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COVID-19 Complications and Critical Care: Lessons Learned and Challenges Ahead

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Intensive Care".

Deadline for manuscript submissions: closed (15 December 2021) | Viewed by 21141

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Dr. Francesco Pugliese

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Department of General Surgery and Organ Transplantation Unit, Sapienza University of Rome, Policlinico Umberto I, 00161 Rome, Italy
Interests: intensive care medicine; lung-kidney-liver transplants; ECMO; COVID-19
Special Issues, Collections and Topics in MDPI journals

Dr. Francesco Alessandri

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Department of General Surgery and Organ Transplantation Unit, Sapienza University of Rome, Policlinico Umberto I, 00161 Rome, Italy
Interests: intensive care medicine; ECCO2R; delirium; ultrasound; COVID-19; polytrauma
Special Issues, Collections and Topics in MDPI journals

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Dear Colleagues,

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is a new coronavirus that had never previously been identified in humans, before being reported in Wuhan, China, in December 2019. The extraordinary effort of intensivists, along with other specialists in virology, epidemiology, and infectious diseases, is associated with a complex reorganization of healthcare assistance in hospitals worldwide during the height of the pandemic, and the one in which we are still immersed. Hospitalization is required in about 15% of severe cases, and ICU admission is mandatory in around 5% of patients. These patients need considerable organ support. The management of critical patients with Coronavirus infectious disease 2019 (COVID-19) pneumonia during this pandemic has been the greatest challenge faced by ICU in all its history. Respiratory and hemodynamic support play a pivotal role in the management of critically ill COVID-19 patients: more than 75% of patients are affected by ARDS and 25% have shock and/or acute kidney injury. Invasive mechanical ventilation and vasopressor support are required in more than 60% of patients; renal replacement therapy occurs in one-fifth of patients, and more than 1 in 20 patients receive extracorporeal membrane oxygenation. This Special Issue intends to describe the streamlining of workflows for rapid diagnosis and isolation, clinical management, and infection prevention for COVID-19 patients, healthcare providers, and patients who are at risk from nosocomial transmission. Researchers must address unanswered questions, including the role of repurposed and experimental therapies.

Dr. Francesco Pugliese
Dr. Francesco Alessandri
Guest Editors

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Keywords

COVID-19
pandemic
management
therapies
perspectives

Published Papers (8 papers)

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11 pages, 263 KiB

Open AccessArticle

Perioperative Complications of Patients with SARS-CoV-2 Infection in Neurosurgery

by Ladina Greuter, Christian Zweifel, Raphael Guzman and Jehuda Soleman

J. Clin. Med. 2022, 11(3), 657; https://doi.org/10.3390/jcm11030657 - 27 Jan 2022

Cited by 3 | Viewed by 1445

Abstract

Background: The outbreak of coronavirus disease 2019 (COVID-19) has been rapidly evolving, resulting in a pandemic, with 270,031,622 infections according to the World Health Organization. Patients suffering from COVID-19 have also been described to suffer from neurologic and coagulopathic symptoms apart from the better-known flu-like symptoms. Some studies showed that patients suffering from COVID-19 were likely to developed intracranial hemorrhages. To our knowledge, only a few studies have investigated postoperative complications in COVID-19-positive neurosurgical patients and investigated the perioperative complications, either thrombotic or hemorrhagic, in patients with SARS-CoV-2 undergoing a neurosurgical intervention. Methods: We conducted a retrospective cohort study including patients from March 2020 to March 2021 undergoing neurosurgical interventions and suffering from COVID-19. Our primary outcome parameter was a hemorrhagic or thrombotic complication within 30 days after surgery. These outcomes were compared to those for a COVID-19-negative cohort of patients using propensity score matching. Results: We included ten COVID-19-positive patients with a mean age of 56.00 (±14.91) years. Twelve postoperative complications occurred in five patients. Three thrombotic complications (30%) were observed, with two cerebral sinus vein thromboses and one pulmonary embolus. Two patients suffered from a postoperative hemorrhagic complication (20%). The mean postoperative GCS was 14.30 (±1.57). COVID-19-positive patients showed a significantly higher rate of overall postoperative complications ((6 (60.0%) vs. 10 (19.2%), p = 0.021), thrombotic complications (3 (30.0%) vs. 1 (1.9%), p = 0.009), and mortality (2 (20.0%) vs. 0 (0.0%), p = 0.021) compared to the matched cohort of COVID-19-negative patients, treated at our institute before the SARS-CoV-2 pandemic. Conclusion: Patients undergoing neurosurgical operations with concomitant COVID-19 infection have higher rates of perioperative complications. Full article

