[German recommendations for treatment of critically ill patients with COVID-19-version 3 : S1-guideline]

Serum KL-6 as a Candidate Predictor of Outcome in Patients with SARS-CoV-2 Pneumonia

Severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2)-infection is associated with an extremely variable disease course. When interstitial pneumonia (IP) occurs, it can lead to acute respiratory distress syndrome and death. Serum Krebs von den Lungen-6 (KL-6) is an established marker of IP, but its role as a marker of SARS-CoV-2 pneumonia is debated. This bicentric study included 157 patients with SARS-CoV-2 pneumonia. The WHO Ordinal Scale for Clinical Improvement (0-10 points) was used to classify the clinical course. Serum samples were collected at admission, and on days 3 and 7 of hospitalization. KL-6 was measured by using automated chemiluminescence immunoassay. A total of 68 patients developed a severe SARS-CoV-2 pneumonia, 135 of them required oxygen, and 15 died during hospitalization. The patients requiring non-invasive ventilation, invasive ventilation, or extracorporeal membrane oxygenation had significantly higher serum KL-6 levels at admission. The serum KL-6 levels were tendentially higher in patients who died than in those who survived. Logistic regression identified serum KL-6 at a cut-off of 335 U/mL at admission as a significant predictor of severe SARS-CoV-2 pneumonia outcome. Serum KL-6 seems to be a candidate biomarker for the clinical routine to stratify patients with SARS-CoV-2 pneumonia for the risk of a severe disease outcome or death.

Characteristics and mortality of 561,379 hospitalized COVID-19 patients in Germany until December 2021 based on real-life data

The ongoing SARS-CoV-2 pandemic is characterized by poor outcome and a high mortality especially in the older patient cohort. Up to this point there is a lack of data characterising COVID-19 patients in Germany admitted to intensive care (ICU) vs. non-ICU patients. German Reimbursement inpatient data covering the period in Germany from January 1st, 2020 to December 31th, 2021 were analyzed. 561,379 patients were hospitalized with COVID-19. 24.54% (n = 137,750) were admitted to ICU. Overall hospital mortality was 16.69% (n = 93,668) and 33.36% (n = 45,947) in the ICU group. 28.66% (n = 160,881) of all patients suffer from Cardiac arrhythmia and 17.98% (n = 100,926) developed renal failure. Obesity showed an odds-ratio ranging from 0.83 (0.79-0.87) for WHO grade I to 1.13 (1.08-1.19) for grade III. Mortality-rates peaked in April 2020 and January 2021 being 21.23% (n = 4539) and 22.99% (n = 15,724). A third peak was observed November and December 2021 (16.82%, n = 7173 and 16.54%, n = 9416). Hospitalized COVID-19 patient mortality in Germany is lower than previously shown in other studies. 24.54% of all patients had to be treated in the ICU with a mortality rate of 33.36%. Congestive heart failure was associated with a higher risk of death whereas low grade obesity might have a protective effect on patient survival. High admission numbers are accompanied by a higher mortality rate.

Clinical Evidence Informing Treatment Guidelines on Repurposed Drugs for Hospitalized Patients During the Early COVID-19 Pandemic: Corticosteroids, Anticoagulants, (Hydroxy)chloroquine

INTRODUCTION

In early 2020, the coronavirus disease 2019 (COVID-19) pandemic spread worldwide, overwhelming hospitals with severely ill patients and posing the urgent need for clinical evidence to guide patient care. First treatment options available were repurposed drugs to fight inflammation, coagulopathy, and viral replication. A vast number of clinical studies were launched globally to test their efficacy and safety. Our analysis describes the development of global evidence on repurposed drugs, in particular corticosteroids, anticoagulants, and (hydroxy)chloroquine in hospitalized COVID-19 patients based on different study types. We track the incorporation of clinical data in international and national treatment guidelines and identify factors that characterize studies and analyses with the greatest impact on treatment recommendations.

METHODS

A literature search in MEDLINE was conducted to assess the clinical evidence on treatment with corticosteroids, anticoagulants, and (hydroxy)chloroquine in hospitalized COVID-19 patients during the first year of the pandemic. Adoption of the evidence from this clinical data in treatment guidelines of the World Health Organization (WHO), Germany, and United States (US) was evaluated over time.

