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Asmar R, Stergiou G, de la Sierra A, Jelaković B, Millasseau S, Topouchian J, Shirai K, Blacher J, Avolio A, Jankowski P, Parati G, Bilo G, Rewiuk K, Mintale I, Rajzer M, Agabiti-Rosei E, Ince C, Postadzhiyan A, Zimlichman R, Struijker-Boudier H, Benetos A, Bäck M, Tasic N, Sirenko Y, Zelveian P, Wang H, Fantin F, Kotovskaya Y, Ezhov M, Kotsis V. Blood pressure measurement and assessment of arterial structure and function: an expert group position paper. J Hypertens 2024; 42:1465-1481. [PMID: 38899971 PMCID: PMC11296277 DOI: 10.1097/hjh.0000000000003787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 05/20/2024] [Accepted: 05/21/2024] [Indexed: 06/21/2024]
Abstract
Measuring blood pressure (BP) and investigating arterial hemodynamics are essential in understanding cardiovascular disease and assessing cardiovascular risk. Several methods are used to measure BP in the doctor's office, at home, or over 24 h under ambulatory conditions. Similarly, several noninvasive methods have been introduced for assessing arterial structure and function; these methods differ for the large arteries, the small ones, and the capillaries. Consequently, when studying arterial hemodynamics, the clinician is faced with a multitude of assessment methods whose technical details, advantages, and limitations are sometimes unclear. Moreover, the conditions and procedures for their optimal implementation, and/or the reference normality values for the parameters they yield are not always taken into sufficient consideration. Therefore, a practice guideline summarizing the main methods and their use in clinical practice is needed. This expert group position paper was developed by an international group of scientists after a two-day meeting during which each of the most used methods and techniques for blood pressure measurement and arterial function and structure evaluation were presented and discussed, focusing on their advantages, limitations, indications, normal values, and their pragmatic clinical application.
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Affiliation(s)
- Roland Asmar
- Foundation-Medical Research Institutes. Paris France
| | - George Stergiou
- Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece
| | - Alejandro de la Sierra
- Hypertension Unit. Department of Internal Medicine. Hospital Mutua Terrassa. University of Barcelona, Spain
| | - Bojan Jelaković
- University hospital Centre Zagreb and University of Zagreb, School of Medicine. Zagreb, Croatia
| | | | - Jirar Topouchian
- Centre de diagnostic et de thérapeutique, Hôpital Hôtel-Dieu. Paris, France
| | - Kohji Shirai
- Toho University Sakura medical center, Department of Internal Medicine. Toho Japan
| | - Jacques Blacher
- Centre de diagnostic et de thérapeutique, Hôpital Hôtel-Dieu; AP-HP; Université Paris Cité, Paris, France
| | - Alberto Avolio
- Macquarie Medical School, Faculty of Medicine, Health and Humans Sciences, Macquarie University, Sydney, Australia
| | - Piotr Jankowski
- Department of Internal Medicine and Geriatric Cardiology, Medical Centre for Postgraduate Education, Warsaw, Poland
| | - Gianfranco Parati
- Department of Medicine and Surgery, University of Milano-Bicocca Milan, Italy
- IRCCS, Istituto Auxologico Italiano, Departmentof Cardiology, Milan, Italy
| | - Grzegorz Bilo
- Department of Medicine and Surgery, University of Milano-Bicocca Milan, Italy
- IRCCS, Istituto Auxologico Italiano, Departmentof Cardiology, Milan, Italy
| | - Krzysztof Rewiuk
- Department of Internal Medicine and Gerontology, Jagiellonian University Medical College, Cracow, Poland
| | - Iveta Mintale
- Institute of Cardiology and Regenerative Medicine, Latvian Centre of Cardiology; Riga Latvia
| | - Marek Rajzer
- First Department of Cardiology, Interventional Electro-cardiology and Hypertension, Jagiellonian University Medical College, Krakow, Poland
| | - Enrico Agabiti-Rosei
- Department of Clinical and Experimental Sciences, University of Brescia and IRCCS Multimedica, Milan, Italy
| | - Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center, Dr Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | | | - Reuven Zimlichman
- The Brunner Institute for Cardiovascular Research, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | | | | | - Magnus Bäck
- Department of Medicine Solna, Karolinska Institutet and Department of Cardiology Karolinska University Hospital, Stockholm, Sweden
| | | | | | | | - Hongyu Wang
- Department of Heart and Vascular Medicine, PKU Shougang Hospital, Beijing China
| | - Francesco Fantin
- Centre for Medical Sciences – CISMed, Department of Psychology and Cognitive Science, Section of Geriatric Medicine, University of Trento, Rovereto, Italy
| | - Yulia Kotovskaya
- Russian Clinical and Research Center of Gerontology – Pirogov Russian National Research Medical University, Moscow, Russia
| | - Marat Ezhov
- Myasnikov Clinical Cardiology Research Institute. Chazov National Medical Research Center of Cardiology. Moscow, Russia
| | - Vasilios Kotsis
- Department of Internal Medicine, Papageorgiou Hospital, Thessaloniki Greece
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Sigg AA, Zivkovic V, Bartussek J, Schuepbach RA, Ince C, Hilty MP. The physiological basis for individualized oxygenation targets in critically ill patients with circulatory shock. Intensive Care Med Exp 2024; 12:72. [PMID: 39174691 PMCID: PMC11341514 DOI: 10.1186/s40635-024-00651-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 07/21/2024] [Indexed: 08/24/2024] Open
Abstract
BACKGROUND Circulatory shock, defined as decreased tissue perfusion, leading to inadequate oxygen delivery to meet cellular metabolic demands, remains a common condition with high morbidity and mortality. Rapid restitution and restoration of adequate tissue perfusion are the main treatment goals. To achieve this, current hemodynamic strategies focus on adjusting global physiological variables such as cardiac output (CO), hemoglobin (Hb) concentration, and arterial hemoglobin oxygen saturation (SaO2). However, it remains a challenge to identify optimal targets for these global variables that best support microcirculatory function. Weighting up the risks and benefits is especially difficult for choosing the amount of oxygen supplementation in critically ill patients. This review assesses the physiological basis for oxygen delivery to the tissue and provides an overview of the relevant literature to emphasize the importance of considering risks and benefits and support decision making at the bedside. PHYSIOLOGICAL PREMISES Oxygen must reach the tissue to enable oxidative phosphorylation. The human body timely detects hypoxia via different mechanisms aiming to maintain adequate tissue oxygenation. In contrast to the pulmonary circulation, where the main response to hypoxia is arteriolar vasoconstriction, the regulatory mechanisms of the systemic circulation aim to optimize oxygen availability in the tissues. This is achieved by increasing the capillary density in the microcirculation and the capillary hematocrit thereby increasing the capacity of oxygen diffusion from the red blood cells to the tissue. Hyperoxia, on the other hand, is associated with oxygen radical production, promoting cell death. CURRENT STATE OF RESEARCH Clinical trials in critically ill patients have primarily focused on comparing macrocirculatory endpoints and outcomes based on stroke volume and oxygenation targets. Some earlier studies have indicated potential benefits of conservative oxygenation. Recent trials show contradictory results regarding mortality, organ dysfunction, and ventilatory-free days. Empirical studies comparing various targets for SaO2, or partial pressure of oxygen indicate a U-shaped curve balancing positive and negative effects of oxygen supplementation. CONCLUSION AND FUTURE DIRECTIONS To optimize risk-benefit ratio of resuscitation measures in critically ill patients with circulatory shock in addition to individual targets for CO and Hb concentration, a primary aim should be to restore tissue perfusion and avoid hyperoxia. In the future, an individualized approach with microcirculatory targets will become increasingly relevant. Further studies are needed to define optimal targets.