(This article belongs to the Special Issue COVID-19 Complications and Critical Care: Lessons Learned and Challenges Ahead)

15 pages, 527 KiB

Open AccessArticle

Mortality Predictors in Severe COVID-19 Patients from an East European Tertiary Center: A Never-Ending Challenge for a No Happy Ending Pandemic

by Amalia-Stefana Timpau, Radu-Stefan Miftode, Antoniu Octavian Petris, Irina-Iuliana Costache, Ionela-Larisa Miftode, Florin Manuel Rosu, Dana-Teodora Anton-Paduraru, Daniela Leca and Egidia Gabriela Miftode

J. Clin. Med. 2022, 11(1), 58; https://doi.org/10.3390/jcm11010058 - 23 Dec 2021

Cited by 15 | Viewed by 3038

Abstract

(1) Background: There are limited clinical data in patients from the Eastern European regions hospitalized for a severe form of Coronavirus disease 2019 (COVID-19). This study aims to identify risk factors associated with intra-hospital mortality in patients with COVID-19 severe pneumonia admitted to a tertiary center in Iasi, Romania. (2) Methods: The study is of a unicentric retrospective observational type and includes 150 patients with severe COVID-19 pneumonia divided into two subgroups, survivors and non-survivors. Demographic and clinical parameters, as well as comorbidities, laboratory and imaging investigations upon admission, treatments, and evolution during hospitalization were recorded. First, we sought to identify the risk factors associated with intra-hospital mortality using logistic regression. Secondly, we assessed the correlations between D-Dimer and C-reactive protein and predictors of poor prognosis. (3) Results: The predictors of in-hospital mortality identified in the study are D-dimers >0.5 mg/L (p = 0.002), C-reactive protein >5 mg/L (p = 0.001), and heart rate above 100 beats per minute (p = 0.001). The biomarkers were also significantly correlated the need for mechanical ventilation, admission to intensive care unit, or multiple organ dysfunction syndrome. By area under the curve (AUC) analysis, we noticed that both D-Dimer (AUC 0.741) and C-reactive protein (AUC 0.707) exhibit adequate performance in predicting a poor prognosis in patients with severe viral infection. (4) Conclusions: COVID-19′s outcome is significantly influenced by several laboratory and clinical factors. As mortality induced by severe COVID-19 pneumonia is considerable, the identification of risk factors associated with negative outcome coupled with an early therapeutic approach are of paramount importance, as they may significantly improve the outcome and survival rates. Full article

(This article belongs to the Special Issue COVID-19 Complications and Critical Care: Lessons Learned and Challenges Ahead)

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12 pages, 1151 KiB

Open AccessArticle

Association of COVID-19 with Intracranial Hemorrhage during Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: A 10-Year Retrospective Observational Study

by Tobias Pantel, Kevin Roedl, Dominik Jarczak, Yuanyuan Yu, Daniel Peter Frings, Barbara Sensen, Hans Pinnschmidt, Alexander Bernhardt, Bastian Cheng, Iris Lettow, Manfred Westphal, Patrick Czorlich, Stefan Kluge and Marlene Fischer

J. Clin. Med. 2022, 11(1), 28; https://doi.org/10.3390/jcm11010028 - 22 Dec 2021

Cited by 9 | Viewed by 3578

Abstract

Extracorporeal membrane oxygenation (ECMO) is potentially lifesaving for patients with acute respiratory distress syndrome (ARDS) but may be accompanied by serious adverse events, including intracranial hemorrhage (ICRH). We hypothesized that ICRH occurs more frequently in patients with COVID-19 than in patients with ARDS of other etiologies. We performed a single-center retrospective analysis of adult patients treated with venovenous (vv-) ECMO for ARDS between January 2011 and April 2021. Patients were included if they had received a cranial computed tomography (cCT) scan during vv-ECMO support or within 72 h after ECMO removal. Cox regression analysis was used to identify factors associated with ICRH. During the study period, we identified 204 patients with vv-ECMO for ARDS, for whom a cCT scan was available. We observed ICRH in 35.4% (n = 17/48) of patients with COVID-19 and in 16.7% (n = 26/156) of patients with ARDS attributable to factors other than COVID-19. COVID-19 (HR: 2.945; 95%; CI: 1.079–8.038; p = 0.035) and carboxyhemoglobin (HR: 0.330; 95%; CI: 0.135–0.806; p = 0.015) were associated with ICRH during vv-ECMO. In patients receiving vv-ECMO, the incidence of ICRH is doubled in patients with COVID-19 compared to patients suffering from ARDS attributable to other causes. More studies on the association between COVID-19 and ICRH during vv-ECMO are urgently needed to identify risk patterns and targets for potential therapeutic interventions. Full article

