Risks of ventilator-associated pneumonia and invasive pulmonary aspergillosis in patients with viral acute respiratory distress syndrome related or not to Coronavirus 19 disease

 

Risks of ventilator-associated pneumonia and invasive pulmonary aspergillosis in patients with viral acute respiratory distress syndrome related or not to Coronavirus 19 disease

 

by Keyvan Razazi, Romain Arrestier, Anne Fleur Haudebourg, Brice Benelli, Guillaume Carteaux, Jean‑Winoc Decousser, Slim Fourati, Paul Louis Woerther, Frederic Schlemmer, Anais Charles-Nelson, Francoise Botterel, Nicolas de Prost and Armand Mekontso Dessap

 

Critical Care volume 24, Article number: 699 (2020) Published: 18 December 2020

 

Background

Data on incidence of ventilator-associated pneumonia (VAP) and invasive pulmonary aspergillosis in patients with severe SARS-CoV-2 infection are limited.

Methods

We conducted a monocenter retrospective study comparing the incidence of VAP and invasive aspergillosis between patients with COVID-19-related acute respiratory distress syndrome (C-ARDS) and those with non-SARS-CoV-2 viral ARDS (NC-ARDS).

Results

We assessed 90 C-ARDS and 82 NC-ARDS patients, who were mechanically ventilated for more than 48 h. At ICU admission, there were significantly fewer bacterial coinfections documented in C-ARDS than in NC-ARDS: 14 (16%) vs 38 (48%), p < 0.01. Conversely, significantly more patients developed at least one VAP episode in C-ARDS as compared with NC-ARDS: 58 (64%) vs. 36 (44%), p = 0.007. The probability of VAP was significantly higher in C-ARDS after adjusting on death and ventilator weaning [sub-hazard ratio = 1.72 (1.14–2.52), p < 0.01]. The incidence of multi-drug-resistant bacteria (MDR)-related VAP was significantly higher in C-ARDS than in NC-ARDS: 21 (23%) vs. 9 (11%), p = 0.03. Carbapenem was more used in C-ARDS than in NC-ARDS: 48 (53%), vs 21 (26%), p < 0.01. According to AspICU algorithm, there were fewer cases of putative aspergillosis in C-ARDS than in NC-ARDS [2 (2%) vs. 12 (15%), p = 0.003], but there was no difference in Aspergillus colonization.

Conclusions

In our experience, we evidenced a higher incidence of VAP and MDR-VAP in C-ARDS than in NC-ARDS and a lower risk for invasive aspergillosis in the former group.

Resuscitation fluid types in sepsis, surgical, and trauma patients: a systematic review and sequential network meta-analyses

 

Resuscitation fluid types in sepsis, surgical, and trauma patients: a systematic review and sequential network meta-analyses

 

by Chien-Hua Tseng, Tzu-Tao Chen, Mei-Yi Wu, Ming-Cheng Chan, Ming-Chieh Shih and Yu-Kang Tu 

Critical Care volume 24, Article number: 693 (2020) Published: 14 December 2020

Background

Crystalloids and different component colloids, used for volume resuscitation, are sometimes associated with various adverse effects. Clinical trial findings for such fluid types in different patients’ conditions are conflicting. Whether the mortality benefit of balanced crystalloid than saline can be inferred from sepsis to other patient group is uncertain, and adverse effect profile is not comprehensive. This study aims to compare the survival benefits and adverse effects of seven fluid types with network meta-analysis in sepsis, surgical, trauma, and traumatic brain injury patients.

Methods

Searched databases (PubMed, EMBASE, and Cochrane CENTRAL) and reference lists of relevant articles occurred from inception until January 2020. Studies on critically ill adults requiring fluid resuscitation were included. Intervention studies reported on balanced crystalloid, saline, iso-oncotic albumin, hyperoncotic albumin, low molecular weight hydroxyethyl starch (L-HES), high molecular weight HES, and gelatin. Network meta-analyses were conducted using random-effects model to calculate odds ratio (OR) and mean difference. Risk of Bias tool 2.0 was used to assess bias. Confidence in Network Meta-Analysis (CINeMA) web application was used to rate confidence in synthetic evidence.

Results

Fifty-eight trials (n = 26,351 patients) were identified. Seven fluid types were evaluated. Among patients with sepsis and surgery, balanced crystalloids and albumin achieved better survival, fewer acute kidney injury, and smaller blood transfusion volumes than saline and L-HES. In those with sepsis, balanced crystalloids significantly reduced mortality more than saline (OR 0.84; 95% CI 0.74–0.95) and L-HES (OR 0.81; 95% CI 0.69–0.95) and reduced acute kidney injury more than L-HES (OR 0.80; 95% CI 0.65–0.99). However, they required the greatest resuscitation volume among all fluid types, especially in trauma patients. In patients with traumatic brain injury, saline and L-HES achieved lower mortality than albumin and balanced crystalloids; especially saline was significantly superior to iso-oncotic albumin (OR 0.55; 95% CI 0.35–0.87).

