicated. Fluid removal using diuretic or ultrafiltration is a part of the treatment of organ congestion and fluid overload after the initial phase of shock resuscitation to achieve negative fluid balance. This case showed that restricted fluid and fluid removal improve the patient outcome, especially in diabetic ketoacidosis and septic AKI patients.

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Outcomes in severe SARS-CoV-2 patients with liberal oxygenation and steroid therapy – a single centre experience

Authors: Priyadarshini Varadaraj, Sowmya Gopalan, Aiswarya M. Nair, Lakshmi Marappa, Vaasanthi Rajendran, Viswanathan Pandurangan, Sudha Madhavan, Rajkumar Mani, Emmanuel Bhaskar

Real-world reports on outcomes of SARS-CoV-2 infection using higher oxygenation targets along with steroid therapy are lacking. We conducted a retrospective study of patients requiring oxygen support following targets of oxygenation >95% along with steroid therapy. Group 1 with oxygenation through a nasal cannula or Hudson mask, Group 2 oxygenation with venturi system, and Group 3 with high flow nasal oxygen, 35-50 litres; non-invasive ventilation; mechanical ventilation delivering. One hundred and eighteen patients (Group 1 74 patients, Group 2 15 patients, and Group 3 29 patients) were studied. The mean age was 55.7 years and most were male (n=77). One hundred and fourteen received dexamethasone or methylprednisolone. Most (88.3%) had at least one pre-existing chronic medical illness. Overall mortality was 22.8% (n=27). Group 3 had the highest mortality (75.9%) followed by Group 2 (26.7%) and Group 1 (1.35%). Our observation raises the query if a higher target of oxygenation for non-mechanical ventilated patients coupled with steroid therapy is beneficial.

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What is low cardiac output syndrome? A report of two cases

Authors: Yuichi Baba, Toru Kubo, Yuri Ochi, Tatsuya Noguchi, Naohito Yamasaki, Hiroaki Kitaoka


Background: One of the diagnostic criteria of low cardiac output syndrome (LOS) is a cardiac index of less than 1.8 l/min/m2. However, recognition of this syndrome differs among intensivists as to whether or not LOS is synonymous with cardiogenic shock.

Case reports: Here, we present two cases of heart failure who were initially treated with diuretics and subsequently fell into a state of low cardiac output. We treated the patient with low blood pressure with inotropes and the patient with high blood pressure with a vasodilator according to their hemodynamics. We observed that cardiac power was the most significant hemodynamic change in response to these treatments. In this paper, we discuss the definition of LOS and show several criteria for determining LOS.

Conclusions: Broadly, there are several conditions of determining LOS. Even with those conditions, we should still be aware of the pathophysiology of each patient with heart failure. We propose that the definition of LOS should be a state of low cardiac output with corresponding symptoms, even if their blood pressure is high.

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Restrictive versus liberal fluid bolus therapy in septic shock children: An evidence-based case report

Authors: Irene Yuniar


Fluid bolus therapy (FBT) is one of prime management in early goal-directed therapy (EGDT) to achieve adequate cardiac output. The Fluid Expansion as Supportive Therapy (FEAST) trial, a randomized-clinical trial that was used as an evidence to support fluid resuscitation recommendation in Surviving Sepsis Campaign (SSC) 2020, must be discontinued because of increasing mortality in the group that received higher volume of FBT. We present a case of a 9-year-old girl, 15 kg, came to emergency ward with refractory septic shock and became fluid overload after the second FBT. This proceeding aimed to deliver evidence-based case practice if the comparison between liberal versus restrictive FBT in children with septic shock.

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Position statement for critical care nutrition in Hong Kong

Authors: Li Li Chang, Yue Ho Vincent Lau, Ting Ting Sinn, Siu Pik Peggy Lee, Ka Ming Kwok, Tin Yan Li, Anfernee Yim


Nutrition therapy is an important yet controversial issue in critical care field. There are numerous international guidelines or publications showing different views; therefore it is difficult to practice critical care nutrition in clinical setting. We believed that by providing appropriate and individualized nutrition therapy, patient’s outcome can be improved.

A local position statement was written by the opinion of critical care physicians, intensivists, and dietitians in Hong Kong after reviewing available evidence; with the aim to provide recommendations in nutrition therapy in local critical care setting and to stress the importance of appropriate nutrition therapy. The position statement includes recommendations on the general aspects, enteral nutrition, parenteral nutrition, and nutrition for specific diseases. A flow chart (Figure 1) is constructed to provide a pathway for implementing nutritional therapy in clinical practice. The position statement was endorsed by the Hong Kong Society of Critical Care Medicine (HKSCCM) and the Hong Kong Society of Parenteral and Enteral Nutrition (HKSPEN).

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Is hyperchloremia following sepsis resuscitation with 0.9% saline clinically important?

Authors: Elliot Long, Franz E. Babl, Fran Balamuth, Scott Weiss

The authors of the article titled “Balanced salt solution versus normal saline solution as initial fluid resuscitation in pediatric septic shock: a randomized, double-blind controlled trial”, published in Critical Care and Shock, should be congratulated for design and conduct of a randomized, double-blind clinical trial in severely unwell children with sepsis. The patient population included in the study was severely unwell: all patients enrolled went on to require inotropic therapy, and overall mortality was 24.6%. This stands in contrast to industrialized countries, where inotrope use and death from septic shock are significantly lower. The generalizability of findings between regions...