(This article belongs to the Special Issue COVID-19 Complications and Critical Care: Lessons Learned and Challenges Ahead)

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12 pages, 943 KiB

Open AccessArticle

Factors Associated with 90-Day Mortality in Invasively Ventilated Patients with COVID-19 in Marseille, France

by Maxime Volff, David Tonon, Youri Bommel, Noémie Peres, David Lagier, Geoffray Agard, Alexis Jacquier, Axel Bartoli, Julien Carvelli, Howard Max, Pierre Simeone, Valery Blasco, Bruno Pastene, Anderson Loundou, Laurent Boyer, Marc Leone, Lionel Velly, Jeremy Bourenne, Salah Boussen, Mickaël Bobot and Nicolas Bruder Show full author list Hide full author list

J. Clin. Med. 2021, 10(23), 5650; https://doi.org/10.3390/jcm10235650 - 30 Nov 2021

Cited by 3 | Viewed by 2263

Abstract

Objectives: To describe clinical characteristics and management of intensive care units (ICU) patients with laboratory-confirmed COVID-19 and to determine 90-day mortality after ICU admission and associated risk factors. Methods: This observational retrospective study was conducted in six intensive care units (ICUs) in three university hospitals in Marseille, France. Between 10 March and 10 May 2020, all adult patients admitted in ICU with laboratory-confirmed SARS-CoV-2 and respiratory failure were eligible for inclusion. The statistical analysis was focused on the mechanically ventilated patients. The primary outcome was the 90-day mortality after ICU admission. Results: Included in the study were 172 patients with COVID-19 related respiratory failure, 117 of whom (67%) received invasive mechanical ventilation. 90-day mortality of the invasively ventilated patients was 27.4%. Median duration of ventilation and median length of stay in ICU for these patients were 20 (9–33) days and 29 (17–46) days. Mortality increased with the severity of ARDS at ICU admission. After multivariable analysis was carried out, risk factors associated with 90-day mortality were age, elevated Charlson comorbidity index, chronic statins intake and occurrence of an arterial thrombosis. Conclusion: In this cohort, age and number of comorbidities were the main predictors of mortality in invasively ventilated patients. The only modifiable factor associated with mortality in multivariate analysis was arterial thrombosis. Full article

(This article belongs to the Special Issue COVID-19 Complications and Critical Care: Lessons Learned and Challenges Ahead)

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12 pages, 1300 KiB

Open AccessArticle

Association between Early Absolute Neutrophil Count and Level of D-Dimer among Patients with COVID-19 Infection in Central Taiwan

by Wen-Cheng Chao, Chieh-Liang Wu, Jin-An Huang, Jyh-Wen Chai, Chieh-Lin Teng, Wen-Lieng Lee, Yun-Ching Fu and Shih-Ann Chen

