Experts in Italy and Asia share the experience and warnings of the COVID-19 intensive care unit

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A study published yesterday in JAMA out of 1591 COVID-19 patients in intensive care units (ICUs) of 72 hospitals Lombardy, Italy, found that 99% needed respiratory assistance with high oxygen levels, 82% were men, 68% had at least one underlying disease, and 26% died.

Yesterday too Lancet respiratory medicine, the Asian Critical Care Clinical Trials Group has published comprehensive guidelines for the intensive care treatment of patients with coronavirus.

Advanced age, underlying conditions linked to poorer results

In the largest series of intensive care cases known to date, the researchers described the basic characteristics and outcomes of patients with coronavirus from February 20 to March 18. The researchers analyzed data collected by the coordination center of the COVID-19 Lombardy intensive care network in Milan via daily telephone calls with intensive care. doctors.

The median age of the patients was 63 years and 1,304 (82%) were men. A total of 363 patients (23%) were aged 71 and over, while 203 (13%) were under 51 years of age. Of the 1,043 patients for whom data were available, 709 (68%) had at least one underlying disease, 509 (49%) with high blood pressure, 223 (21%) with cardiovascular disease, 188 ( 18%) with high cholesterol and 42 (4%) with chronic obstructive pulmonary disease.

High blood pressure was 23 percentage points more common in deceased patients (63%, 195 of 309 patients) than in those discharged from intensive care (40%, 84 of 212). All patients over the age of 80 had at least one underlying disease, as did 496 of the 650 patients over the age of 60 (76%).

The authors noted that because the median age of ICU patients was the same as the median age of all COVID-19 patients, older age alone could not be a risk factor. for admission to intensive care.

The 786 patients aged 64 or older had a mortality rate of 21 percentage points higher than the 795 patients aged 63 or younger (36% versus 15%).

Overall, 1,287 (99%) of the 1,300 patients with available respiratory support data required respiratory assistance, of which 1,150 (88%) required mechanical ventilation and 137 (11%) required non-invasive ventilation. Of the 1,581 patients with intensive care status available as of March 25, 920 (58%) remained in intensive care, 256 (16%) had been released from intensive care and 405 (26%) had died.

In an editorial in the same review, Deborah Cook, MD, MSc, and co-authors noted the pressure the pandemic was placing on intensive care units in the study, which described an average of 22 patients per intensive care unit and one Median stay in intensive care unit for 9 days. “This demand far exceeds the capacity of even the best-resourced health care system and indicates the potential morbidity and mortality that awaits in the resource-poor areas,” they said.

According to this afternoon, Italy had reported 135,586 cases of coronavirus, behind only the United States and Spain, and 17,127 deaths, more than any other country, according to Johns Hopkins University coronavirus tracker .

Prepare for an influx of limited resources

in the Lancet review, the authors use the experience of critical care clinicians in Asia and the literature to describe the challenges of caring for critically ill patients with COVID-19 and offer advice and algorithms for diagnosis, management, infection prevention, triage and critical care infrastructure and staff for intensive care. hospitals waiting for a high number of admissions.

“The intensive care community must prepare for this potentially overwhelming wave of patients and optimize workflows in advance for rapid diagnosis and isolation, clinical management and infection prevention,” said they write.

Specifically, they advise clinicians to adopt a low threshold for diagnostic tests, if available, and to repeat sampling of the lower respiratory tract, if necessary.

Because intubation poses a risk of transmission to healthcare workers, the authors stated that intubation exercises should be performed and that the most qualified intubator should perform the procedure with full personal protective equipment and a ventilation limited by bag mask.

Regular fit testing of N95 respirators should be performed, the authors said, noting that clinicians may have to reuse face masks and respirators between patients and beyond their recommended shelf life due to global shortages.

“Resource rationing also involves the suspension and withdrawal of life-saving treatments for ICU patients,” they said. “To this end, it should be noted that a quarter of the patients who died at the start of the Wuhan epidemic did not receive invasive ventilation. “

If isolation rooms for negative pressure airborne infections are not available, standard single rooms with adequate ventilation could be used, they said. Several patients could share a room if their beds were spaced.

Since more than a third of cell phones used by health professionals could be contaminated with pathogens, the authors recommended disinfecting them regularly or wrapping them in bags of samples which are discarded after contact with the patient or at the end of the day.

They also called for research on issues such as short and long term patient prognosis, risk of coronavirus transmission in shared intensive care rooms and indications for corticosteroid use.

“Collaboration at local, regional, national and international levels – with a focus on high quality research, evidence-based practice, sharing of data and resources and ethical integrity in the face of unprecedented challenges – will be the key to the success of these efforts, “they wrote.

In a commentary by the same journal, Jean-Louis Vincent, MD, PhD, and Fabio Taccone, MD, PhD, from Erasme University Hospital in Brussels, Belgium, noted that the Asian journal raises the question of how to interpret COVID-19 case fatality rate.

“Ethical issues also play an important role in the interpretation of case fatality rates, especially when the elderly and the frail are more at risk and when resources are sought so that some form of rationing or triage becomes necessary, ”they wrote. “In such a scenario, it can be difficult to determine whether the cause of death is specifically due to COVID-19 or the result of treatment limitations. “

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