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Affiliation(s)
- Anne-Aylin Sigg
- Institute of Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
| | - Vanja Zivkovic
- Institute of Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Jan Bartussek
- Institute of Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Reto A Schuepbach
- Institute of Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Matthias P Hilty
- Institute of Intensive Care Medicine, University Hospital of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
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Mahmoodpoor A, Chalkias A, Izadi M, Gohari-Moghadam K, Rahimi-Bashar F, Karadağ A, Khosh-Fetrat M, Vahedian-Azimi A. Association of norepinephrine with pressure ulcer development in critically ill patients with COVID-19-related acute respiratory distress syndrome: A dose-response analysis. Intensive Crit Care Nurs 2024:103796. [PMID: 39117534 DOI: 10.1016/j.iccn.2024.103796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Revised: 07/23/2024] [Accepted: 08/01/2024] [Indexed: 08/10/2024]
Abstract
OBJECTIVES To investigate the correlation between varying doses of norepinephrine (NE) and the incidence of pressure injuries (PIs) in COVID-19 patients in intensive care units (ICUs). DESIGN A retrospective multicenter study was conducted on 1,078 COVID-19 patients admitted to ICUs with acute respiratory distress syndrome (ARDS) requiring mechanical ventilation. The research spanned from March 2020 to April 2021 across five university-affiliated hospitals in Iran. Univariate and multivariate binary logistic regression analyses, along with linear and non-linear dose-response assessments, were utilized to evaluate the relationship between NE dosages and the probability of PI development. FINDINGS The multivariate analysis revealed a significant association between higher doses of NE administered over 24 h (OR: 1.832, 95 % CI: 1.218-2.754, P=0.004) and cumulative doses (OR: 1.408, 95 % CI: 1.204-1.975, P=0.048) with the occurrence of PIs. Moreover, patients receiving high NE doses had a nearly fourfold increased risk of developing PIs, regardless of PIs stage, compared to those on low or moderate doses (>15 µg/min vs. ≤ 15 µg/min; OR: 4.401, 95 % CI: 3.339-5.801, P=0.001). Although the linear dose-response analysis did not show a significant correlation between NE doses (µg/min) and PI development (P>0.05), the non-linear analysis indicated that NE doses ≤ 9 µg/min were associated with a reduced risk of PI development. CONCLUSION Maintaining NE infusion within the range of 1-9 µg/min appears to be most effective in reducing the likelihood of PIs in ICU patients with COVID-19. Lower NE doses (≤9 µg/min) were associated with a lower risk of PI development, suggesting that factors beyond NE dosage or the use of other vasopressors may play a crucial role in PI formation in this patient cohort. IMPLICATIONS FOR CLINICAL PRACTICE Rather than suggesting a specific threshold, clinicians should consider further studies to determine the optimal dose that balances microvascular perfusion and patient outcomes. It is crucial to comprehensively evaluate additional factors and selectively use vasopressors. Individualized care, including regular monitoring and personalized treatment plans, is essential for achieving the best outcomes in this patient population.
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Affiliation(s)
- Ata Mahmoodpoor
- Research Center for Integrative Medicine in Aging, Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Athanasios Chalkias
- Institute for Translational Medicine and Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Outcomes Research Consortium, Cleveland, OH 44195, USA.
| | - Morteza Izadi
- Health Research Center, Life Style Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran.
| | - Kievan Gohari-Moghadam
- Medical ICU and Pulmonary Unit, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.
| | - Farshid Rahimi-Bashar
- Department of Anesthesiology and Critical Care, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran.
| | - Ayişe Karadağ
- Koc University School of Nursing, 34010 Istanbul, Türkiye.
| | - Masoum Khosh-Fetrat
- Department of Anesthesiology and Critical Care, Khatamolanbia Hospital, Zahedan University of Medical Sciences, Zahedan, Iran.
| | - Amir Vahedian-Azimi
- Nursing Care Research Center, Clinical Sciences Institute, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran.
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De Lorenzo A, Fernandes M, Tibirica E. From bench to bedside: A review of the application and potential of microcirculatory assessment by hand-held videomicroscopy. IJC HEART & VASCULATURE 2024; 53:101451. [PMID: 39050555 PMCID: PMC11266521 DOI: 10.1016/j.ijcha.2024.101451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 06/02/2024] [Accepted: 06/19/2024] [Indexed: 07/27/2024]
Abstract
In clinical practice, there is vast knowledge regarding the evaluation of macrocirculatory parameters, such as systemic blood pressure and cardiac output, for the hemodynamic monitoring of patients. However, assessment of the microcirculation has not yet been incorporated into the bedside armamentarium. Hand-held intravital video microscopy enables the direct, noninvasive, evaluation of the sublingual microcirculation at the bedside, offering insights into the status of the systemic microcirculation. It is easily performed and may be employed in several clinical settings, providing immediate results that may help guide patient management. Therefore, the incorporation of hand-held intravital video microscopy into clinical practice may lead to tremendous improvements in the quality of care of critical, unstable patients or offer new data in the evaluation of patients with chronic diseases, especially those with microcirculatory involvement, such as occurs in diabetes.
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Scheim DE, Parry PI, Rabbolini DJ, Aldous C, Yagisawa M, Clancy R, Borody TJ, Hoy WE. Back to the Basics of SARS-CoV-2 Biochemistry: Microvascular Occlusive Glycan Bindings Govern Its Morbidities and Inform Therapeutic Responses. Viruses 2024; 16:647. [PMID: 38675987 PMCID: PMC11054389 DOI: 10.3390/v16040647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 04/12/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024] Open
Abstract
Consistent with the biochemistry of coronaviruses as well established over decades, SARS-CoV-2 makes its initial attachment to host cells through the binding of its spike protein (SP) to sialylated glycans (containing the monosaccharide sialic acid) on the cell surface. The virus can then slide over and enter via ACE2. SARS-CoV-2 SP attaches particularly tightly to the trillions of red blood cells (RBCs), platelets and endothelial cells in the human body, each cell very densely coated with sialic acid surface molecules but having no ACE2 or minimal ACE2. These interlaced attachments trigger the blood cell aggregation, microvascular occlusion and vascular damage that underlie the hypoxia, blood clotting and related morbidities of severe COVID-19. Notably, the two human betacoronaviruses that express a sialic acid-cleaving enzyme are benign, while the other three-SARS, SARS-CoV-2 and MERS-are virulent. RBC aggregation experimentally induced in several animal species using an injected polysaccharide caused most of the same morbidities of severe COVID-19. This glycan biochemistry is key to disentangling controversies that have arisen over the efficacy of certain generic COVID-19 treatment agents and the safety of SP-based COVID-19 vaccines. More broadly, disregard for the active physiological role of RBCs yields unreliable or erroneous reporting of pharmacokinetic parameters as routinely obtained for most drugs and other bioactive agents using detection in plasma, with whole-blood levels being up to 30-fold higher. Appreciation of the active role of RBCs can elucidate the microvascular underpinnings of other health conditions, including cardiovascular disease, and therapeutic opportunities to address them.
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Affiliation(s)
- David E. Scheim
- US Public Health Service, Commissioned Corps, Inactive Reserve, Blacksburg, VA 24060, USA
| | - Peter I. Parry
- Children’s Health Research Clinical Unit, Faculty of Medicine, The University of Queensland, South Brisbane, QLD 4101, Australia;
- Department of Psychiatry, Flinders University, Bedford Park, SA 5042, Australia
| | - David J. Rabbolini
- Kolling Institute, Faculty of Medicine and Health, The University of Sydney, St Leonards, NSW 2064, Australia
| | - Colleen Aldous
- College of Health Sciences, University of KwaZulu-Natal, Durban 4041, South Africa;
| | - Morimasa Yagisawa
- Satoshi Omura Memorial Research Institute, Kitasato University, Tokyo 108-8641, Japan
- Louis Pasteur Center for Medical Research, Kyoto 606-8225, Japan
| | - Robert Clancy
- Emeritus Professor, School of Medicine and Public Health, University of Newcastle, Newcastle, NE1 7RU, Australia
| | | | - Wendy E. Hoy
- Emeritus Professor of Medicine, University of Queensland, Herston, QLD 4029, Australia
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Hilderink BN, Crane RF, van den Bogaard B, Pillay J, Juffermans NP. Hyperoxemia and hypoxemia impair cellular oxygenation: a study in healthy volunteers. Intensive Care Med Exp 2024; 12:37. [PMID: 38619625 PMCID: PMC11018572 DOI: 10.1186/s40635-024-00619-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 03/28/2024] [Indexed: 04/16/2024] Open
Abstract
INTRODUCTION Administration of oxygen therapy is common, yet there is a lack of knowledge on its ability to prevent cellular hypoxia as well as on its potential toxicity. Consequently, the optimal oxygenation targets in clinical practice remain unresolved. The novel PpIX technique measures the mitochondrial oxygen tension in the skin (mitoPO2) which allows for non-invasive investigation on the effect of hypoxemia and hyperoxemia on cellular oxygen availability. RESULTS During hypoxemia, SpO2 was 80 (77-83)% and PaO2 45(38-50) mmHg for 15 min. MitoPO2 decreased from 42(35-51) at baseline to 6(4.3-9)mmHg (p < 0.001), despite 16(12-16)% increase in cardiac output which maintained global oxygen delivery (DO2). During hyperoxic breathing, an FiO2 of 40% decreased mitoPO2 to 20 (9-27) mmHg. Cardiac output was unaltered during hyperoxia, but perfused De Backer density was reduced by one-third (p < 0.01). A PaO2 < 100 mmHg and > 200 mmHg were both associated with a reduction in mitoPO2. CONCLUSIONS Hypoxemia decreases mitoPO2 profoundly, despite complete compensation of global oxygen delivery. In addition, hyperoxemia also decreases mitoPO2, accompanied by a reduction in microcirculatory perfusion. These results suggest that mitoPO2 can be used to titrate oxygen support.