Conclusions

Our network meta-analysis found that balanced crystalloids and albumin decreased mortality more than L-HES and saline in sepsis patients; however, saline or L-HES was better than iso-oncotic albumin or balanced crystalloids in traumatic brain injury patients.

Protracted viral shedding and viral load are associated with ICU mortality in Covid-19 patients with acute respiratory failure

 

Protracted viral shedding and viral load are associated with ICU mortality in Covid-19 patients with acute respiratory failure

 

by L. Bitker, F. Dhelft, L. Chauvelot, E. Frobert, L. Folliet, M. Mezidi, S. Trouillet-Assant, A. Belot, B. Lina, F. Wallet and J. C. Richard

 

Annals of Intensive Care volume 10, Article number: 167 (2020) Published: 10 December 2020

Background

Protracted viral shedding is common in hospitalized patients with COVID-19 pneumonia, and up to 40% display signs of pulmonary fibrosis on computed tomography (CT) after hospital discharge. We hypothesized that COVID-19 patients with acute respiratory failure (ARF) who die in intensive care units (ICU) have a lower viral clearance in the respiratory tract than ICU patients discharged alive, and that protracted viral shedding in respiratory samples is associated with patterns of fibroproliferation on lung CT. We, therefore, conducted a retrospective observational study, in 2 ICU of Lyon university hospital.

Results

129 patients were included in the study, of whom 44 (34%) died in ICU. 432 RT-PCR for SARS-CoV-2 were performed and 137 CT scans were analyzed. Viral load was significantly higher in patients deceased as compared to patients alive at ICU discharge (p < 0.001), after adjustment for the site of viral sampling and RT-PCR technique. The median time to SARS-CoV-2 negativation on RT-PCR was 19 days [CI95 %:15–21] in patients alive at ICU discharge and 26 days [CI95 %:17-infinity] in non-survivors at ICU discharge. Competitive risk regression identified patients who died in ICU and age as independent risk factors for longer time to SARS-CoV-2 negativation on RT-PCR, while antiviral treatment was independently associated with shorter time. None of the CT scores exploring fibroproliferation (i.e., bronchiectasis and reticulation scores) were significantly associated with time to SARS-CoV-2 negativation.

Conclusions

Viral load in respiratory samples is significantly lower and viral shedding significantly shorter in ICU survivors of COVID-19 associated acute respiratory failure. Protracted viral shedding is unrelated to occurrence of fibrosis on lung CT.

Sepsis and Coronavirus Disease 2019: Common Features and Anti-Inflammatory Therapeutic Approaches

 

Sepsis and Coronavirus Disease 2019: Common Features and Anti-Inflammatory Therapeutic Approaches

 

by Beltrán-García, Jesús; Osca-Verdegal, Rebeca; Pallardó, Federico V.; Ferreres, José; Rodríguez, María; Mulet, Sandra; Ferrando-Sánchez, Carolina; Carbonell, Nieves; García-Giménez, José Luis

 

Critical Care Medicine: December 2020 - Volume 48 - Issue 12 - p 1841-1844

 

Great efforts are being made worldwide to identify the specific clinical characteristics of infected critically ill patients that mediate the associated pathogenesis, including vascular dysfunction, thrombosis, dysregulated inflammation, and respiratory complications. Recently, coronavirus disease 2019 has been closely related to sepsis, which suggests that most deaths in ICUs in infected patients are produced by viral sepsis. Understanding the physiopathology of the disease that lead to sepsis after severe acute respiratory syndrome coronavirus 2 infection is a current clinical need to improve intensive care–applied therapies applied to critically ill patients. Although the whole representative data characterizing the immune and inflammatory status in coronavirus disease 2019 patients are not completely known, it is clear that hyperinflammation and coagulopathy contribute to disease severity. Here, we present some common features shared by severe coronavirus disease 2019 patients and sepsis and describe proposed anti-inflammatory therapies for coronavirus disease 2019 which have been previously evaluated in sepsis.