RESULTS

We identified 106 studies on corticosteroids, 141 studies on anticoagulants, and 115 studies on (hydroxy)chloroquine. Most studies were retrospective cohort studies; some were randomized clinical trials (RCTs), and a few were platform trials. These studies were compared to studies directly and indirectly referred to in WHO (7 versions), German (5 versions), and US (21 versions) guidelines. We found that initially large, well-adjusted, mainly retrospective cohort studies and ultimately large platform trials or coordinated meta-analyses of RCTs provided best available clinical evidence supporting treatment recommendations.

DISCUSSION

Particularly early in the pandemic, evidence for the efficacy and safety of repurposed drugs was of low quality, since time and scientific rigor seemed to be competing factors. Pandemic preparedness, coordinated efforts, and combined analyses were crucial to generating timely and robust clinical evidence that informed national and international treatment guidelines on corticosteroids, anticoagulants, and (hydroxy)chloroquine. Multi-arm platform trials with master protocols and coordinated meta-analyses proved particularly successful, with researchers joining forces to answer the most pressing questions as quickly as possible.

Risk Assessment for Patients with Chronic Respiratory Conditions in the Context of the SARS-CoV-2 Pandemic Statement of the German Respiratory Society with the Support of the German Association of Chest Physicians

Assessing the risk for specific patient groups to suffer from severe courses of COVID-19 is of major importance in the current SARS-CoV-2 pandemic. This review focusses on the risk for specific patient groups with chronic respiratory conditions, such as patients with asthma, chronic obstructive pulmonary disease, cystic fibrosis (CF), sarcoidosis, interstitial lung diseases, lung cancer, sleep apnea, tuberculosis, neuromuscular diseases, a history of pulmonary embolism, and patients with lung transplants. Evidence and recommendations are detailed in exemplary cases. While some patient groups with chronic respiratory conditions have an increased risk for severe courses of COVID-19, an increasing number of studies confirm that asthma is not a risk factor for severe COVID-19. However, other risk factors such as higher age, obesity, male gender, diabetes, cardiovascular diseases, chronic kidney or liver disease, cerebrovascular and neurological disease, and various immunodeficiencies or treatments with immunosuppressants need to be taken into account when assessing the risk for severe COVID-19 in patients with chronic respiratory diseases.

Services for homeless people in Germany during the COVID-19-pandemic: A descriptive study

DESIGN

A cross-sectional study was conducted in December 2020/January 2021 in the five significant cities of Germany.

SAMPLE

135 of 244 identified service institutions took part in the evaluation.

MEASUREMENTS

This evaluation included changes in institutions' operating hours as well as capacity for homeless people. Service institutions described changes in guests' characteristics, moods, and mental burden. Finally, equipment including face masks, coveralls, and gloves was investigated. In addition, the study examined how the cooperation with the health authorities works.

RESULTS

Institutions reduced their operating hours and capacity for guests (62.4%). Increased costs, which they had to cover themselves, were reported by 70.9% of institutions. Institutions reported, that guests showed more symptoms of aggression (15%), anxiety (25%), and desperation (32%) and fewer signs of being relaxed (75%). The institutions reported room for improvement in PPE supplies and collaboration with health authorities.

CONCLUSIONS

Services are limited for a vulnerable population, which shows changes in moods and mental health. Health authorities are not sufficiently engaged to take over the role of institutions in caring for homeless people. In the future, in-depth investigation to improve this is necessary.

[Development of a giant bulla under spontaneous breathing by self-inflicted lung injury in a patient with COVID-19 pneumonia]

SARS-CoV‑2 und die damit assoziierte COVID-19-Erkrankung stellen Gesundheitssysteme weltweit vor große Herausforderungen. Fast täglich werden neue Erkenntnisse zu Diagnostik, Klinik und Therapie der Erkrankung publiziert. Dieser Fallbericht beschreibt den letalen Krankheitsverlauf eines 81-jährigen Patienten ohne pulmonale Vorerkrankungen, der als Komplikation der COVID-19-Pneumonie unter nichtinvasiver High-Flow-Sauerstofftherapie eine Riesenbulla entwickelte. Pathophysiologisch kommen/kommt eine virusbedingte diffuse Zerstörung des Alveolargewebes und/oder die „patient self-inflicted lung injury“ in Betracht.