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Affiliation(s)
- Bashar N Hilderink
- Department of Intensive Care, OLVG Hospital, Amsterdam, The Netherlands.
| | - Reinier F Crane
- Department of Intensive Care, OLVG Hospital, Amsterdam, The Netherlands
| | | | - Janesh Pillay
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care, OLVG Hospital, Amsterdam, The Netherlands
- Laboratory of Translational Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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Brouwer F, Ince C, Pols J, Uz Z, Hilty MP, Arbous MS. The microcirculation in the first days of ICU admission in critically ill COVID-19 patients is influenced by severity of disease. Sci Rep 2024; 14:6454. [PMID: 38499589 PMCID: PMC10948764 DOI: 10.1038/s41598-024-56245-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 03/04/2024] [Indexed: 03/20/2024] Open
Abstract
The objective of this study was to investigate the relationship between sublingual microcirculatory parameters and the severity of the disease in critically ill coronavirus disease 2019 (COVID-19) patients in the initial period of Intensive Care Unit (ICU) admission in a phase of the COVID-19 pandemic where patients were being treated with anti-inflammatory medication. In total, 35 critically ill COVID-19 patients were included. Twenty-one critically ill COVID-19 patients with a Sequential Organ Failure Assessment (SOFA) score below or equal to 7 were compared to 14 critically ill COVID-19 patients with a SOFA score exceeding 7. All patients received dexamethasone and tocilizumab at ICU admission. Microcirculatory measurements were performed within the first five days of ICU admission, preferably as soon as possible after admission. An increase in diffusive capacity of the microcirculation (total vessel density, functional capillary density, capillary hematocrit) and increased perfusion of the tissues by red blood cells was found in the critically ill COVID-19 patients with a SOFA score of 7-9 compared to the critically ill COVID-19 patients with a SOFA score ≤ 7. No such effects were found in the convective component of the microcirculation. These effects occurred in the presence of administration of anti-inflammatory medication.
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Affiliation(s)
- Fleur Brouwer
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Jiska Pols
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Zühre Uz
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Matthias Peter Hilty
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Mendi Sesmu Arbous
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands.
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8
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Scheim DE, Vottero P, Santin AD, Hirsh AG. Sialylated Glycan Bindings from SARS-CoV-2 Spike Protein to Blood and Endothelial Cells Govern the Severe Morbidities of COVID-19. Int J Mol Sci 2023; 24:17039. [PMID: 38069362 PMCID: PMC10871123 DOI: 10.3390/ijms242317039] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 11/24/2023] [Accepted: 11/27/2023] [Indexed: 12/18/2023] Open
Abstract
Consistent with well-established biochemical properties of coronaviruses, sialylated glycan attachments between SARS-CoV-2 spike protein (SP) and host cells are key to the virus's pathology. SARS-CoV-2 SP attaches to and aggregates red blood cells (RBCs), as shown in many pre-clinical and clinical studies, causing pulmonary and extrapulmonary microthrombi and hypoxia in severe COVID-19 patients. SARS-CoV-2 SP attachments to the heavily sialylated surfaces of platelets (which, like RBCs, have no ACE2) and endothelial cells (having minimal ACE2) compound this vascular damage. Notably, experimentally induced RBC aggregation in vivo causes the same key morbidities as for severe COVID-19, including microvascular occlusion, blood clots, hypoxia and myocarditis. Key risk factors for COVID-19 morbidity, including older age, diabetes and obesity, are all characterized by markedly increased propensity to RBC clumping. For mammalian species, the degree of clinical susceptibility to COVID-19 correlates to RBC aggregability with p = 0.033. Notably, of the five human betacoronaviruses, the two common cold strains express an enzyme that releases glycan attachments, while the deadly SARS, SARS-CoV-2 and MERS do not, although viral loads for COVID-19 and the two common cold infections are similar. These biochemical insights also explain the previously puzzling clinical efficacy of certain generics against COVID-19 and may support the development of future therapeutic strategies for COVID-19 and long COVID patients.
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Affiliation(s)
- David E Scheim
- US Public Health Service, Commissioned Corps, Inactive Reserve, Blacksburg, VA 24060, USA
| | - Paola Vottero
- Department of Biomedical Engineering, University of Alberta, Edmonton, AB T6G 1Z2, Canada
| | - Alessandro D Santin
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, P.O. Box 208063, New Haven, CT 06520, USA
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9
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Hilty MP, Jung C. Tissue oxygenation: how to measure, how much to target. Intensive Care Med Exp 2023; 11:64. [PMID: 37740840 PMCID: PMC10517908 DOI: 10.1186/s40635-023-00551-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 09/15/2023] [Indexed: 09/25/2023] Open
Affiliation(s)
- Matthias P Hilty
- Institute of Intensive Care Medicine, University Hospital of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
| | - Christian Jung
- Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany
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10
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Damiani E, Carsetti A, Casarotta E, Domizi R, Scorcella C, Donati A, Adrario E. Microcirculation-guided resuscitation in sepsis: the next frontier? Front Med (Lausanne) 2023; 10:1212321. [PMID: 37476612 PMCID: PMC10354242 DOI: 10.3389/fmed.2023.1212321] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 06/20/2023] [Indexed: 07/22/2023] Open
Abstract
Microcirculatory dysfunction plays a key role in the pathogenesis of tissue dysoxia and organ failure in sepsis. Sublingual videomicroscopy techniques enable the real-time non-invasive assessment of microvascular blood flow. Alterations in sublingual microvascular perfusion were detected during sepsis and are associated with poor outcome. More importantly, sublingual videomicroscopy allowed to explore the effects of commonly applied resuscitative treatments in septic shock, such as fluids, vasopressors and inotropes, and showed that the optimization of macro-hemodynamic parameters may not be accompanied by an improvement in microvascular perfusion. This loss of "hemodynamic coherence," i.e., the concordance between the response of the macrocirculation and the microcirculation, advocates for the integration of microvascular monitoring in the management of septic patients. Nonetheless, important barriers remain for a widespread use of sublingual videomicroscopy in the clinical practice. In this review, we discuss the actual limitations of this technique and future developments that may allow an easier and faster evaluation of the microcirculation at the bedside, and propose a role for sublingual microvascular monitoring in guiding and titrating resuscitative therapies in sepsis.
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Affiliation(s)
- Elisa Damiani
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Andrea Carsetti
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Erika Casarotta
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Roberta Domizi
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Claudia Scorcella
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Abele Donati
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Erica Adrario
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
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11
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Eder J, Schumm L, Armann JP, Puhan MA, Beuschlein F, Kirschbaum C, Berner R, Toepfner N. Increased red blood cell deformation in children and adolescents after SARS-CoV-2 infection. Sci Rep 2023; 13:9823. [PMID: 37330522 PMCID: PMC10276822 DOI: 10.1038/s41598-023-35692-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 05/22/2023] [Indexed: 06/19/2023] Open
Abstract
Severe coronavirus disease 2019 (COVID-19) is associated with hyperinflammation, hypercoagulability and hypoxia. Red blood cells (RBCs) play a key role in microcirculation and hypoxemia and are therefore of special interest in COVID-19 pathophysiology. While this novel disease has claimed the lives of many older patients, it often goes unnoticed or with mild symptoms in children. This study aimed to investigate morphological and mechanical characteristics of RBCs after SARS-CoV-2 infection in children and adolescents by real-time deformability-cytometry (RT-DC), to investigate the relationship between alterations of RBCs and clinical course of COVID-19. Full blood of 121 students from secondary schools in Saxony, Germany, was analyzed. SARS-CoV-2-serostatus was acquired at the same time. Median RBC deformation was significantly increased in SARS-CoV-2-seropositive compared to seronegative children and adolescents, but no difference could be detected when the infection dated back more than 6 months. Median RBC area was the same in seropositive and seronegative adolescents. Our findings of increased median RBC deformation in SARS-CoV-2 seropositive children and adolescents until 6 months post COVID-19 could potentially serve as a progression parameter in the clinical course of the disease with an increased RBC deformation pointing towards a mild course of COVID-19.
