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Objective To assess the efficacy of therapeutic plasma exchange (TPE) following life-threatening COVID-19. Design, setting, and participants Open-label, randomized clinical trial of intensive care unit (ICU) patients with life-threatening COVID-19 [positive real-time-polymerase-chain-reaction test, plus acute respiratory distress syndrome (ARDS), sepsis, organ failure, hyperinflammation]. The study was terminated after 87/120 patients were enrolled. Intervention and randomization Standard treatment plus TPE (n = 43) versus standard treatment (n = 44), and stratified by peripheral arterial oxygen saturation/fraction of inspired oxygen (PaO 2 /FiO 2 ) ratio (> 150 versus ≤ 150). Main Outcomes and measures Primary outcomes were 35-day mortality and TPE safety. Secondary outcomes were association between TPE and mortality, improvement in Sequential Organ Function Assessment (SOFA) score, change in inflammatory biomarkers, days on mechanical ventilation (MV), and ICU length-of-stay. Results Eighty-seven patients [median years of age 49 (IQR: 34-63); 72 males (82.8%)] were randomized [44 to standard care; 43 to standard care plus TPE]. Days on MV (p=0.007) and ICU length-of-stay (p=0.02) were lower in the TPE group versus controls. Thirty-five-day mortality was lower in the TPE group (20.9% vs. 34.1% in controls), but this did not reach statistical significance [Kaplan-Meir analysis: p=0.582). TPE was associated with increased lymphocytes and ADAMTS-13 activity; plus decreased serum lactate, lactate dehydrogenase, ferritin, D-dimers, and interleukin-6. Multivariable regression analysis provided several predictors of 35-day mortality: PaO 2 /FiO 2 ratio [hazard ratio (HR): 0.98, 95% CI: 0.96-1.00, p=0.02], ADAMTS-13 activity (HR: 0.89, 95% CI: 0.82-0.98, p=0.01), and PE (HR: 3.57, 95% CI: 1.43-8.92, p=0.007). Post-hoc analysis revealed a significant reduction in SOFA score for TPE patients (p<0.05) compared to controls. Conclusion In critically ill COVID-19 patients the addition of TPE to standard ICU therapy was associated with faster clinical recovery and no increased 35-day mortality.

Background: Since the first COVID-19 patient in Saudi Arabia (March, 2020) more than 338,539 cases and approximately 4996 dead were reported. We present the main characteristics and outcomes of critically ill COVID-19 patients that were admitted in the largest Ministry of Health Intensive Care Unit (ICU) in Saudi Arabia. Methods: This retrospective study, analyzed routine epidemiologic, clinical, and laboratory data of COVID-19 critically ill patients in King Saud Medical City (KSMC), Riyadh, Saudi Arabia, between March 20, 2020 and May 31, 2020. Severe acute respiratory syndrome coronavirus-2 infection was confirmed by real-time reverse transcriptase polymerase chain reaction assays performed on nasopharyngeal swabs in all enrolled cases. Outcome measures such as 28-days mortality, duration of mechanical ventilation, and ICU length of stay were analyzed. Results: Three-hundred-and-fifty-two critically ill COVID-19 patients were included in the study. Patients had a mean age of 50.63 ± 13.3 years, 87.2% were males, and 49.4% were active smokers. Upon ICU admission, 56.8% of patients were mechanically ventilated with peripheral oxygen saturation/fraction of inspired oxygen (SpO 2 /FiO 2 ) ratio of 158 ± 32. No co-infections with other endemic viruses were observed. Duration of mechanical ventilation was 16 (IQR: 8–28) days; ICU length of stay was 18 (IQR: 9–29) days, and 28-day mortality was 32.1%. Multivariate regression analysis showed that old age [Odds Ratio (OR): 1.15, 95% Confidence Intervals (CI): 1.03–1.21], active smoking [OR: 3, 95% CI: 2.51–3.66], pulmonary embolism [OR: 2.91, 95% CI: 2.65–3.36), decreased SpO 2 /FiO 2 ratio [OR: 0.94, 95% CI: 0.91–0.97], and increased lactate [OR: 3.9, 95% CI: 2.4–4.9], and d -dimers [OR: 2.54, 95% CI: 1.57–3.12] were mortality predictors. Conclusion: Old age, active smoking, pulmonary embolism, decreased SpO 2 /FiO 2 ratio, and increased lactate and d -dimers were predictors of 28-day mortality in critically ill COVID-19 patients.