Assessment of health equity consideration in masking/PPE policies to contain COVID-19 using PROGRESS-plus framework: a systematic review

INTRODUCTION

There is increasing evidence that COVID-19 has unmasked the true magnitude of health inequity worldwide. Policies and guidance for containing the infection and reducing the COVID-19 related deaths have proven to be effective, however the extent to which health inequity factors were considered in these policies is rather unknown. The aim of this study is to measure the extent to which COVID-19 related policies reflect equity considerations by focusing on the global policy landscape around wearing masks and personal protection equipment (PPE).

METHODS

A systematic search for published documents on COVID-19 and masks/PPE was conducted across six databases: PubMed, EMBASE, CINAHL, ERIC, ASSIA and Psycinfo. Reviews, policy documents, briefs related to COVID-19 and masks/PPE were included in the review. To assess the extent of incorporation of equity in the policy documents, a guidance framework known as 'PROGRESS-Plus': Place of residence, Race/ethnicity, Occupation, Gender/sex, Religion, Education, Socioeconomic status, Social capital, Plus (age, disability etc.) was utilized.

RESULTS

This review included 212 policy documents. Out of 212 policy documents, 190 policy documents (89.62%) included at least one PROGRESS-plus component. Most of the policy documents (n = 163, 85.79%) focused on "occupation" component of the PROGRESS-plus followed by personal characteristics associated with discrimination (n = 4;2.11%), place of residence (n = 2;1.05%) and education (n = 1;0.53%). Subgroup analysis revealed that most of the policy documents (n = 176, 83.01%) were focused on "workers" such as healthcare workers, mortuary workers, school workers, transportation workers, essential workers etc. Of the remaining policy documents, most were targeted towards whole population (n = 30; 14.15%). Contrary to "worker focused" policy documents, most of the 'whole population focused' policy documents didn't have a PROGRESS-plus equity component rendering them equity limiting for the society.

CONCLUSION

Our review highlights even if policies considered health inequity during the design/implementation, this consideration was often one dimensional in nature. In addition, population wide policies should be carefully designed and implemented after identifying relevant equity related barriers in order to produce better outcomes for the whole society.

Thromboprophylaxis in Patients with COVID-19: Systematic Review of National and International Clinical Guidance Reports

BACKGROUND

Venous thromboembolism (VTE) is common among patients with severe coronavirus disease 2019 (COVID-19). Anticoagulation in hospitalized COVID-19 patients has been associated with survival benefits; however, the optimal thromboprophylaxis strategy has not yet been defined. <P> Objective: To identify published guidance reports by national and international societies regarding thromboprophylaxis strategies in COVID-19 patients in different settings (outpatients, hospitalized, post-discharge). <P> Methods: A systematic review of the literature (Pubmed/EMBASE) was conducted independently by two investigators. <P> Results: Among 1942 initially identified articles, 33 guidance documents were included: 20 published by national and 13 by international societies. These documents provide recommendations mainly for hospitalized (97% of reports) and post-discharge (75%) COVID-19 patients, and less so for outpatients (34%). Thrombotic and bleeding risk stratification prior to any treatment decision is the cornerstone of all suggested thromboprophylaxis strategies; 81% of the documents recommend thromboprophylaxis for all hospitalized patients with a prophylactic dosage of low molecular weight heparin irrespective of VTE risk. Intermediate or therapeutic dose intensity is recommended in high VTE risk patients by 56% and 28% of documents, respectively. Mechanical thromboprophylaxis is suggested in case of high bleeding risk or contraindication to pharmacological thromboprophylaxis (59% of documents). Extended pharmacological thromboprophylaxis is recommended for patients with high VTE risk after hospital discharge (63% of documents). For non-hospitalized outpatients, 28% of documents recommend pharmacological thromboprophylaxis for high VTE risk. <P> Conclusion: The current guidance identifies thromboprophylaxis in COVID-19 patients, especially during hospitalization, as of major importance for the prevention of VTE. Recommendations are derived from limited evidence from observational studies.

COVID-19 und das Risiko für Schlaganfälle

Die Pandemie durch SARS-CoV-2 und das dadurch ausgelöste Krankheitsbild COVID-19 haben Auswirkungen auf alle Bereiche der Medizin. Neben anderen möglichen neurologischen Manifestationen ist bereits frühzeitig über neurovaskuläre Komplikationen berichtet worden. Darüber hinaus hat die COVID-19-Pandemie aber auch direkte und indirekte Auswirkungen auf die Versorgung von Patienten mit neurovaskulären Erkrankungen.