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Affiliation(s)
- Julian Eder
- Biopsychology, Technische Universität Dresden, Dresden, Germany
| | - Leonie Schumm
- Department of Paediatrics, University Hospital and Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jakob P Armann
- Department of Paediatrics, University Hospital and Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Milo A Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Felix Beuschlein
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich, Zurich, Switzerland
| | | | - Reinhard Berner
- Department of Paediatrics, University Hospital and Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Nicole Toepfner
- Department of Paediatrics, University Hospital and Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
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12
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Duranteau J, De Backer D, Donadello K, Shapiro NI, Hutchings SD, Rovas A, Legrand M, Harrois A, Ince C. The future of intensive care: the study of the microcirculation will help to guide our therapies. Crit Care 2023; 27:190. [PMID: 37193993 PMCID: PMC10186296 DOI: 10.1186/s13054-023-04474-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 05/03/2023] [Indexed: 05/18/2023] Open
Abstract
The goal of hemodynamic resuscitation is to optimize the microcirculation of organs to meet their oxygen and metabolic needs. Clinicians are currently blind to what is happening in the microcirculation of organs, which prevents them from achieving an additional degree of individualization of the hemodynamic resuscitation at tissue level. Indeed, clinicians never know whether optimization of the microcirculation and tissue oxygenation is actually achieved after macrovascular hemodynamic optimization. The challenge for the future is to have noninvasive, easy-to-use equipment that allows reliable assessment and immediate quantitative analysis of the microcirculation at the bedside. There are different methods for assessing the microcirculation at the bedside; all have strengths and challenges. The use of automated analysis and the future possibility of introducing artificial intelligence into analysis software could eliminate observer bias and provide guidance on microvascular-targeted treatment options. In addition, to gain caregiver confidence and support for the need to monitor the microcirculation, it is necessary to demonstrate that incorporating microcirculation analysis into the reasoning guiding hemodynamic resuscitation prevents organ dysfunction and improves the outcome of critically ill patients.
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Affiliation(s)
- J Duranteau
- Department of Anesthesiology and Intensive Care, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), INSERM UMR-S 999, Paris-Saclay University, Le Kremlin-Bicêtre, France.
| | - D De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Boulevard du Triomphe 201, 1160, Brussels, Belgium
| | - K Donadello
- Anaesthesia and Intensive Care Unit B, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, University Hospital Integrated Trust of Verona, Verona, Italy
| | - N I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School, Boston, MA, USA
| | - S D Hutchings
- King's College Hospital NHS Foundation Trust, London, UK
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK
| | - A Rovas
- Division of General Internal and Emergency Medicine, Nephrology, and Rheumatology, Department of Medicine D, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - M Legrand
- Division of Critical Care Medicine, Department of Anesthesia and Perioperative Care, UCSF, San Francisco, USA
| | - A Harrois
- Department of Anesthesiology and Intensive Care, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), INSERM UMR-S 999, Paris-Saclay University, Le Kremlin-Bicêtre, France
| | - C Ince
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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13
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De Backer D. Novelties in the evaluation of microcirculation in septic shock. JOURNAL OF INTENSIVE MEDICINE 2023; 3:124-130. [PMID: 37188120 PMCID: PMC10175708 DOI: 10.1016/j.jointm.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 08/25/2022] [Accepted: 09/01/2022] [Indexed: 05/17/2023]
Abstract
Microvascular alterations were first described in critically ill patients about 20 years ago. These alterations are characterized by a decrease in vascular density and presence of non-perfused capillaries close to well-perfused vessels. In addition, heterogeneity in microvascular perfusion is a key finding in sepsis. In this narrative review, we report our actual understanding of microvascular alterations, their role in the development of organ dysfunction, and the implications for outcome. Herein, we discuss the state of the potential therapeutic interventions and the potential impact of novel therapies. We also discuss how recent technologic development may affect the evaluation of microvascular perfusion.
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14
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Druzak S, Iffrig E, Roberts BR, Zhang T, Fibben KS, Sakurai Y, Verkerke HP, Rostad CA, Chahroudi A, Schneider F, Wong AKH, Roberts AM, Chandler JD, Kim SO, Mosunjac M, Mosunjac M, Geller R, Albizua I, Stowell SR, Arthur CM, Anderson EJ, Ivanova AA, Ahn J, Liu X, Maner-Smith K, Bowen T, Paiardini M, Bosinger SE, Roback JD, Kulpa DA, Silvestri G, Lam WA, Ortlund EA, Maier CL. Multiplatform analyses reveal distinct drivers of systemic pathogenesis in adult versus pediatric severe acute COVID-19. Nat Commun 2023; 14:1638. [PMID: 37015925 PMCID: PMC10073144 DOI: 10.1038/s41467-023-37269-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 03/08/2023] [Indexed: 04/06/2023] Open
Abstract
The pathogenesis of multi-organ dysfunction associated with severe acute SARS-CoV-2 infection remains poorly understood. Endothelial damage and microvascular thrombosis have been identified as drivers of COVID-19 severity, yet the mechanisms underlying these processes remain elusive. Here we show alterations in fluid shear stress-responsive pathways in critically ill COVID-19 adults as compared to non-COVID critically ill adults using a multiomics approach. Mechanistic in-vitro studies, using microvasculature-on-chip devices, reveal that plasma from critically ill COVID-19 adults induces fibrinogen-dependent red blood cell aggregation that mechanically damages the microvascular glycocalyx. This mechanism appears unique to COVID-19, as plasma from non-COVID sepsis patients demonstrates greater red blood cell membrane stiffness but induces less significant alterations in overall blood rheology. Multiomics analyses in pediatric patients with acute COVID-19 or the post-infectious multi-inflammatory syndrome in children (MIS-C) demonstrate little overlap in plasma cytokine and metabolite changes compared to adult COVID-19 patients. Instead, pediatric acute COVID-19 and MIS-C patients show alterations strongly associated with cytokine upregulation. These findings link high fibrinogen and red blood cell aggregation with endotheliopathy in adult COVID-19 patients and highlight differences in the key mediators of pathogenesis between adult and pediatric populations.
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Grants
- T32 GM142617 NIGMS NIH HHS
- P51 OD011132 NIH HHS
- R35 HL145000 NHLBI NIH HHS
- K99 HL150626 NHLBI NIH HHS
- T32 GM135060 NIGMS NIH HHS
- F31 DK126435 NIDDK NIH HHS
- R01 DK115213 NIDDK NIH HHS
- R38 AI140299 NIAID NIH HHS
- A F31 training fellowship from the National Institutes of Health National Institute of Diabetes and Digestive and Kidney Diseases (NIH/NIDDK), F31DK126435, supported S.A.D during the duration of this work. Stimulating Access to Research in Residency of the National Institutes of Health under Award Number R38AI140299 supported E.I. R35HL145000 supported E.I, Y.S, K.S.F and W.A.L. National Institutes of Health National Heart, Lung, and Blood Institute (NIH/NHLBI) HL150658, awarded to J.D.C. A training grant supported by the Biochemistry and Cell Developmental Biology program (BCDB) at Emory university, T32GM135060-02S1, to S.O.K. NIH/NIDDK Grant R01-DK115213 and Winship Synergy Award to E.A.O. NIH/NHLBI K99 HL150626-01 awarded to C.L.M. The lipidomics and metabolomics experiments were supported by the Emory Integrated Metabolomics and Lipidomics Core, which is subsidized by the Emory University School of Medicine and is one of the Emory Integrated Core Facilities.
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Affiliation(s)
- Samuel Druzak
- Department of Biochemistry, Emory University School of Medicine, Atlanta, GA, USA
| | - Elizabeth Iffrig
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Wallace H Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - Blaine R Roberts
- Department of Biochemistry, Emory University School of Medicine, Atlanta, GA, USA
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Tiantian Zhang
- Emory Integrated Metabolomics and Lipidomics Core, Emory University School of Medicine, Atlanta, GA, USA
| | - Kirby S Fibben
- Wallace H Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - Yumiko Sakurai
- Wallace H Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Hans P Verkerke
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Christina A Rostad
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
- Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Ann Chahroudi
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
- Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Frank Schneider
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Andrew Kam Ho Wong
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Emory National Primate Research Center, Atlanta, GA, USA
| | - Anne M Roberts
- Department of Biochemistry, Emory University School of Medicine, Atlanta, GA, USA
| | - Joshua D Chandler
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
- Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Susan O Kim
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Mario Mosunjac
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Marina Mosunjac
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Rachel Geller
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Georgia Bureau of Investigation, Decatur, GA, USA
| | - Igor Albizua
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Sean R Stowell
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Connie M Arthur
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Evan J Anderson
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
- Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Anna A Ivanova
- Emory Integrated Metabolomics and Lipidomics Core, Emory University School of Medicine, Atlanta, GA, USA
| | - Jun Ahn
- Emory Integrated Metabolomics and Lipidomics Core, Emory University School of Medicine, Atlanta, GA, USA
| | - Xueyun Liu
- Emory Integrated Metabolomics and Lipidomics Core, Emory University School of Medicine, Atlanta, GA, USA
| | - Kristal Maner-Smith
- Emory Integrated Metabolomics and Lipidomics Core, Emory University School of Medicine, Atlanta, GA, USA
| | - Thomas Bowen
- Emory Integrated Metabolomics and Lipidomics Core, Emory University School of Medicine, Atlanta, GA, USA
| | - Mirko Paiardini
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Emory National Primate Research Center, Atlanta, GA, USA
| | - Steve E Bosinger
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Emory National Primate Research Center, Atlanta, GA, USA
- Emory Vaccine Center, Atlanta, GA, USA
| | - John D Roback
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Deanna A Kulpa
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Emory National Primate Research Center, Atlanta, GA, USA
- Center for AIDS Research, Emory University, Atlanta, GA, USA
| | - Guido Silvestri
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Emory National Primate Research Center, Atlanta, GA, USA
- Emory Vaccine Center, Atlanta, GA, USA
- Center for AIDS Research, Emory University, Atlanta, GA, USA
| | - Wilbur A Lam
- Wallace H Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA.