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Mortality in COVID-19 patients receiving systemic anticoagulant: A systematic review and meta-analysis

Authors: Patan Ahmad Setiabudi, Andry Gonius, Thoha Muhajir Albaar, Wella Karolina, Eliana Susilowati, Novi Kurnianingsih


Background: Coronavirus disease 2019 (COVID-19)/Severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) is a pandemic disease that quickly spreads throughout the world. There are no definitive therapeutic recommendations that give benefit results until recently. Recent studies suggest that coagulopathy is one of the complications of COVID-19 that increases the mortality rate regardless of the severity. This systematic review and meta-analysis aims to explore the association between systemic anticoagulant use and mortality in COVID-19 patients with various clinical conditions.

Methods: We performed a comprehensive search from several databases. The anticoagulant used in this study comprises of systemic anticoagulants such as low molecular weight heparin (LMWH) or others. The primary outcome was all-cause mortality related to anticoagulant use in COVID-19 patients. The meta-analysis was performed to see the significance of anticoagulants in decreasing the mortality rate of COVID-19 patients.

Results: 7064 patients were analyzed from 7 studies. The meta-analysis showed that systemic anticoagulant use was related with lower mortality rate (RR 0.70 [0.51, 0.97], p<0.03; I2: 87%, p<0.00001). The systematic review reported that 4 of 7 studies favor decreasing the mortality rate in COVID-19 patients administered with systemic anticoagulants.

Conclusion: Systemic use of anticoagulants was associated with a lower mortality rate in COVID-19 patients. Further studies are needed for better causation explanation. The implication of this study is to measure the mortality impact of systemic anticoagulant use in COVID-19 patients.

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Neutrophil to lymphocyte ratio, monocyte to lymphocyte ratio, platelet to lymphocyte ratio, mean platelet volume as a predictor of sepsis mortality in children at Dr. Soetomo General Hospital

Authors: Frans M. Pasaribu, Arina Setyaningtyas, Mia Ratwita Andarsini


Objective: The purpose of this study was to analyze the neutrophil to lymphocyte ratio (NLR), monocyte to lymphocyte ratio (MLR), platelet to lymphocyte ratio (PLR), mean platelet volume (MPV) as a predictor for mortality in children with sepsis.

Design: This was a prospective cohort study.

Setting: In Pediatric Intensive Care Unit (PICU), Emergency Room, and pediatric ward at Dr. Soetomo General Hospital, Surabaya on March 1, 2020 to August 2020.

Patients and participants: A total of 80 children consisted of 40 septic and 40 non-septic patients were included.

Measurement and results: The leukocyte count in septic patients was not significantly higher than in non-septic patients with a p value>0.05. The number of neutrophils (12.99±7.35x103/mm3 versus 9.12±6.67x103/mm3) had a relevant and significantly higher increase in septic patients (p=0.014). The NLR value (8.99±6.73 versus 4.80±5.30; p=0.001) was higher in septic patients. The cut-off of NLR as a diagnostic marker for sepsis was 3.52 with sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and odds ratio (OR) of 82.50%, 47.50%, 61.11%, 73.08%, and 4.26 (p=0.004), respectively. The MLR, PLR, and MPV did not differ significantly between septic and non-septic patients. NLR values (11.61±7.39 versus 5.77±4.05; p=0.014) between survive and dead septic patients. The NLR cut-off 8.98 has sensitivity, specificity, PPV, NPV, and OR of 77.78%, 54.55%, 58.3%, 75%, and 4.20 (p=0.038), respectively, as a predictor for mortality. Patient with NLR more than 8.98 has a risk for mortality 4.20 times higher than those with a low or equal NLR value.

Conclusion: NLR can be used as a predictor of mortality in children with sepsis.

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The correlation between vasoactive-inotropic score with mortality and the use of mechanical ventilation in pediatric shock admitted to the PICU in Dr. Soetomo General Hospital, Surabaya

Authors: Iin Fatimah, Arina Setyaningtyas, Ira Dharmawati, Abdul Latief Azis, Neurinda Permata Kusumastuti, Dwi Putri Lestari


Objective: To evaluate and to assess the correlation between the vasoactive-inotropic score (VIS) with mortality and the used of mechanical ventilation in pediatric shock.

Design: A retrospective cross-sectional study.

Setting: The study was conducted in the Pediatric Intensive Care Unit (PICU) at Dr. Soetomo General Hospital, Surabaya from November 1st, 2017 until April 30th, 2018.

Patients and participants: All children <18-year-old with shock who were admitted to the PICU.

Interventions: None.

Measurement and results: Eighty children with shock were admitted in PICU using minimal one vasoactive-inotropic treatment in the first 48 hours were included. Fifty-nine patients were eligible and met the inclusion criteria such as age <18-year-old, has one or more types of shock (hypovolemic shock, cardiogenic shock, obstructive shock, distributive shock), and received at least one vasoactive-inotropic drug £48 hours. We used Chi-square and Fisher’s Exact test and Receiver Operating Characteristic (ROC) curve analysis. The children consisted of 31 males (52.5%) and 28 females (47.5%). The median age was 36 ranging from 2-216 months. Fifty-four used mechanical ventilation. The mean of VIS was 10±6 and the mortality rate was 47.5%. The cut-off value of the ROC curve of VIS in relation to mortality was 6 with sensitivity 82.1% and specificity 64.5%. We divided our subjects into two groups based on the cut-off value of 6 as High VIS (>6) and Low VIS (≤6). The High VIS group consisted of 34 subjects, in which 68% of them died and 59% of them needed mechanical ventilation. VIS had a correlation with mortality (r=-0.472, p<0.001).

Conclusion: VIS had a moderately correlation with mortality, but had no correlation with the used of mechanical ventilation. Nevertheless, VIS may be a better screening tool for pediatric shock in our setting.

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