Patient Characteristics and Clinical Course of COVID-19 Patients Treated at a German Tertiary Center during the First and Second Waves in the Year 2020

In this study, we directly compared coronavirus disease 2019 (COVID-19) patients hospitalized during the first (27 February-28 July 2020) and second (29 July-31 December 2020) wave of the pandemic at a large tertiary center in northern Germany. Patients who presented during the first (n = 174) and second (n = 331) wave did not differ in age (median [IQR], 59 years [46, 71] vs. 58 years [42, 73]; p = 0.82) or age-adjusted Charlson Comorbidity Index (median [IQR], 2 [1, 4] vs. 2 [0, 4]; p = 0.50). During the second wave, a higher proportion of patients were treated as outpatients (11% [n = 20] vs. 20% [n = 67]), fewer patients were admitted to the intensive care unit (43% [n = 75] vs. 29% [n = 96]), and duration of hospitalization was significantly shorter (median days [IQR], 14 [8, 34] vs. 11 [5, 19]; p < 0.001). However, in-hospital mortality was high throughout the pandemic and did not differ between the two periods (16% [n = 27] vs. 16% [n = 54]; p = 0.89). While novel treatment strategies and increased knowledge about the clinical management of COVID-19 may have resulted in a less severe disease course in some patients, in-hospital mortality remained unaltered at a high level. These findings highlight the unabated need for efforts to hamper severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) transmission, to increase vaccination coverage, and to develop novel treatment strategies to prevent mortality and decrease morbidity.

[Weaning from Mechanical Ventilation in Patients with SARS-CoV-2 Infection after Prolonged Mechanical Ventilation - First Experience]

AIM

 With the emergence of a new virus and the associated pandemic, the ICU started to see a brand new kind of patient with severe ARD. As with any disease, sometimes the discontinuation of mechanical ventilation for any reason can be difficult. As a center specializing in weaning patients after prolonged mechanical ventilation, we wanted to compare our results with weaning patients who had prolonged mechanical ventilation for other reasons than those of patients who had prolonged mechanical ventilation due to SARS-CoV-2 infection.

METHODS

 We obtained our data from WeanNet register, the weaning register of the German Institute for Lung Research (ILF). In our analysis, we included only patient data from January until July 2020, which was recorded in our in-house study files.

RESULTS

 Our analysis included data on 28 patients; 11 were treated with prolonged mechanical ventilation due to SARS-CoV-2 pneumonia, 17 had no SARS-CoV-2 infection. 81.2 % of SARS-CoV-2 patients were successfully weaned from invasive ventilator therapy compared to 76.4 % of patients without SARS-CoV-2. Mortality in the SARS-CoV-2 group was 18.2 % compared to 11.8 % in the other group. Patients with SARS-CoV-2 infections were predominantly males with preexisting cardiovascular disease or a history of nicotine abuse. ARDS was the most common cause of respiratory failure which led to primary intubation.

CONCLUSION

 Even though we were only able to analyze a small number of patient histories due to the novelty of the disease, we were able to show that patients with prolonged mechanical ventilation after SARS-CoV-2 infection can be equally successfully weaned compared to patients with prolonged mechanical ventilation due to other diseases. Risk factors for prolonged mechanical ventilation after a severe case of SARS-CoV-2 infection seemed to be male gender, nicotine abuse and cardiovascular disease.

Surgical tracheostomy in a cohort of COVID-19 patients

Background

One of the main symptoms of severe infection with the new coronavirus‑2 (SARS-CoV-2) is hypoxemic respiratory failure because of viral pneumonia with the need for mechanical ventilation. Prolonged mechanical ventilation may require a tracheostomy, but the increased risk for contamination is a matter of considerable debate.

Objective

Evaluation of safety and effects of surgical tracheostomy on ventilation parameters and outcome in patients with COVID-19.

Study design

Retrospective observational study between March 27 and May 18, 2020, in a single-center coronavirus disease-designated ICU at a tertiary care German hospital.

Patients

Patients with COVID-19 were treated with open surgical tracheostomy due to severe hypoxemic respiratory failure requiring mechanical ventilation.

Measurements

Clinical and ventilation data were obtained from medical records in a retrospective manner.