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.
- Children's Healthcare of Atlanta, Atlanta, GA, USA.
| | - Eric A Ortlund
- Department of Biochemistry, Emory University School of Medicine, Atlanta, GA, USA.
- Emory Integrated Metabolomics and Lipidomics Core, Emory University School of Medicine, Atlanta, GA, USA.
| | - Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA.
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15
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Zharkikh EV, Loktionova YI, Fedorovich AA, Gorshkov AY, Dunaev AV. Assessment of Blood Microcirculation Changes after COVID-19 Using Wearable Laser Doppler Flowmetry. Diagnostics (Basel) 2023; 13:diagnostics13050920. [PMID: 36900064 PMCID: PMC10000665 DOI: 10.3390/diagnostics13050920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/20/2023] [Accepted: 02/24/2023] [Indexed: 03/05/2023] Open
Abstract
The present work is focused on the study of changes in microcirculation parameters in patients who have undergone COVID-19 by means of wearable laser Doppler flowmetry (LDF) devices. The microcirculatory system is known to play a key role in the pathogenesis of COVID-19, and its disorders manifest themselves long after the patient has recovered. In the present work, microcirculatory changes were studied in dynamics on one patient for 10 days before his disease and 26 days after his recovery, and data from the group of patients undergoing rehabilitation after COVID-19 were compared with the data from a control group. A system consisting of several wearable laser Doppler flowmetry analysers was used for the studies. The patients were found to have reduced cutaneous perfusion and changes in the amplitude-frequency pattern of the LDF signal. The obtained data confirm that microcirculatory bed dysfunction is present in patients for a long period after the recovery from COVID-19.
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Affiliation(s)
- Elena V. Zharkikh
- Research and Development Center of Biomedical Photonics, Orel State University, Komsomolskaya 95, Orel 302026, Russia
- Correspondence:
| | - Yulia I. Loktionova
- Research and Development Center of Biomedical Photonics, Orel State University, Komsomolskaya 95, Orel 302026, Russia
| | - Andrey A. Fedorovich
- Research and Development Center of Biomedical Photonics, Orel State University, Komsomolskaya 95, Orel 302026, Russia
- National Medical Research Center for Therapy and Preventive Medicine of the Ministry of Healthcare of the Russian Federation, Petroverigsky 10, Moscow 101990, Russia
| | - Alexander Y. Gorshkov
- National Medical Research Center for Therapy and Preventive Medicine of the Ministry of Healthcare of the Russian Federation, Petroverigsky 10, Moscow 101990, Russia
| | - Andrey V. Dunaev
- Research and Development Center of Biomedical Photonics, Orel State University, Komsomolskaya 95, Orel 302026, Russia
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16
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MONTOMOLI J, HILTY MP, INCE C. Artificial intelligence in intensive care: moving towards clinical decision support systems. Minerva Anestesiol 2022; 88:1066-1072. [DOI: 10.23736/s0375-9393.22.16739-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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17
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Hilty MP, Favaron E, Wendel Garcia PD, Ahiska Y, Uz Z, Akin S, Flick M, Arbous S, Hofmaenner DA, Saugel B, Endeman H, Schuepbach RA, Ince C. Microcirculatory alterations in critically ill COVID-19 patients analyzed using artificial intelligence. Crit Care 2022; 26:311. [PMID: 36242010 PMCID: PMC9568900 DOI: 10.1186/s13054-022-04190-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 10/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The sublingual microcirculation presumably exhibits disease-specific changes in function and morphology. Algorithm-based quantification of functional microcirculatory hemodynamic variables in handheld vital microscopy (HVM) has recently allowed identification of hemodynamic alterations in the microcirculation associated with COVID-19. In the present study we hypothesized that supervised deep machine learning could be used to identify previously unknown microcirculatory alterations, and combination with algorithmically quantified functional variables increases the model's performance to differentiate critically ill COVID-19 patients from healthy volunteers. METHODS Four international, multi-central cohorts of critically ill COVID-19 patients and healthy volunteers (n = 59/n = 40) were used for neuronal network training and internal validation, alongside quantification of functional microcirculatory hemodynamic variables. Independent verification of the models was performed in a second cohort (n = 25/n = 33). RESULTS Six thousand ninety-two image sequences in 157 individuals were included. Bootstrapped internal validation yielded AUROC(CI) for detection of COVID-19 status of 0.75 (0.69-0.79), 0.74 (0.69-0.79) and 0.84 (0.80-0.89) for the algorithm-based, deep learning-based and combined models. Individual model performance in external validation was 0.73 (0.71-0.76) and 0.61 (0.58-0.63). Combined neuronal network and algorithm-based identification yielded the highest externally validated AUROC of 0.75 (0.73-0.78) (P < 0.0001 versus internal validation and individual models). CONCLUSIONS We successfully trained a deep learning-based model to differentiate critically ill COVID-19 patients from heathy volunteers in sublingual HVM image sequences. Internally validated, deep learning was superior to the algorithmic approach. However, combining the deep learning method with an algorithm-based approach to quantify the functional state of the microcirculation markedly increased the sensitivity and specificity as compared to either approach alone, and enabled successful external validation of the identification of the presence of microcirculatory alterations associated with COVID-19 status.
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Affiliation(s)
- Matthias Peter Hilty
- grid.412004.30000 0004 0478 9977Institute of Intensive Care Medicine, University Hospital of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland ,grid.5645.2000000040459992XDepartment of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Emanuele Favaron
- grid.5645.2000000040459992XDepartment of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Pedro David Wendel Garcia
- grid.412004.30000 0004 0478 9977Institute of Intensive Care Medicine, University Hospital of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | | | - Zuhre Uz
- grid.10419.3d0000000089452978Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Sakir Akin
- grid.413591.b0000 0004 0568 6689Department of Intensive Care, Haga Hospital, The Hague, The Netherlands
| | - Moritz Flick
- grid.13648.380000 0001 2180 3484Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sesmu Arbous
- grid.10419.3d0000000089452978Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Daniel A. Hofmaenner
- grid.412004.30000 0004 0478 9977Institute of Intensive Care Medicine, University Hospital of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Bernd Saugel
- grid.13648.380000 0001 2180 3484Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Henrik Endeman
- grid.5645.2000000040459992XDepartment of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Reto Andreas Schuepbach
- grid.412004.30000 0004 0478 9977Institute of Intensive Care Medicine, University Hospital of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Can Ince
- grid.5645.2000000040459992XDepartment of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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18
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Raia L, Urbina T, Gabarre P, Bonny V, Hariri G, Ehrminger S, Bigé N, Baudel JL, Guidet B, Maury E, Joffre J, Ait-Oufella H. Impaired skin microvascular endothelial reactivity in critically ill COVID-19 patients. Ann Intensive Care 2022; 12:51. [PMID: 35696007 PMCID: PMC9188908 DOI: 10.1186/s13613-022-01027-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 06/01/2022] [Indexed: 11/25/2022] Open
Abstract
Background Some clinical and histological studies have reported that SARS-CoV-2 infection may damage the endothelium. However, the impact of this virus on endothelial function in vivo remains poorly characterized. In this single-center pilot observational study, we performed iontophoresis of acetylcholine coupled with Laser doppler to investigate microvascular endothelial reactivity in COVID-19 patients compared to patients with non-COVID-19 bacterial pneumonia (NCBP) patients. Results During three consecutive months, 32 COVID-19 patients and 11 control NCBP patients with acute respiratory failure were included. The median age was 59 [50–68] and 69 [57–75] years in COVID-19 and NCBP groups, respectively (P = 0.11). There was no significant difference in comorbidities or medications between the two groups, except for body mass index, which was higher in COVID-19 patients. NCBP patients had a higher SAPS II score compared to COVID-19 patients (P < 0.0001), but SOFA score was not different between groups (P = 0.51). Global hemodynamic and peripheral tissue perfusion parameters were not different between groups. COVID-19 patients had significantly lower skin microvascular basal blood flow than NCBP patients (P = 0.02). In addition, endothelium-dependent microvascular reactivity was threefold lower in COVID-19 patients than NCBP patients (P = 0.008). Conclusions Both baseline skin microvascular blood flow and skin endothelial-dependent microvascular reactivity were impaired in critically ill COVID-19 patients compared to NCBP patients, despite a lower disease severity score supporting a specific pathogenic role of SARS-CoV-2 on the endothelium. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-01027-3.
