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Intensive Care Management of COVID-19 Patients

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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 (23 February 2024) | Viewed by 5979

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Dr. Maddalena Alesssandra Wu

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Division of Internal Medicine, ASST Fatebenefratelli Sacco, Department of Biomedical and Clinical Sciences “L. Sacco”, University of Milan, Milan, Italy
Interests: COVID-19; endothelium; paroxysmal permeability disorders; idiopathic systemic capillary leak syndrome; venous thromboembolism; angioedema; autonomic nervous system; myocarditis and pericarditis; hypertension

Dr. Riccardo Colombo

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Division of Anesthesiology and Intensive Care, ASST Fatebenefratelli-Sacco, Luigi Sacco Hospital, 20157 Milan, Italy
Interests: idiopathic systemic capillary leak syndrome; autonomic nervous system; septic shock; extracorporeal circulatory support; extracorporeal cytokine removal
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Dear Colleagues,

Since the first wave of the Coronavirus disease (COVID-19) pandemic, we realized that we were coping with a challenging clinical entity, characterized by a wide variety of clinical manifestations and potential multisystem involvement due to a complex interplay of many pathophysiological mechanisms, such as uncontrolled activation of inflammatory and immune pathways (with the so-called “cytokine storm”), alterations of the balance between pro- and anti-coagulant factors (with a peculiar coagulopathy), oxidative stress and endothelial dysfunction. Over the course of these two years, our knowledge of COVID-19 has been markedly expanded thanks to the efforts of multidisciplinary research teams worldwide, and the management of the disease has radically changed due to the availability of vaccines, as well as data on the usefulness/correct regimen of both “old” drugs (e.g., corticosteroids, anticoagulants) and “new” drugs (antivirals, monoclonal antibodies, Janus kinase inhibitors). Besides pharmacological therapies, other types of organ support, above all the most appropriate ventilation strategy, have been topics of lively discussions in the scientific community. Even when sharing some guidelines on the most appropriate management of COVID-19, some crucial points are still a matter of debate, as risk stratification, individualized assessment of each patient and the correct timing for administration of each specific treatment.

This Special Issue aims to provide stimulating insights into what we have learnt since the onset of the COVID-19 pandemic, new inputs on pathophysiological mechanisms as well as practical recommendations for the intensive care management of COVID-19 patients. Moreover, it will highlight the current gaps in evidence and future perspectives.

Dr. Maddalena Alesssandra Wu
Dr. Riccardo Colombo
Guest Editors

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Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Journal of Clinical Medicine is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2600 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

COVID-19
intensive care
management
pathophysiology
thrombosis
inflammation
therapy
ventilation
extracorporeal cytokine removal

Published Papers (6 papers)

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13 pages, 2511 KiB

Open AccessArticle

Autonomic Function and Baroreflex Control in COVID-19 Patients Admitted to the Intensive Care Unit

by Francesca Gelpi, Maddalena Alessandra Wu, Vlasta Bari, Beatrice Cairo, Beatrice De Maria, Tommaso Fossali, Riccardo Colombo and Alberto Porta

J. Clin. Med. 2024, 13(8), 2228; https://doi.org/10.3390/jcm13082228 - 12 Apr 2024

Viewed by 444

Abstract

Background: Autonomic function and baroreflex control might influence the survival rate of coronavirus disease 2019 (COVID-19) patients admitted to the intensive care unit (ICU) compared to respiratory failure patients without COVID-19 (non-COVID-19). This study describes physiological control mechanisms in critically ill COVID-19 patients admitted to the ICU in comparison to non-COVID-19 individuals with the aim of improving stratification of mortality risk. Methods: We evaluated autonomic and baroreflex control markers extracted from heart period (HP) and systolic arterial pressure (SAP) variability acquired at rest in the supine position (REST) and during a modified head-up tilt (MHUT) in 17 COVID-19 patients (age: 63 ± 10 years, 14 men) and 33 non-COVID-19 patients (age: 60 ± 12 years, 23 men) during their ICU stays. Patients were categorized as survivors (SURVs) or non-survivors (non-SURVs). Results: We found that COVID-19 and non-COVID-19 populations exhibited similar vagal and sympathetic control markers; however, non-COVID-19 individuals featured a smaller baroreflex sensitivity and an unexpected reduction in the HP-SAP association during the MHUT compared to the COVID-19 group. Nevertheless, none of the markers of the autonomic and baroreflex functions could distinguish SURVs from non-SURVs in either population. Conclusions: We concluded that COVID-19 patients exhibited a more preserved baroreflex control compared to non-COVID-19 individuals, even though this information is ineffective in stratifying mortality risk. Full article

