Complications of Critical COVID-19

Abstract

Patients admitted to the intensive care unit with critical COVID-19 often require prolonged periods of mechanical ventilation. Difficulty weaning, lack of progress, and clinical deterioration are commonly encountered. These conditions should prompt a thorough evaluation for persistent or untreated manifestations of COVID-19, as well as complications from COVID-19 and its various treatments. Inflammation may persist and lead to fibroproliferative changes in the lungs. Infectious complications may arise including bacterial superinfection in the earlier stages of disease. Use of immunosuppressants may lead to the dissemination of latent infections, and to opportunistic infections. Venous thromboembolic disease is common, as are certain neurologic manifestations of COVID-19 including delirium and stroke. High levels of ventilatory support may lead to ventilator-induced injury to the lungs and diaphragm. We present diagnostic and therapeutic considerations for the mechanically ventilated COVID-19 patient who shows persistent or worsening signs of critical illness, and we offer an approach to managing this complex but common scenario.

The association of COVID-19 severity and susceptibility and genetic risk factors: A systematic review of the literature

“…Fever, cough, myalgias, fatigue, and dyspnea are the most common symptoms seen in moderate to severe cases of COVID-19 ( Huang et al, 2020 ) . Critical COVID-19 cases are depicted by acute respiratory distress syndrome (ARDS) and extrapulmonary manifestations affecting the cardiovascular, renal, gastrointestinal, hepatobiliary, and central nervous system, arising in 15% of COVID-19 cases ( Cascella et al, 2022 , Maslove et al, 2021 , Yildirim et al, 2021 ). It takes around seven days for the patient to develop moderate to critical illness from symptom onset, receiving treatment only in the late phase of COVID-19 during hospitalization ( Giammaria and Pajewski, 2020 ).…”

Extracorporeal membrane oxygenation during the first three waves of the coronavirus disease 2019 pandemic: A retrospective single‐center registry study

“…From the onset of the pandemic, evidence was eagerly collected and rapidly reported, and guidelines were developed and continually revised to provide up‐to‐date evidence to clinicians at the bedside 18,19 . Although there are some unique features in COVID‐19, much of the experience with severe respiratory failure in COVID‐19 patients is not different from that with other forms of ARDS, and therefore similar recommendations apply to the treatment with ECMO as in non‐COVID‐19 ARDS 20,21 …”

Risk factors for mortality in severe COVID-19: Exploring the interplay of immunomodulatory therapy and coinfection

“…1 Although the spectrum of disease is broad, patients with severe disease present particular diagnostic and management challenges to clinicians, including identifying complications of the disease and initiating appropriate therapy in a timely manner. 2 Prognostic information is important to guide management decisions and to inform expectations. Immunomodulatory agents-in particular tocilizumab, sarilumab and baricitinib-form part of the backbone of therapy for severe COVID-19 and are known to have wide-reaching effects on the immune cascade, including the potential for development of opportunistic infections or dissemination of latent infections.…”

“…Immunomodulatory agents-in particular tocilizumab, sarilumab and baricitinib-form part of the backbone of therapy for severe COVID-19 and are known to have wide-reaching effects on the immune cascade, including the potential for development of opportunistic infections or dissemination of latent infections. 2 Meta-analysis 3 and randomised controlled trial data 4 have demonstrated overall reduced mortality in patients with COVID-19 receiving tocilizumab compared with placebo (odds ratio (OR) ¼ 0.86; 95% confidence interval (CI) 0.79-0.95; P ¼ 0.003 3 ; OR¼ 0.85; 95% CI 0Á76-0Á94; P ¼ 0.0028 4 ), although these data did not specifically examine intensive care unit (ICU) cohorts nor tease apart the impact of coinfections in these patients, which may enable more targeted diagnostic algorithms. Detailed data are urgently needed to elucidate the impact of bacterial and fungal coinfection on associated mortality risk in patients receiving immunomodulatory therapy for COVID-19.…”