Intensive care for seriously ill patients affected by novel coronavirus sars - CoV – 2: Experience of the Crema Hospital, Italy

Abstract

Aims In this work, the survival and mortality data of 54 consecutive patients admitted to the Intensive Care Unit (ICU) and suffering from severe respiratory insufficiency imputable to viral SARS - CoV - 2 infection were analyzed and shared, after a critical review of the evidence in order to optimize the most dedicated clinical and treatment strategy, for a future ‘targeted’ management in the care of the possible return flu outbreak. Methods At our Emergency Department of the Crema Hospital, from the beginning of the pandemic until the end of June 2020, 54 consecutive patients admitted to ICU suffering from severe acute respiratory infection (SARI) and severe respiratory distress (ARDS) attributable to viral SARS - CoV - 2 infection were recruited. The recruitment criterion was based on refractory hypoxia, general condition and clinical impairment, comorbidities and CT images. The incoming parameters of the blood chemistry and radiology investigations and the timing of the gold - tracheal intubation were compared. Medical therapy was based on the application of shared protocols. Results The onset of symptoms was varyng, i.e. within the range of 1–14 days. The average time from the admission to the emergency room to the admission to intensive care was approximately 120 h. The average number of days of hospitalization in the ICU was 28 days. With a majority of male patients, the most significant age group was between 60 and 69 years. There were 21 deaths and, compared to the survivors, the deceased ones were older at an average age of about 67 years (vs an average age of the survivors of about 59 years). From the available data entering the ICU, the surviving patients presented average better values of oximetry and blood gas analysis, with a lower average dosage of D-Dimer than the deceased. Ones with a presence of bilateral pneumonia in all patients, the worsening of the ARDS occurred in 31 patients. 9 out of 25 patients early intubated died, while 12 out of 23 patients died when intubation was performed after 24 h of non-invasive ventilation. The presence of multiple comorbidities was shown in 17 of 28 patients and revealed an additional adverse prognostic factor. Also, more than one complication in the same patient were detected; after respiratory worsening, renal failure was more frequently found in 16 patients. Some particular complications such as lesions induced by ventilation with barotrauma mechanism (VILI), ischemic heart disease and the appearance of central and peripheral neurological events were detected too. Considerations SARS - CoV - 2 disease is caused by a new coronavirus that has its main route of transmission through respiratory droplets and close contact, resulting in a sudden onset of the clinical syndrome with acute respiratory infection (SARI) and severe respiratory distress (ARDS). But it can also appear with other symptoms such as gastrointestinal or neurological events, as to be consi...

Effect of timing of intubation on clinical outcomes of critically ill patients with COVID-19: a systematic review and meta-analysis of non-randomized cohort studies

“…Figure 1 shows the flow diagram for study selection. A total of 12 studies [13,14,[18][19][20][21][22][23][24][25][26][27] from Africa, Asia, Europe and America, involving 8944 critically ill patients (7639 early, 1305 late) with COVID-19, were incorporated in our meta-analysis. Table 1 and Additional file 1: Supplementary Table 2 summarize the characteristics and risk of bias assessment of the included studies, respectively.…”

“…Pooled risk ratio (RR) and 95% confidence intervals (CI) were calculated using a random effects model. The authors of two [13,19] of the studies included in this analysis considered a trial of NIV lasting less than 24 h as inconsequential long as possible. This should be taken into consideration when interpreting the results presented in Fig.…”

“…This was also the case for the analysis after excluding two studies [24,26] which used a time threshold other than 24 h from ICU admission for defining early/late intubation; i.e., there was no statistically detectable difference between compared groups regarding allcause mortality (10 studies [13, 14, 18-23, 25, 27]; 3870 deaths; 45.2% versus 38.1%; RR 1.06, 95% CI 0.99-1.15, p = 0.11, I 2 = 0%). Finally, in the sensitivity analysis using an alternate definition of early/late intubation, there was no statistically detectable difference on all-cause mortality between patients undergoing intubation without versus with a prior trial of HFNC/NIV (eight studies [13,14,18,19,22,24,25,27], 1128 deaths; 48.9% versus 42.5%; RR 1.11, 95% CI 0.99-1.25, p = 0.08, I 2 = 0%; Fig. 4).…”

“…All 12 studies [13,14,[18][19][20][21][22][23][24][25][26][27] provided data on all-cause mortality. No statistical heterogeneity was detected (I 2 = 0%).…”

Outcomes of Barotrauma in Critically Ill COVID-19 Patients With Severe Pneumonia

“… 3 , 4 , 6 , 7 The reported incidence of barotrauma in patients with COVID-19 is between 1% to 40%, and there is uncertainty regarding its influence on mortality. 8 – 17 …”