(This article belongs to the Special Issue Intensive Care Management of COVID-19 Patients)

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12 pages, 9704 KiB

Open AccessArticle

Venous Thromboembolism Management throughout the COVID-19 Era: Addressing Acute and Long-Term Challenges

by Maddalena Alessandra Wu, Alba Taino, Pietro Facchinetti, Valentina Rossi, Diego Ruggiero, Silvia Berra, Giulia Blanda, Nicola Flor, Chiara Cogliati and Riccardo Colombo

J. Clin. Med. 2024, 13(6), 1825; https://doi.org/10.3390/jcm13061825 - 21 Mar 2024

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Background: COVID-19 increases the risk of venous thromboembolism (VTE) through a complex interplay of mechanisms collectively referred to as immunothrombosis. Limited data exist on VTE challenges in the acute setting throughout a dynamic long-term follow-up of COVID-19 patients compared to non-COVID-19 patients. The aim of the study was to investigate acute and long-term management and complications in VTE patients with and without COVID-19. Methods: A prospective, observational, single-center cohort study on VTE patients followed from the acute care stage until 24 months post-diagnosis. Results: 157 patients, 30 with COVID-19-associated VTE and 127 unrelated to COVID-19, were enrolled. The mean follow-up was 10.8 (±8.9) months. COVID-19 patients had fewer comorbidities (1.3 ± 1.29 vs. 2.26 ± 1.68, p < 0.001), a higher proportion of pulmonary embolism at baseline (96.7% vs. 76.4%, p = 0.01), and had a lower probability of remaining on anticoagulant therapy after three months (p < 0.003). The most used initial therapy was low-molecular-weight heparin in 130/157 cases, followed by long-term treatment with direct oral anticoagulants in 123/157. Two (6.7%) COVID-19 vs. three (2.4%) non-COVID-19 patients (p = 0.243) had major hemorrhagic events, all of them within the first three months. Four (3.1%) non-COVID-19 patients had VTE recurrence after six months. Three (2.4%) non-COVID-19 patients developed chronic thromboembolic pulmonary hypertension. There were no fatalities among patients with COVID-19, compared to a mortality of 12/127 (9.4%) in the non-COVID-19 subgroup (p = 0.027). Discussion: Our study offers a comprehensive overview of the evolving nature of VTE management, emphasizing the importance of personalized risk-based approaches, including a limited course of anticoagulation for most COVID-19-associated VTE cases and reduced-dose extended therapy for high-risk subsets. Full article

(This article belongs to the Special Issue Intensive Care Management of COVID-19 Patients)

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11 pages, 2339 KiB

Open AccessArticle

Kinetics of C-Reactive Protein and Procalcitonin in the Early Identification of ICU-Acquired Infections in Critically Ill COVID-19 Patients