J. Clin. Med. 2021, 10(17), 3891; https://doi.org/10.3390/jcm10173891 - 30 Aug 2021

Cited by 3 | Viewed by 1999

Abstract

Thromboembolism is a critical event in patients with coronavirus disease (COVID)-19 infection and highly associated with neutrophil extracellular traps. D-dimer has been found to be an essential thromboembolism-associated biomarker; however, the association between absolute neutrophil count (ANC) and level of D-dimer in patients with COVID-19 infection remains unclear. In this study, we enrolled consecutive patients with COVID-19 admitted to Taichung Veterans General Hospital (TCVGH), a referral center in central Taiwan with 20 airborne infection isolation rooms. Spearman correlation was used to determine the association between ANC and level of D-dimer in distinct time periods. A total of 28 consecutive patients with COVID-19 infection were enrolled, and 32.1% (9/28) of them required mechanical ventilation. Patients requiring mechanical ventilation had a higher ANC (8225 vs. 3427/µL, p < 0.01) and levels of D-dimer (6.0 vs. 0.6 mg/L, p < 0.01) compared with those without mechanical ventilation. Notably, we identified five patients with image-proven thromboembolic events during the hospital course, with the number of patients with pulmonary embolism, venous thrombosis and acute ischemic stroke were 2, 1, and 2, respectively. We found that ANC within 4 days correlated with the level of D-dimer to a moderate level (r = 0.71, p < 0.05), and the association between ANC and D-dimer no longer exist after day 5. In conclusion, we found highly prevalent thromboembolic events among patients with severe COVID-19 infection in central Taiwan and identified the association between early ANC and D-dimer. More studies are warranted to elucidate the underlying mechanism. Full article

(This article belongs to the Special Issue COVID-19 Complications and Critical Care: Lessons Learned and Challenges Ahead)

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14 pages, 1340 KiB

Open AccessArticle

Specific Risk Factors for Fatal Outcome in Critically Ill COVID-19 Patients: Results from a European Multicenter Study

by David Meintrup, Stefan Borgmann, Karlheinz Seidl, Melanie Stecher, Carolin E. M. Jakob, Lisa Pilgram, Christoph D. Spinner, Siegbert Rieg, Nora Isberner, Martin Hower, Maria Vehreschild, Siri Göpel, Frank Hanses and Martina Nowak-Machen

J. Clin. Med. 2021, 10(17), 3855; https://doi.org/10.3390/jcm10173855 - 27 Aug 2021

Cited by 13 | Viewed by 2067

Abstract

(1) Background: The aim of our study was to identify specific risk factors for fatal outcome in critically ill COVID-19 patients. (2) Methods: Our data set consisted of 840 patients enclosed in the LEOSS registry. Using lasso regression for variable selection, a multifactorial logistic regression model was fitted to the response variable survival. Specific risk factors and their odds ratios were derived. A nomogram was developed as a graphical representation of the model. (3) Results: 14 variables were identified as independent factors contributing to the risk of death for critically ill COVID-19 patients: age (OR 1.08, CI 1.06–1.10), cardiovascular disease (OR 1.64, CI 1.06–2.55), pulmonary disease (OR 1.87, CI 1.16–3.03), baseline Statin treatment (0.54, CI 0.33–0.87), oxygen saturation (unit = 1%, OR 0.94, CI 0.92–0.96), leukocytes (unit 1000/

μ

L, OR 1.04, CI 1.01–1.07), lymphocytes (unit 100/

μ

L, OR 0.96, CI 0.94–0.99), platelets (unit 100,000/

μ

L, OR 0.70, CI 0.62–0.80), procalcitonin (unit ng/mL, OR 1.11, CI 1.05–1.18), kidney failure (OR 1.68, CI 1.05–2.70), congestive heart failure (OR 2.62, CI 1.11–6.21), severe liver failure (OR 4.93, CI 1.94–12.52), and a quick SOFA score of 3 (OR 1.78, CI 1.14–2.78). The nomogram graphically displays the importance of these 14 factors for mortality. (4) Conclusions: There are risk factors that are specific to the subpopulation of critically ill COVID-19 patients. Full article

(This article belongs to the Special Issue COVID-19 Complications and Critical Care: Lessons Learned and Challenges Ahead)

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14 pages, 1250 KiB

Open AccessArticle

Prone Position in Mechanically Ventilated COVID-19 Patients: A Multicenter Study

by Richard Vollenberg, Philipp Matern, Tobias Nowacki, Valentin Fuhrmann, Jan-Sören Padberg, Kevin Ochs, Katharina Schütte-Nütgen, Markus Strauß, Hartmut Schmidt and Phil-Robin Tepasse