Results

A total of 18 patients with confirmed SARS-CoV‑2 infection and surgical tracheostomy were analyzed. The age range was 42–87 years. All patients received open tracheostomy between 2–16 days after admission. Ventilation after tracheostomy was less invasive (reduction in PEAK and positive end-expiratory pressure [PEEP]) and lung compliance increased over time after tracheostomy. Also, sedative drugs could be reduced, and patients had a reduced need of norepinephrine to maintain hemodynamic stability. Six of 18 patients died. All surgical staff were equipped with N99-masks and facial shields or with powered air-purifying respirators (PAPR).

Conclusion

Our data suggest that open surgical tracheostomy can be performed without severe complications in patients with COVID-19. Tracheostomy may reduce invasiveness of mechanical ventilation and the need for sedative drugs and norepinehprine. Recommendations for personal protective equipment (PPE) for surgical staff should be followed when PPE is available to avoid contamination of the personnel.

[Decision support for patient admission in case of suspicion of COVID-19]

During a pandemic situation, patients with suspected coronavirus disease (COVID-19) are also treated by emergency medical services (EMS). In order to establish an adequate procedure, a decision aid for the allocation of patients in case of suspicion of COVID-19 has been prepared for the ambulance staff as well as for the emergency physician in the Bavarian EMS. The decision-making aid includes the current guidelines and recommendations on COVID-19. A flowchart in A4 format was chosen for the presentation of the decision aid, which is structured according to the ABCDE scheme (A-Airway, B-Breathing, C-Circulation, D-Disability, E-Environment/Exposure) established in EMS. The flowchart allows patients to be categorized in three stages, based on (vital) parameters and criteria such as risk factors and specific framework conditions. The aim is to provide emergency physicians and ambulance staff with guidance for the assessment of patients and the resulting transport decision with a suitable target clinic if necessary.

[S2k Guideline - Recommendations for Inpatient Therapy of Patients with COVID-19]

Since December 2019, the novel coronavirus SARS-CoV-2 (Severe Acute Respiratory Syndrome - Corona Virus-2) has been spreading rapidly in the sense of a global pandemic. This poses significant challenges for clinicians and hospitals and is placing unprecedented strain on the healthcare systems of many countries. The majority of patients with Coronavirus Disease 2019 (COVID-19) present with only mild symptoms such as cough and fever. However, about 6 % require hospitalization. Early clarification of whether inpatient and, if necessary, intensive care treatment is medically appropriate and desired by the patient is of particular importance in the pandemic. Acute hypoxemic respiratory insufficiency with dyspnea and high respiratory rate (> 30/min) usually leads to admission to the intensive care unit. Often, bilateral pulmonary infiltrates/consolidations or even pulmonary emboli are already found on imaging. As the disease progresses, some of these patients develop acute respiratory distress syndrome (ARDS). Mortality reduction of available drug therapy in severe COVID-19 disease has only been demonstrated for dexamethasone in randomized controlled trials. The main goal of supportive therapy is to ensure adequate oxygenation. In this regard, invasive ventilation and repeated prone positioning are important elements in the treatment of severely hypoxemic COVID-19 patients. Strict adherence to basic hygiene, including hand hygiene, and the correct wearing of adequate personal protective equipment are essential when handling patients. Medically necessary actions on patients that could result in aerosol formation should be performed with extreme care and preparation.

[Intensive care back up for infectious disease disasters]

BACKGROUND

Outbreaks of infectious diseases pose particular challenges for hospitals and intensive care units.

OBJECTIVES

Typical infectiological scenarios and their significance for modern intensive care medicine are presented.

MATERIALS AND METHODS

Selected pathogens/infectious diseases that have significantly strained the resources of intensive care units are described.

RESULTS

Intensive medical care is necessary in severe cases of many infectious diseases. In the context of epidemics/pandemics, many critically ill patients have to be admitted within a short time. Examples are the 2009 H1N1 influenza pandemic, the 2011 enterohemorrhagic Escherichia coli (EHEC) outbreak in northern Germany, the 2014/2015 Ebola fever outbreak and the 2020 coronavirus disease 19 (COVID-19) pandemic. Multidisciplinary teams, protocol development, adequate staffing, and training are required to achieve optimal treatment outcomes, including prevention of healthcare worker infections.

CONCLUSIONS

Pandemics and epidemics are unique challenges for intensive care unit preparedness planning.