by José Pedro Cidade, Luís Coelho and Pedro Póvoa

J. Clin. Med. 2023, 12(19), 6110; https://doi.org/10.3390/jcm12196110 - 22 Sep 2023

Cited by 1 | Viewed by 850

Abstract

The SARS-CoV-2 infection is a cause of hypoxemic acute respiratory failure, leading to frequent intensive care unit (ICU) admission. Due to invasive organ support and immunosuppressive therapies, these patients are prone to nosocomial infections. Our aim was to assess the value of daily measurements of C-reactive protein (CRP) and Procalcitonin (PCT) in the early identification of ICU-acquired infections in COVID-19 patients. Methods: We undertook a prospective observational cohort study (12 months). All adult mechanically ventilated patients admitted for ≥72 h to ICU with COVID-19 pneumonia were divided into an infected group (n = 35) and a non-infected group (n = 83). Day 0 was considered as the day of the diagnosis of infection (infected group) and Day 10 was that of ICU stay (non-infected group). The kinetics of CRP and PCT were assessed from Day –10 to Day 10 and evaluated using a general linear model, univariate, repeated-measures analysis. Results: 118 patients (mean age 63 years, 74% males) were eligible for the analysis. The groups did not differ in patient age, gender, CRP and PCT serum levels at ICU admission. However, the infected group encompassed patients with a higher severity (SOFA score at ICU admission, p = 0.009) and a higher 28–day mortality (p < 0.001). Before D0, CRP kinetics showed a significant increase in infected patients, whereas in noninfected it remained almost unchanged (p < 0.001), while PCT kinetics did not appear to retain diagnostic value to predict superinfection in COVID-19 patients (p = 0.593). Conclusion: COVID-19 patients who developed ICU-acquired infections exhibited different biomarker kinetics before the diagnosis of those infections. Daily CRP monitoring and the recognition of the CRP kinetics could be useful in the prediction of ICU-acquired infections. Full article

(This article belongs to the Special Issue Intensive Care Management of COVID-19 Patients)

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10 pages, 2441 KiB

Open AccessArticle

Identification of Distinct Clinical Phenotypes of Critically Ill COVID-19 Patients: Results from a Cohort Observational Study

by José Pedro Cidade, Vicente Cés de Souza Dantas, Alessandra de Figueiredo Thompson, Renata Carnevale Carneiro Chermont de Miranda, Rafaela Mamfrim, Henrique Caroli, Gabriela Escudini, Natalia Oliveira, Taiza Castro and Pedro Póvoa

J. Clin. Med. 2023, 12(8), 3035; https://doi.org/10.3390/jcm12083035 - 21 Apr 2023

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Purpose: COVID-19 presents complex pathophysiology, and evidence collected points towards an intricate interaction between viral-dependent and individual immunological mechanisms. Identifying phenotypes through clinical and biological markers may provide a better understanding of the subjacent mechanisms and an early patient-tailored characterization of illness severity. Methods: A multicenter prospective cohort study was performed in 5 hospitals in Portugal and Brazil for one year between 2020–2021. All adult patients with an Intensive Care Unit admission with SARS-CoV-2 pneumonia were eligible. COVID-19 was diagnosed using clinical and radiologic criteria with a SARS-CoV-2 positive RT-PCR test. A two-step hierarchical cluster analysis was made using several class-defining variables. Results: 814 patients were included. The cluster analysis revealed a three-class model, allowing for the definition of three distinct COVID-19 phenotypes: 407 patients in phenotype A, 244 patients in phenotype B, and 163 patients in phenotype C. Patients included in phenotype A were significantly older, with higher baseline inflammatory biomarkers profile, and a significantly higher requirement of organ support and mortality rate. Phenotypes B and C demonstrated some overlapping clinical characteristics but different outcomes. Phenotype C patients presented a lower mortality rate, with consistently lower C-reactive protein, but higher procalcitonin and interleukin-6 serum levels, describing an immunological profile significantly different from phenotype B. Conclusions: Severe COVID-19 patients exhibit three different clinical phenotypes with distinct profiles and outcomes. Their identification could have an impact on patients’ care, justifying different therapy responses and inconsistencies identified across different randomized control trial results. Full article

(This article belongs to the Special Issue Intensive Care Management of COVID-19 Patients)

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20 pages, 431 KiB

Open AccessArticle

Mortality, Intensive Care Unit Admission, and Intubation among Hospitalized Patients with COVID-19: A One-Year Retrospective Study in Jordan

by Khaled Al Oweidat, Rasmieh Al-Amer, Mohammad Y. Saleh, Asma S. Albtoosh, Ahmad A. Toubasi, Mona Khaled Ribie, Manar M. Hasuneh, Daniah L. Alfaqheri, Abdullah H. Alshurafa, Mohammad Ribie, Amira Mohammed Ali and Nathir Obeidat