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Affiliation(s)
- Lisa Raia
- Medical Intensive Care Unit, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Tomas Urbina
- Medical Intensive Care Unit, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Paul Gabarre
- Medical Intensive Care Unit, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Vincent Bonny
- Medical Intensive Care Unit, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Geoffroy Hariri
- Medical Intensive Care Unit, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Sebastien Ehrminger
- Medical Intensive Care Unit, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Naïke Bigé
- Medical Intensive Care Unit, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Jean-Luc Baudel
- Medical Intensive Care Unit, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Bertrand Guidet
- Medical Intensive Care Unit, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France.,Pierre Louis Institute of Epidemiology and Public Health, Sorbonne University, Inserm U1136, Paris, France
| | - Eric Maury
- Medical Intensive Care Unit, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France.,Pierre Louis Institute of Epidemiology and Public Health, Sorbonne University, Inserm U1136, Paris, France.,Centre de Recherche Saint-Antoine, Sorbonne University, Inserm U938, 75012, Paris, France
| | - Jeremie Joffre
- Medical Intensive Care Unit, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France.,Centre de Recherche Saint-Antoine, Sorbonne University, Inserm U938, 75012, Paris, France
| | - Hafid Ait-Oufella
- Medical Intensive Care Unit, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France. .,Paris Cardiovascular Research Center, Paris University, Inserm U970, Paris, France.
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19
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Oxidative stress-induced endothelial dysfunction and decreased vascular nitric oxide in COVID-19 patients. EBioMedicine 2022; 77:103893. [PMID: 35219085 PMCID: PMC8865837 DOI: 10.1016/j.ebiom.2022.103893] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 01/10/2022] [Accepted: 02/08/2022] [Indexed: 02/06/2023] Open
Abstract
Background SARS-CoV-2 targets endothelial cells through the angiotensin-converting enzyme 2 receptor. The resulting endothelial injury induces widespread thrombosis and microangiopathy. Nevertheless, early specific markers of endothelial dysfunction and vascular redox status in COVID-19 patients are currently missing. Methods Observational study including ICU and non-ICU adult COVID-19 patients admitted in hospital for acute respiratory failure, compared with control subjects matched for cardiovascular risk factors similar to ICU COVID-19 patients, and ICU septic shock patients unrelated to COVID-19. Findings Early SARS-CoV-2 infection was associated with an imbalance between an exacerbated oxidative stress (plasma peroxides levels in ICU patients vs. controls: 1456.0 ± 400.2 vs 436 ± 272.1 mmol/L; P < 0.05) and a reduced nitric oxide bioavailability proportional to disease severity (5-α-nitrosyl-hemoglobin, HbNO in ICU patients vs. controls: 116.1 ± 62.1 vs. 163.3 ± 46.7 nmol/L; P < 0.05). HbNO levels correlated with oxygenation parameters (PaO2/FiO2 ratio) in COVID-19 patients (R2 = 0.13; P < 0.05). Plasma levels of angiotensin II, aldosterone, renin or serum level of TREM-1 ruled out any hyper-activation of the renin-angiotensin-aldosterone system or leucocyte respiratory burst in ICU COVID-19 patients, contrary to septic patients. Interpretation Endothelial oxidative stress with ensuing decreased NO bioavailability appears as a likely pathogenic factor of endothelial dysfunction in ICU COVID-19 patients. A correlation between NO bioavailability and oxygenation parameters is observed in hospitalized COVID-19 patients. These results highlight an urgent need for oriented research leading to a better understanding of the specific endothelial oxidative stress that occurs during SARS-CoV-2. Funding Stated in the acknowledgments section.
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20
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Di Dedda U, Ascari A, Fantinato A, Fina D, Baryshnikova E, Ranucci M. Microcirculatory Alterations in Critically Ill Patients with COVID-19-Associated Acute Respiratory Distress Syndrome. J Clin Med 2022; 11:jcm11041032. [PMID: 35207303 PMCID: PMC8876221 DOI: 10.3390/jcm11041032] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 02/01/2022] [Accepted: 02/14/2022] [Indexed: 01/08/2023] Open
Abstract
Background: Presently, a number of specific observations have been performed on microcirculatory function in a coronavirus disease-19 (COVID-19) setting. We hypothesized that, in the critically ill, endothelial dysfunction secondary to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the subsequent inflammation and coagulopathy may lead to microcirculatory alterations, further exacerbated by the hypoxemic state. A dysfunctional microcirculation may represent the hidden motor underlying the development of COVID-19’s clinical manifestations. Methods: A single center, prospective, observational study. We analyzed bedside sublingual microcirculation in twenty-four consecutive COVID-19-associated acute respiratory distress syndrome (ARDS) patients mechanically ventilated in an Intensive Care Unit (ICU), together with macro-hemodynamics, clinical parameters, echocardiography, and laboratory data at a single time-point after ICU admission. All participants were recruited between March and May 2020. Results: The microcirculatory pattern was characterized by increased values of total vessel density and perfused vessel density, a reduced value of proportion of perfused vessels and microvascular flow index, and high values of heterogeneity index. The duration of mechanical ventilation before microcirculation assessment was inversely associated with the proportion of perfused vessels (p = 0.023). Within the macro-hemodynamic parameters, the right ventricle end-diastolic diameter was inversely associated with proportion of perfused vessels and microvascular flow index (p = 0.039 and 0.014, respectively) and directly associated with the heterogeneity index (p = 0.033). Conclusions: In COVID-19-associated ARDS patients, the microcirculation showed impaired quality of flow parameters coupled with a high vessel density.
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21
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Bottari G, Damiani E, Confalone V, Scorcella C, Casarotta E, Gandolfo C, Stoppa F, Cecchetti C, Donati A. Microvascular dysfunction in pediatric patients with SARS-COV-2 pneumonia: Report of three severe cases. Microvasc Res 2022; 141:104312. [PMID: 35026289 PMCID: PMC8744301 DOI: 10.1016/j.mvr.2022.104312] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 01/01/2022] [Accepted: 01/02/2022] [Indexed: 02/06/2023]
Abstract
The coronavirus 19 (COVID-19) pandemic has affected hundreds of millions of people worldwide: in most of cases children and young people developed asymptomatic or pauci-symptomatic clinical pictures. However authors have showed that there are some categories of childhood more vulnerable to COVID-19 infection such as newborns or children with comorbidities. We report for the first time to the best of our knowledge about microvascular dysfunction in three pediatric clinical cases who developed COVID-19 infections with need of pediatric critical care. We found that sublingual microcirculation is altered in children with severe COVID-19 infection. Our findings confirmed most of data already observed by other authors in adult population affected by severe COVID-19 infection, but with distinct characteristics than microcirculation alterations previous observed in a clinical case of MIS-C. However we cannot establish direct correlation between microcirculation analysis and clinical or laboratory parameters in our series, by our experience we have found that sublingual microcirculation analysis allow clinicians to report directly about microcirculation dysfunction in COVID-19 patients and it could be a valuable bedside technique to monitor thrombosis complication in this population.
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Affiliation(s)
- G Bottari
- Pediatric Emergency Department Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - E Damiani
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - V Confalone
- Pediatric Emergency Department Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - C Scorcella
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - E Casarotta
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - C Gandolfo
- Neuroradiologic Unit, Department of Radiology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - F Stoppa
- Pediatric Emergency Department Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - C Cecchetti
- Pediatric Emergency Department Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - A Donati
- Anesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
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22
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Bottari G, Ince C, Confalone V, Perdichizzi S, Casamento Tumeo C, Nunziata J, Bernardi S, Calò Carducci F, Lancella L, Bernaschi P, Russo C, Perno CF, Cecchetti C, Villani A. Case report: Microcirculatory leukocytes in a pediatric patient with severe SARS-CoV-2 pneumonia. Findings of leukocytes trafficking beyond the lungs. Front Pediatr 2022; 10:978381. [PMID: 36160802 PMCID: PMC9493019 DOI: 10.3389/fped.2022.978381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 08/09/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND SARS-CoV-2 can lead to excessive coagulation and thrombo-inflammation with deposition of microthrombi and microvascular dysfunction. Several studies in human and animal models have already evidenced biomarkers of endothelial injury during SARS-CoV-2 infection. Real-time observation of sublingual microcirculation using an handheld vital microscopy with an Incident Dark Field (IDF) technique could represent a non-invasive way to assess early signs of microvascular dysfunction and endothelial inflammation in patients with severe COVID-19 infection. CLINICAL CASE We report for the first time in a pediatric patient with severe SARS-CoV-2 pneumonia findings about microcirculatory leukocytes in the sublingual microcirculation of a 7 month-old patient admitted to our PICU using handheld vital microscopy with IDF technique. RESULTS Sublingual microcirculation analysis revealed the presence of microcirculatory alterations and an extensive presence of leukocytes in the patient's sublingual microcirculation. It's significant to underline how the patient didn't show a contextual significant increase in inflammatory biomarkers or other clinical signs related to an inflammatory response, beyond the presence of severe hypoxic respiratory failure. CONCLUSION Leukocyte activation in multiple organs can occur at the endothelial lining of the microvasculature where a surge of pro-inflammatory mediators can result in accumulation of activated leukocytes and degradation of the endothelium. The introduction of a method to assess in a non-invasive, real-time manner the extent of inflammation in a patient with COVID19 could lead to potential clinical and therapeutic implications. However, more studies are required to prove that studying leukocytes microcirculation using sublingual microcirculation analysis could be useful as a bedside point of care monitor to predict the presence of systemic inflammation associated with the impact of COVID-19, leading in a late phase of severe SARS-CoV-2 infection to a microvascular dysfunction and micro-thrombosis.
