Contrast enhanced ultrasonography (CEUS) to detect abdominal microcirculatory disorders in severe cases of COVID-19 infection: First experience

COVID-19 and the endothelium

There is growing evidence that COVID-19 not only affects the lungs but beyond that the endothelial system. Recent studies showed that this can lead to microcirculatory impairments and in consequence to functional disorders of all inner organs. The combination of endothelial dysfunction with a generalized inflammatory state and complement elements may together contribute to the overall pro-coagulative state described in COVID-19 patients leading to venular as well as to arteriolar occlusions.

The compelling arguments for the need of microvascular investigation in COVID-19 critical patients

The burden of pandemic COVID-19 is growing worldwide, as the continuous increases of contagion. Only 10–15% of the entire infected population has the necessity of intensive care unit (ICU) treatments. But, this relatively low rate of patients has absorbed almost the whole availability of ICU during few days, becoming at least in Italy, an emergency for the national health system. In COVID-19 ICU patients massive aggression of lung with severe pulmonary failure, as well as kidney and liver injuries, heart, brain, bowel and spleen damages with lymph nodes necrosis and even cutaneous manifestations have been observed. Moreover, increased levels of cytokines so-called “cytokines storm (CS), and overt intravascular disseminated coagulation have been also reported. The hypercoagulation and CS would speculate about a microvascular dysfunction. Unfortunately, no specific observations have been performed on microcirculatory dysfunction in COVID-19 patients. Hence the presumed pathophysiological pathways and models about a microvascular involvement can be gathered by sepsis models studies. But despite this lack of evidence, the COVID-19 has emphasized the compelling need for microcirculation monitoring at the bedside in ICU patients.

Contrast enhanced ultrasound (CEUS) to assess pleural pulmonal changes in severe COVID-19 infection: First results

AIM:

Use of contrast enhanced ultrasound (CEUS) in severe cases of COVID-19 infection to assess pulmonary changes near the pleura.

MATERIAL AND METHODS:

Bedside examinations by an experienced intensive care unit examiner using a multi-frequency probe (C1-6 MHz) with B-mode and CEUS to assess pleural-near changes in severe cases of COVID-19 infection with respiratory failure. CEUS with bolus delivery via a central venous catheter of 2.4 ml Sulphur hexafluoride microbubbles from the arterial phase (10–15 s) to the late phase of 5 min. Digital storage of cine sequences of the lung sound with abdomen for independent assessment with the subsequently performed contrast-enhanced dual-source CT.

RESULTS:

In 11 intubated and ventilated patients (arithmetic mean 62 years, 48 to 78 years, 3 women) with confirmed severe COVID-19 infections, a peripherally accentuated consolidation with irregular hyperemia was found in the CEUS and also in the CT examination. Of the 5 cases with pulmonary arterial embolisms, signs of right ventricular failure were found. In all cases, using CEUS low perfused areas of the pleura with adjacent hyperemia could be detected, while, with CT segmental contrast medium, gaps with subpleural compressions were found. Interstitial changes near the pleura led to B-lines and to ground glass opacities in the CT. Near the diaphragm a delayed arterial contrast of the liver was observed. In addition, in 2 cases partial atelectasis, in 3 cases marginal pleural effusions were found.

CONCLUSION:

CEUS opens up new possibilities for bedside monitoring of pleural reactive inflammatory or peripheral thrombus embolism in severe cases of COVID-19 infection.

How we should respond to the Coronavirus SARS-CoV-2 outbreak: A German perspective

BACKGROUND

In the early phase of the COVID-19 pandemic Germany missed to set up efficient containment measures. Consequently, the number of cases increased exponentially until a lockdown was implemented to suppress the spread of SARS-CoV-2. Fortunately, Germany has a high capability for coronavirus lab testing and more than 30,000 ICU beds. These capabilities and the lockdown turned out to be an advantage to combat the pandemic and to prevent a health-system overload.

AIM

The aim was to predict the plateau day of SARS-CoV-2 infections or deaths.

RESULTS

The effect on the viral spread of the German measures taken and the impact on the peak of new infection cases is shown. By normalizing daily case numbers, the plateau day of the current outbreak in Germany could be calculated to be reached at April 12, 2020 (day 103 of 2020).

CONCLUSION

Normalized case number curves are helpful to predict the time point at which no further new infections will occur if the epidemic situation remains stable. Upon reaching the plateau day during a lockdown phase, a residual time-period of about 2-3 weeks can be utilized to prepare a safe unlocking period. As can be learned from Asian countries such as South Korea and Taiwan there must be strict rules to keep the risk of infection low. Those include social distancing, face mask wearing in combination with digital contact tracing and serosurveillance studies. Following those rules, a safe dance around the infection curve allows to keep the population at a reduced infection rate.