The Use of Central Venous to Arterial Carbon Dioxide Tension Gap for Outcome Prediction in Critically Ill Patients: A Systematic Review and Meta-Analysis*

 

The Use of Central Venous to Arterial Carbon Dioxide Tension Gap for Outcome Prediction in Critically Ill Patients: A Systematic Review and Meta-Analysis*

 

by Al Duhailib, Zainab; Hegazy, Ahmed F.; Lalli, Raj; Fiorini, Kyle; Priestap, Fran; Iansavichene, Alla; Slessarev, Marat

 

Critical Care Medicine: December 2020 - Volume 48 - Issue 12 - p 1855-1861

Objectives: 

In this systematic review and meta-analysis, we assessed whether a high Co2 gap predicts mortality in adult critically ill patients with circulatory shock.

Data Sources: 

A systematic search of MEDLINE and EMBASE electronic databases from inception to October 2019.

Study Selection: 

Studies from adult (age ≥ 18 yr) ICU patients with shock reporting Co2 gap and outcomes of interest. Case reports and conference abstracts were excluded.

Data Extraction: 

Data extraction and study quality assessment were performed independently in duplicate.

Data Synthesis: 

We used the Newcastle-Ottawa Scale to assess methodological study quality. Effect sizes were pooled using a random-effects model. The primary outcome was mortality (28 d and hospital). Secondary outcomes were ICU length of stay, hospital length of stay, duration of mechanical ventilation, use of renal replacement therapy, use of vasopressors and inotropes, and association with cardiac index, lactate, and central venous oxygen saturation.

Conclusions: 

We included 21 studies (n = 2,155 patients) from medical (n = 925), cardiovascular (n = 685), surgical (n = 483), and mixed (n = 62) ICUs. A high Co2 gap was associated with increased mortality (odds ratio, 2.22; 95% CI, 1.30–3.82; p = 0.004) in patients with shock, but only those from medical and surgical ICUs. A high Co2 gap was associated with higher lactate levels (mean difference 0.44 mmol/L; 95% CI, 0.20–0.68 mmol/L; p = 0.0004), lower cardiac index (mean difference, –0.76 L/min/m2; 95% CI, –1.04 to –0.49 L/min/m2; p = 0.00001), and central venous oxygen saturation (mean difference, –5.07; 95% CI, –7.78 to –2.37; p = 0.0002). A high Co2 gap was not associated with longer ICU or hospital length of stays, requirement for renal replacement therapy, longer duration of mechanical ventilation, or higher vasopressors and inotropes use. Future studies should evaluate whether resuscitation aimed at closing the Co2 gap improves mortality in shock.

Percutaneous right ventricular assist device, rapid employment in right ventricular failure during septic shock

 

Percutaneous right ventricular assist device, rapid employment in right ventricular failure during septic shock

 

by Ignazio Condello 

 

Critical Care volume 24, Article number: 674 (2020) Published: 02 December 2020

 

 

Right ventricular (RV) failure, defined by critical care echocardiography Right Ventricular dilatation) and a surrogate of venous congestion (Central Venous Pressure ≥ 8 mmHg), was frequently observed in septic shock patients and negatively associated with response to a fluid challenge despite significant pulse pressure variation (PPV). Right Heart Failure with invasive ventricular device is associated with significant morbidity and mortality. A new generation of percutaneous right ventricular assist devices (RVADs) may mitigate the need for invasive surgical RVAD implantation. The Protek Duo (TPD) temporary RVAD, capable of providing up to 4.5 L/min, is a dual-lumen cannula inserted via the right internal jugular vein, with its proximal inflow lumen positioned in the right atrium and distal lumen positioned in the main pulmonary artery…

The future of AI in critical care is augmented, not artificial, intelligence

 

The future of AI in critical care is augmented, not artificial, intelligence

by Vincent X. Liu 

 

Critical Care volume 24, Article number: 673 (2020) Published: 02 December 2020

 

The field of AI—artificial intelligence—has seen tremendous success over the past decade. Today, AI touches billions of lives each day through voice and text processing, computer vision, prediction algorithms, video games, and much more. Naturally, there has also been enormous interest in applying AI to health care and, in particular, to data-rich environments like the intensive care unit. Early examples of AI in healthcare and critical care have already shown great promise [1], but also raise concerns that can be mitigated with preparation and foresight [2,3,4].

Recently, I put my own life into the hands of AI: it nearly killed me and, later, it also saved me. This harrowing experience was a potent reminder for me, an AI practitioner, that we must work to ensure this technology’s formidable capabilities are used to produce ‘augmented’, rather than just ‘artificial’, intelligence. Augmented intelligence places clinicians and ultimately patients, rather than algorithms, at its center. Where we successfully bridge the interface of clinician and machine intelligence, we have vast potential to make healthcare more effective, efficient, and sustainable. This will also ensure that health AI is safe, reliable, and equitable for all patients.