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Affiliation(s)
- Gabriella Bottari
- Pediatric Intensive Care Unit, Department of Emergency and General Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Valerio Confalone
- Pediatric Intensive Care Unit, Department of Emergency and General Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Salvatore Perdichizzi
- Pediatric Intensive Care Unit, Department of Emergency and General Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Chiara Casamento Tumeo
- Department of Pediatrics, Residency School of Pediatrics, Bambino Gesù Children's Hospital, IRCCS, University of Rome Tor Vergata, Rome, Italy
| | - Joseph Nunziata
- Pediatric Intensive Care Unit, Department of Emergency and General Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Stefania Bernardi
- Infectious Diseases and Immuno-Infectiology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Francesca Calò Carducci
- Infectious Diseases and Immuno-Infectiology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Laura Lancella
- Infectious Diseases and Immuno-Infectiology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Paola Bernaschi
- Unit of Microbiology and Diagnostic Immunology, Department of Diagnostic and Laboratory Medicine, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Cristina Russo
- Virology and Mycobacteria Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.,Multimodal Medicine Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Carlo Federico Perno
- Multimodal Medicine Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.,Unit of Microbiology and Diagnostic Immunology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Corrado Cecchetti
- Pediatric Intensive Care Unit, Department of Emergency and General Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alberto Villani
- General Pediatric and Infectious Disease Unit, Department of Emergency and General Pediatrics, Bambino Gesù Children's Hospital, IRCSS, Rome, Italy
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23
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Çakmak F, Demirbuga A, Demirkol D, Gümüş S, Torun SH, Kayaalp GK, Ömeroglu RE, Somer A, Uysalol M, Yıldız R, Ayaz NA. Nailfold capillaroscopy: A sensitive method for evaluating microvascular involvement in children with SARS-CoV-2 infection. Microvasc Res 2021; 138:104196. [PMID: 34097919 PMCID: PMC8190529 DOI: 10.1016/j.mvr.2021.104196] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/06/2021] [Accepted: 06/01/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVES The hyperinflammatory state and the viral invasion may result in endothelial dysfunction in SARS-CoV-2 infection. Although a method foreseeing microvascular dysfunction has not been defined yet, studies conducted in patients diagnosed with COVID-19 have demonstrated the presence of endotheliitis. With this study, we aimed to investigate the microvascular circulation in patients diagnosed with COVID-19 and multisystem inflammatory syndrome in children (MIS-C) by nailfold videocapillaroscopy (NVC). METHODS Thirty-one patients with SARS-CoV-2 infection, 25 of whom were diagnosed with COVID-19 and 6 with MIS-C and 58 healthy peers were included in the study. NVC was performed in eight fingers with 2 images per finger and 16 images were examined for the morphology of capillaries, presence of pericapillary edema, microhemorrhage, avascular area, and neoangiogenesis. Capillary length, capillary width, apical loop, arterial and venous width, and intercapillary distance were measured from three consecutive capillaries from the ring finger of the non-dominant hand. RESULTS COVID-19 patients showed significantly more capillary ramification (p < 0.001), capillary meandering (p = 0.04), microhemorrhage (p < 0.001), neoangiogenesis (p < 0.001), capillary tortuosity (p = 0.003). Capillary density (p = 0.002) and capillary length (p = 0.002) were significantly lower in the patient group while intercapillary distance (p = 0.01) was significantly longer compared with healthy volunteers. Morphologically, patients with MIS-C had a higher frequency of capillary ramification and neoangiogenesis compared with COVID-19 patients (p = 0.04). CONCLUSION Abnormal capillary alterations seen in COVID-19 and MIS-C patients indicate both similar and different aspects of these two spectra of SARS-CoV-2 infection and NVC appears to be a simple and non-invasive method for evaluation of microvascular involvement.
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Affiliation(s)
- Figen Çakmak
- Department of Pediatric Rheumatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Asuman Demirbuga
- Department of Pediatric Infectious Diseases, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Demet Demirkol
- Department of Pediatric Intensive Care Unit, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Süheyla Gümüş
- Department of Pediatric Emergency Unit, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Selda Hancerli Torun
- Department of Pediatric Infectious Diseases, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Gülşah Kavrul Kayaalp
- Department of Pediatric Rheumatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Rukiye Eker Ömeroglu
- Department of Pediatric Rheumatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.
| | - Ayper Somer
- Department of Pediatric Infectious Diseases, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Metin Uysalol
- Department of Pediatric Emergency Unit, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.
| | - Raif Yıldız
- Department of Pediatric Emergency Unit, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Nuray Aktay Ayaz
- Department of Pediatric Rheumatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.
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24
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Montomoli J, Romeo L, Moccia S, Bernardini M, Migliorelli L, Berardini D, Donati A, Carsetti A, Bocci MG, Wendel Garcia PD, Fumeaux T, Guerci P, Schüpbach RA, Ince C, Frontoni E, Hilty MP, Vizmanos-Lamotte G, Tschoellitsch T, Meier J, Aguirre-Bermeo H, Apolo J, Martínez A, Jurkolow G, Delahaye G, Novy E, Losser MR, Wengenmayer T, Rilinger J, Staudacher DL, David S, Welte T, Stahl K, Pavlos” “A, Aslanidis T, Korsos A, Babik B, Nikandish R, Rezoagli E, Giacomini M, Nova A, Fogagnolo A, Spadaro S, Ceriani R, Murrone M, Wu MA, Cogliati C, Colombo R, Catena E, Turrini F, Simonini MS, Fabbri S, Potalivo A, Facondini F, Gangitano G, Perin T, Grazia Bocci M, Antonelli M, Gommers D, Rodríguez-García R, Gámez-Zapata J, Taboada-Fraga X, Castro P, Tellez A, Lander-Azcona A, Escós-Orta J, Martín-Delgado MC, Algaba-Calderon A, Franch-Llasat D, Roche-Campo F, Lozano-Gómez H, Zalba-Etayo B, Michot MP, Klarer A, Ensner R, Schott P, Urech S, Zellweger N, Merki L, Lambert A, Laube M, Jeitziner MM, Jenni-Moser B, Wiegand J, Yuen B, Lienhardt-Nobbe B, Westphalen A, Salomon P, Drvaric I, Hillgaertner F, Sieber M, Dullenkopf A, Petersen L, Chau I, Ksouri H, Sridharan GO, Cereghetti S, Boroli F, Pugin J, Grazioli S, Rimensberger PC, Bürkle C, Marrel J, Brenni M, Fleisch I, Lavanchy J, Perez MH, Ramelet AS, Weber AB, Gerecke P, Christ A, Ceruti S, Glotta A, Marquardt K, Shaikh K, Hübner T, Neff T, Redecker H, Moret-Bochatay M, Bentrup FZ, Studhalter M, Stephan M, Brem J, Gehring N, Selz D, Naon D, Kleger GR, Pietsch U, Filipovic M, Ristic A, Sepulcri M, Heise A, Franchitti Laurent M, Laurent JC, Wendel Garcia PD, Schuepbach R, Heuberger D, Bühler P, Brugger S, Fodor P, Locher P, Camen G, Gaspert T, Jovic M, Haberthuer C, Lussman RF, Colak E. Machine learning using the extreme gradient boosting (XGBoost) algorithm predicts 5-day delta of SOFA score at ICU admission in COVID-19 patients. JOURNAL OF INTENSIVE MEDICINE 2021; 1:110-116. [PMID: 36785563 PMCID: PMC8531027 DOI: 10.1016/j.jointm.2021.09.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/20/2021] [Accepted: 09/06/2021] [Indexed: 02/08/2023]
Abstract
Background Accurate risk stratification of critically ill patients with coronavirus disease 2019 (COVID-19) is essential for optimizing resource allocation, delivering targeted interventions, and maximizing patient survival probability. Machine learning (ML) techniques are attracting increased interest for the development of prediction models as they excel in the analysis of complex signals in data-rich environments such as critical care. Methods We retrieved data on patients with COVID-19 admitted to an intensive care unit (ICU) between March and October 2020 from the RIsk Stratification in COVID-19 patients in the Intensive Care Unit (RISC-19-ICU) registry. We applied the Extreme Gradient Boosting (XGBoost) algorithm to the data to predict as a binary outcome the increase or decrease in patients' Sequential Organ Failure Assessment (SOFA) score on day 5 after ICU admission. The model was iteratively cross-validated in different subsets of the study cohort. Results The final study population consisted of 675 patients. The XGBoost model correctly predicted a decrease in SOFA score in 320/385 (83%) critically ill COVID-19 patients, and an increase in the score in 210/290 (72%) patients. The area under the mean receiver operating characteristic curve for XGBoost was significantly higher than that for the logistic regression model (0.86 vs. 0.69, P < 0.01 [paired t-test with 95% confidence interval]). Conclusions The XGBoost model predicted the change in SOFA score in critically ill COVID-19 patients admitted to the ICU and can guide clinical decision support systems (CDSSs) aimed at optimizing available resources.