J. Clin. Med. 2021, 10(5), 1046; https://doi.org/10.3390/jcm10051046 - 03 Mar 2021

Cited by 17 | Viewed by 3533

Abstract

Background: The prone position (PP) is increasingly used in mechanically ventilated coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS) patients. However, studies investigating the influence of the PP are currently lacking in these patients. This is the first study to investigate the influence of the PP on the oxygenation and decarboxylation in COVID-19 patients. Methods: A prospective bicentric study design was used, and in mechanically ventilated COVID-19 patients, PP was indicated from a partial pressure of oxygen in arterial blood (P_aO2)/fraction of inspired oxygen (F_IO2) ratio of <200. Patients were left prone for 16 h each. Pressure levels, F_IO2, were adjusted to ensure a P_aO2 greater than 60 mmHg. Blood gas analyses were performed before (baseline 0.5 h), during (1/2/5.5/9.5/13 h), and after being in the PP (1 h), the circulatory/ventilation parameters were continuously monitored, and lung compliance (LC) was roughly calculated. Responders were defined compared to the baseline value (P_aO2/F_IO2 ratio increase of ≥15%; partial pressure of carbon dioxide (P_aCO2) decrease of ≥2%). Results: 13 patients were included and 36 PP sessions were conducted. Overall, P_aO2/F_IO2 increased significantly in the PP (p < 0.001). Most P_aO2/F_IO2 responders (29/36 PP sessions, 77%) were identified 9.5 h after turning prone (14% slow responders), while most P_aCO2 responders (15/36 PP sessions, 42%) were identified 13 h after turning prone. A subgroup of patients (interval intubation to PP ≥3 days) showed less P_aO2/F_IO2 responders (16% vs. 77%). An increase in P_aCO2 and minute ventilation in the PP showed a significant negative correlation (p < 0.001). LC (median before the PP = 38 mL/cm H₂O; two patients with LC >80 mL/cm H₂O) showed a significant positive correlation with the 28 day survival of patients (p = 0.01). Conclusion: The PP significantly improves oxygenation in COVID-19 ARDS patients. The data suggest that they also benefit most from an early PP. A decrease in minute ventilation may result in fewer P_aCO2 responders. LC may be a predictive outcome parameter in COVID-19 patients. Trial registration: Retrospectively registered. Full article

(This article belongs to the Special Issue COVID-19 Complications and Critical Care: Lessons Learned and Challenges Ahead)

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7 pages, 235 KiB

Open AccessBrief Report

Prone Positioning as a Potential Risk Factor for Deep Vein Thrombosis in COVID-19 Patients: A Hypothesis Generating Observation

by Caroline E. Gebhard, Núria Zellweger, Catherine Gebhard, Alexa Hollinger, Leon Chrobok, David Stähli, Christof M. Schönenberger, Atanas Todorov, Markus Aschwanden and Martin Siegemund

J. Clin. Med. 2022, 11(1), 103; https://doi.org/10.3390/jcm11010103 - 25 Dec 2021

Cited by 2 | Viewed by 2240

Abstract

Aims of the study: Virchow’s triad with stasis, activated coagulation, and endothelial damage is common in SARS-CoV2. Therefore, we sought to retrospectively assess whether the duration of prone position may serve as a risk factor for deep vein thrombosis in critically ill patients. Methods: In this single center retrospective study of a tertiary referral hospital, patients with acute respiratory distress syndrome (ARDS) due to COVID-19 pneumonia admitted to critical care underwent venous ultrasound screening for deep vein thrombosis (DVT). Data on DVT diagnosis, duration of prone positioning, demographic, respiratory, and laboratory parameters were retrospectively collected and compared between DVT and non-DVT patients. Results: 21 patients with ARDS from COVID-19 pneumonia were analyzed. DVT was detected in 11 (52%) patients (76.2% male, median age 64 (58; 68.5) years, median body mass index 31 (27; 33.8) kg/m²). In patients diagnosed with DVT, median prone ventilation had been maintained twice as long as compared to patients without DVT (57 (19; 72) versus 28 (0; 56.3) h, p = 0.227) on ICU day 5 with a trend towards longer prone position time (71 (19; 104) versus 28 (0; 73) h, p = 0.06) on ICU day 7. Conclusions: Prone ventilation and constitutional factors may constitute an additional risk factor for DVT in COVID-19 patients. Since recent studies have shown that therapeutic anticoagulation does not impact the occurrence of thromboembolic events, it may be worthwhile to consider mechanical factors potentially affecting blood flow stasis in this high-risk population. However, due to the limited number of patients, our observations should only be considered as hypothesis-generating. Future studies, sufficiently powered and preferably prospective, will be needed to confirm our hypothesis. Full article

(This article belongs to the Special Issue COVID-19 Complications and Critical Care: Lessons Learned and Challenges Ahead)

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