J. Clin. Med. 2023, 12(7), 2651; https://doi.org/10.3390/jcm12072651 - 02 Apr 2023

Cited by 2 | Viewed by 1693

Abstract

COVID-19 is a public health crisis that has caused numerous deaths, necessitated an increased number of hospital admissions, and led to extended inpatient stays. This study aimed to identify the factors associated with COVID-19 mortality, intensive care unit admission, intubation, and length of hospital stay among Jordanian patients. This was a one-year retrospective study of 745 COVID-19 patients admitted to Jordan University Hospital. Data regarding the patients’ demographics, clinical and co-morbid conditions, imaging, laboratory parameters, mortality, intensive care unit admission (ICU), and intubation were collected from their medical records using a coding manual. The data revealed that the overall rates of COVID-19-related mortality, ICU admission, and invasive intubation were 23.0%, 28.3%, and 10.8%, respectively. Chronic kidney disease (CKD), troponin, lactate dehydrogenase (LDH), and O₂ saturation <90% were significantly associated with the mortality rate. The variables that were significantly associated with ICU admission were heart failure and the use of remdesivir. However, O₂ saturation <90% and gastrointestinal (GI) symptoms were the only variables associated with invasive intubation. The findings of this study suggest that study-related health outcomes can be used to predict the severity of COVID-19, and they can inform future research aiming to identify specific populations who are at a higher risk of COVID-19 complications. Full article

(This article belongs to the Special Issue Intensive Care Management of COVID-19 Patients)

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25 pages, 1926 KiB

Open AccessSystematic Review

Relationship between the Pre-ECMO and ECMO Time and Survival of Severe COVID-19 Patients: A Systematic Review and Meta-Analysis

by Ziqi Tan, Longxiang Su, Xiangyu Chen, Huaiwu He and Yun Long

J. Clin. Med. 2024, 13(3), 868; https://doi.org/10.3390/jcm13030868 - 01 Feb 2024

Viewed by 631

Abstract

Background: Coronavirus disease 2019 (COVID-19) is the etiology of acute respiratory distress syndrome (ARDS). Extracorporeal membrane oxygenation (ECMO) is used to support gas exchange in patients who have failed conventional mechanical ventilation. However, there is no clear consensus on the timing of ECMO use in severe COVID-19 patients. Objective: The aim of this study is to compare the differences in pre-ECMO time and ECMO duration between COVID-19 survivors and non-survivors and to explore the association between them. Methods: PubMed, the Cochrane Library, Embase, and other sources were searched until 21 October 2022. Studies reporting the relationship between ECMO-related time and COVID-19 survival were included. All available data were pooled using random-effects methods. Linear regression analysis was used to determine the correlation between pre-ECMO time and ECMO duration. The meta-analysis was registered with PROSPERO under registration number CRD42023403236. Results: Out of the initial 2473 citations, we analyzed 318 full-text articles, and 54 studies were included, involving 13,691 patients. There were significant differences between survivors and non-survivors in the time from COVID-19 diagnosis (standardized mean difference (SMD) = −0.41, 95% confidence interval (CI): [−0.53, −0.29], p < 0.00001), hospital (SMD = −0.53, 95% CI: [−0.97, −0.09], p = 0.02) and intensive care unit (ICU) admission (SMD = −0.28, 95% CI: [−0.49, −0.08], p = 0.007), intubation or mechanical ventilation to ECMO (SMD = −0.21, 95% CI: [−0.32, −0.09], p = 0.0003) and ECMO duration (SMD = −0.18, 95% CI: [−0.30, −0.06], p = 0.003). There was no statistical association between a longer time from symptom onset to ECMO (hazard ratio (HR) = 1.05, 95% CI: [0.99, 1.12], p = 0.11) or time from intubation or mechanical ventilation (MV) and the risk of mortality (highest vs. lowest time groups odds ratio (OR) = 1.18, 95% CI: [0.78, 1.78], p = 0.42; per one-day increase OR = 1.14, 95% CI: [0.86, 1.52], p = 0.36; HR = 0.99, 95% CI: [0.95, 1.02], p = 0.39). There was no linear relationship between pre-ECMO time and ECMO duration. Conclusion: There are differences in pre-ECMO time between COVID-19 survivors and non-survivors, and there is insufficient evidence to conclude that longer pre-ECMO time is responsible for reduced survival in COVID-19 patients. ECMO duration differed between survivors and non-survivors, and the timing of pre-ECMO does not have an impact on ECMO duration. Further studies are needed to explore the association between pre-ECMO and ECMO time in the survival of COVID-19 patients. Full article

(This article belongs to the Special Issue Intensive Care Management of COVID-19 Patients)

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