Plasma Exchange: An Effective Rescue Therapy in Critically Ill Patients With Coronavirus Disease 2019 Infection

 

Plasma Exchange: An Effective Rescue Therapy in Critically Ill Patients With Coronavirus Disease 2019 Infection

 

by Fernandez, Javier; Gratacos-Ginès, Jordi; Olivas, Pol; Costa, Montserrat; Nieto, Susana; Mateo, Dolors; Sánchez, María Belén; Aguilar, Ferran; Bassegoda, Octavi; Ruiz, Pablo; Caballol, Berta; Pocurull, Anna; Llach, Joan; Mustieles, María Jesús; Cid, Joan; Reverter, Enric; Toapanta, Nestor David; Hernández-Tejero, María; Martínez, José Antonio; Claria, Joan; Fernández, Carlos; Mensa, José; Arroyo, Vicente; Castro, Pedro; Lozano, Miquel; for the Covid Clinic Critical Care (CCCC) Group

 

Objectives: 

Infection by severe acute respiratory syndrome coronavirus-2 can induce uncontrolled systemic inflammation and multiple organ failure. The aim of this study was to evaluate if plasma exchange, through the removal of circulating mediators, can be used as rescue therapy in these patients.

Design: 

Single center case series.

Setting: 

Local study.

Subjects: 

Four critically ill adults with coronavirus disease 19 pneumonia that failed conventional interventions.

Interventions: 

Plasma exchange. Two to six sessions (1.2 plasma volumes). Human albumin (5%) was used as the main replacement fluid. Fresh frozen plasma and immunoglobulins were administered after each session to avoid coagulopathy and hypogammaglobulinemia.

Measurements and Main Results: 

Serum markers of inflammation and macrophage activation. All patients showed a dramatic reduction in inflammatory markers, including the main cytokines, and improved severity scores after plasma exchange. All survived to ICU admission.

Conclusions: 

Plasma exchange mitigates cytokine storm, reverses organ failure, and could improve survival in critically ill patients with coronavirus disease 2019 infection.

Right ventricular-arterial uncoupling independently predicts survival in COVID-19 ARDS

 

Right ventricular-arterial uncoupling independently predicts survival in COVID-19 ARDS

 

by Michele D’Alto, Alberto M. Marra, Sergio Severino, Andrea Salzano, Emanuele Romeo, Rosanna De Rosa, Francesca Maria Stagnaro, Gianpiero Pagnano, Raffaele Verde, Patrizia Murino, Andrea Farro, Giovanni Ciccarelli, Maria Vargas, Giuseppe Fiorentino, Giuseppe Servillo, Ivan Gentile

 

Aim

To investigate the prevalence and prognostic impact of right heart failure and right ventricular-arterial uncoupling in Corona Virus Infectious Disease 2019 (COVID-19) complicated by an Acute Respiratory Distress Syndrome (ARDS).

Methods

Ninety-four consecutive patients (mean age 64 years) admitted for acute respiratory failure on COVID-19 were enrolled. Coupling of right ventricular function to the pulmonary circulation was evaluated by a comprehensive trans-thoracic echocardiography with focus on the tricuspid annular plane systolic excursion (TAPSE) to systolic pulmonary artery pressure (PASP) ratio

Results

The majority of patients needed ventilatory support, which was noninvasive in 22 and invasive in 37. There were 25 deaths, all in the invasively ventilated patients. Survivors were younger (62 ± 13 vs. 68 ± 12 years, p = 0.033), less often overweight or usual smokers, had lower NT-proBNP and interleukin-6, and higher arterial partial pressure of oxygen (PaO2)/fraction of inspired O2 (FIO2) ratio (270 ± 104 vs. 117 ± 57 mmHg, p < 0.001). In the non-survivors, PASP was increased (42 ± 12 vs. 30 ± 7 mmHg, p < 0.001), while TAPSE was decreased (19 ± 4 vs. 25 ± 4 mm, p < 0.001). Accordingly, the TAPSE/PASP ratio was lower than in the survivors (0.51 ± 0.22 vs. 0.89 ± 0.29 mm/mmHg, p < 0.001). At univariate/multivariable analysis, the TAPSE/PASP (HR: 0.026; 95%CI 0.01–0.579; p: 0.019) and PaO2/FIO2 (HR: 0.988; 95%CI 0.988–0.998; p: 0.018) ratios were the only independent predictors of mortality, with ROC-determined cutoff values of 159 mmHg and 0.635 mm/mmHg, respectively.

Conclusions

COVID-19 ARDS is associated with clinically relevant uncoupling of right ventricular function from the pulmonary circulation; bedside echocardiography of TAPSE/PASP adds to the prognostic relevance of PaO2/FIO2 in ARDS on COVID-19.