Objectives To perform a prospective longitudinal analysis of lung ultrasound findings in critically ill patients with coronavirus disease 2019 (COVID‐19). Methods Eighty‐nine intensive care unit (ICU) patients with confirmed COVID‐19 were prospectively enrolled and tracked. Point‐of‐care ultrasound (POCUS) examinations were performed with phased array, convex, and linear transducers using portable machines. The thorax was scanned in 12 lung areas: anterior, lateral, and posterior (superior/inferior) bilaterally. Lower limbs were scanned for deep venous thrombosis and chest computed tomographic angiography was performed to exclude suspected pulmonary embolism (PE). Follow‐up POCUS was performed weekly and before hospital discharge. Results Patients were predominantly male (84.2%), with a median age of 43 years. The median duration of mechanical ventilation was 17 (interquartile range, 10–22) days; the ICU length of stay was 22 (interquartile range, 20.2–25.2) days; and the 28‐day mortality rate was 28.1%. On ICU admission, POCUS detected bilateral irregular pleural lines (78.6%) with accompanying confluent and separate B‐lines (100%), variable consolidations (61.7%), and pleural and cardiac effusions (22.4% and 13.4%, respectively). These findings appeared to signify a late stage of COVID‐19 pneumonia. Deep venous thrombosis was identified in 16.8% of patients, whereas chest computed tomographic angiography confirmed PE in 24.7% of patients. Five to six weeks after ICU admission, follow‐up POCUS examinations detected significantly lower rates ( P < .05) of lung abnormalities in survivors. Conclusions Point‐of‐care ultrasound depicted B‐lines, pleural line irregularities, and variable consolidations. Lung ultrasound findings were significantly decreased by ICU discharge, suggesting persistent but slow resolution of at least some COVID‐19 lung lesions. Although POCUS identified deep venous thrombosis in less than 20% of patients at the bedside, nearly one‐fourth of all patients were found to have computed tomography–proven PE.

Aim To investigate continuous renal replacement therapy (CRRT) with CytoSorb ® cartridge for patients with life‐threatening COVID‐19 plus acute kidney injury (AKI), sepsis, acute respiratory distress syndrome (ARDS), and cytokine release syndrome (CRS). Patients and methods Of 492 COVID‐19 patients admitted to our intensive care unit (ICU), 50 had AKI necessitating CRRT (10.16%) and were enrolled in the study. Upon ICU admission, all had AKI, ARDS, septic shock, and CRS. In addition to CRRT with CytoSorb ® , all received ARDS‐net ventilation, prone positioning, plus empiric ribavirin, interferon beta‐1b, antibiotics, hydrocortisone, and prophylactic anticoagulation. We retrospectively analyzed inflammatory biomarkers, oxygenation, organ function, duration of mechanical ventilation, ICU length‐of‐stay, and mortality on day‐28 post‐ICU admission. Results Patients were 49.64 ±8.90 years old (78% male) with body mass index of 26.70±2.76 kg/m 2 . On ICU admission, mean Acute Physiology and Chronic Health Evaluation II, was 22.52±1.1. Sequential Organ Function Assessment (SOFA) score was 9.36±2.068 and the ratio of partial arterial pressure of oxygen to fractional inspired concentration of oxygen (PaO 2 /FiO 2 ) was 117.46±36.92. Duration of mechanical ventilation was 17.38±7.39 days, ICU length‐of‐stay was 20.70±8.83 days, and mortality 28 days post‐ICU admission was 30%. Non‐survivors had higher levels of inflammatory biomarkers, and more unresolved shock, ARDS, AKI, and pulmonary emboli (8% vs. 4 %, p<0.05) compared to survivors. After 2±1 CRRT sessions with CytoSorb ® , survivors had decreased SOFA scores, lactate dehydrogenase, ferritin, D‐dimers, C‐reactive protein, and interleukin‐6; and increased PaO 2 /FiO 2 ratios, and lymphocyte counts (all p<0.05). Receiver‐operator‐curve analysis showed that post therapy values of interleukin‐6 (cutoff point > 620 pg/ml) predicted in‐hospital mortality for critically ill COVID‐19 patients (area‐under‐the‐curve: 0.87, 95% confidence‐intervals: 0.81‐0.93; p=0.001). No side effects of therapy were recorded. Conclusion In this retrospective case‐series, CRRT with the CytoSorb ® cartridge provided a safe rescue therapy in life‐threatening COVID‐19 with associated AKI, ARDS, sepsis, and hyperinflammation.