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Affiliation(s)
- Jonathan Montomoli
- Department of Anaesthesia and Intensive Care, Infermi Hospital, AUSL della Romagna, Rimini 47923, Italy
| | - Luca Romeo
- Department of Information Engineering, Università Politecnica delle Marche, Ancona 60131, Italy
| | - Sara Moccia
- Department of Information Engineering, Università Politecnica delle Marche, Ancona 60131, Italy,The BioRobotics Institute and Department of Excellence in Robotics and AI, Scuola Superiore Sant'Anna, Pisa 56127, Italy
| | - Michele Bernardini
- Department of Information Engineering, Università Politecnica delle Marche, Ancona 60131, Italy
| | - Lucia Migliorelli
- Department of Information Engineering, Università Politecnica delle Marche, Ancona 60131, Italy
| | - Daniele Berardini
- Department of Information Engineering, Università Politecnica delle Marche, Ancona 60131, Italy
| | - Abele Donati
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria Ospedali Riuniti, Ancona 60126, Italy,Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona 60126, Italy
| | - Andrea Carsetti
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria Ospedali Riuniti, Ancona 60126, Italy,Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona 60126, Italy
| | - Maria Grazia Bocci
- Department of Anaesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome 00168, Italy
| | | | - Thierry Fumeaux
- Swiss Society of Intensive Care Medicine, Basel 4001, Switzerland
| | - Philippe Guerci
- Department of Anesthesiology and Critical Care Medicine, University Hospital of Nancy, Nancy 54511, France
| | - Reto Andreas Schüpbach
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zurich 8091, Switzerland
| | - Can Ince
- Department of Intensive Care Erasmus MC, University Medical Center Rotterdam, Rotterdam, 3015 GD, Netherlands,Corresponding author: Erasmus MC, University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
| | - Emanuele Frontoni
- Department of Information Engineering, Università Politecnica delle Marche, Ancona 60131, Italy
| | - Matthias Peter Hilty
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zurich 8091, Switzerland
| | - RISC-19-ICU InvestigatorsAlfaro-FariasMarioMDVizmanos-LamotteGerardoMD, PhDTschoellitschThomasMDMeierJensMDAguirre-BermeoHernánMD, PhDApoloJaninaBScMartínezAlbertoMDJurkolowGeoffreyMDDelahayeGauthierMDNovyEmmanuelMDLosserMarie-ReineMD, PhDWengenmayerTobiasMDRilingerJonathanMDStaudacherDawid L.MDDavidSaschaMDWelteTobiasMDStahlKlausMDPavlos”“AgiosAslanidisTheodorosMD, PhDKorsosAnitaMDBabikBarnaMD, PhDNikandishRezaMDRezoagliEmanueleMD, PhDGiacominiMatteoMDNovaAliceMDFogagnoloAlbertoMDSpadaroSavinoMD, PhDCerianiRobertoMDMurroneMartinaMDWuMaddalena A.MDCogliatiChiaraMDColomboRiccardoMDCatenaEmanueleMDTurriniFabrizioMD, MScSimoniniMaria SoleMDFabbriSilviaMDPotalivoAntonellaMDFacondiniFrancescaMDGangitanoGianfilippoMDPerinTizianaMDGrazia BocciMariaMDAntonelliMassimoMDGommersDiederikMD, PhDRodríguez-GarcíaRaquelMDGámez-ZapataJorgeMDTaboada-FragaXianaMDCastroPedroMDTellezAdrianMDLander-AzconaArantxaMDEscós-OrtaJesúsMDMartín-DelgadoMaria C.MDAlgaba-CalderonAngelaMDFranch-LlasatDiegoMDRoche-CampoFerranMD, PhDLozano-GómezHerminiaMDZalba-EtayoBegoñaMD, PhDMichotMarc P.MDKlarerAlexanderEnsnerRolfMDSchottPeterMDUrechSeverinMDZellwegerNuriaMerkiLukasMDLambertAdrianaMDLaubeMarcusMDJeitzinerMarie M.RN, PhDJenni-MoserBeatriceRN, MScWiegandJanMDYuenBerndMDLienhardt-NobbeBarbaraWestphalenAndreaMDSalomonPetraMDDrvaricIrisMDHillgaertnerFrankMDSieberMarianneDullenkopfAlexanderMDPetersenLinaMDChauIvanMDKsouriHatemMD, PhDSridharanGovind OliverMDCereghettiSaraMDBoroliFilippoMDPuginJeromeMD, PhDGrazioliSergeMDRimensbergerPeter C.MDBürkleChristianMDMarrelJulienMDBrenniMirkoMDFleischIsabelleMDLavanchyJeromeMDPerezMarie-HeleneMDRameletAnne-SylvieMDWeberAnja BaltussenMDGereckePeterMDChristAndreasMDCerutiSamueleMDGlottaAndreaMDMarquardtKatharinaMDShaikhKarimMDHübnerTobiasMDNeffThomasMDRedeckerHermannMDMoret-BochatayMalloryMDBentrupFriederikeMeyer zuMD, MBAStudhalterMichaelMDStephanMichaelMDBremJanMDGehringNadineMDSelzDanielaMDNaonDidierMDKlegerGian-RetoMDPietschUrsMDFilipovicMiodragMDRisticAnetteMDSepulcriMichaelMDHeiseAntjeMDFranchitti LaurentMarileneMDLaurentJean-ChristopheMDWendel GarciaPedro D.MScSchuepbachRetoMDHeubergerDorotheaPhDBühlerPhilippMDBruggerSilvioMD, PhDFodorPatriciaMDLocherPascalMDCamenGiovanniMDGaspertTomislavMDJovicMarijaMDHaberthuerChristophMDLussmanRoger F.MDColakElifMD
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Vincent JL, Ince C, Pickkers P. Endothelial dysfunction: a therapeutic target in bacterial sepsis? Expert Opin Ther Targets 2021; 25:733-748. [PMID: 34602020 DOI: 10.1080/14728222.2021.1988928] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Endothelial cells maintain vascular integrity, tone, and patency and have important roles in hemostasis and inflammatory responses. Although some degree of endothelial dysfunction with increased vascular permeability may be necessary to control local infection, excessive dysfunction plays a central role in the pathogenesis of sepsis-related organ dysfunction and failure as it results in dysregulated inflammation, vascular leakage, and abnormal coagulation. The vascular endothelium has thus been proposed as a potential target for therapeutic intervention in patients with sepsis. AREAS COVERED Different mechanisms underlying sepsis-related dysfunction of the vascular endothelium are discussed, including glycocalyx shedding, nitrosative stress, and coagulation factors. Potential therapeutic implications of each mechanism are mentioned. EXPERT OPINION Multiple targets to protect or restore endothelial function have been suggested, but endothelium-driven treatments remain a future potential at present. As some endothelial dysfunction and permeability may be necessary to remove infection and repair damaged tissue, targeting the endothelium may be a particular challenge. Ideally, therapies should be guided by biomarkers related to that specific pathway to ensure they are given only to patients most likely to respond. This enrichment based on biological plausibility and theragnostics will increase the likelihood of a beneficial response in individual patients and enable more personalized treatment.
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Affiliation(s)
- Jean-Louis Vincent
- Dept of Intensive Care, Erasme Hospital, Université Libre De Bruxelles, Brussels, Belgium
| | - Can Ince
- Department of Intensive Care, Laboratory of Translational Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Peter Pickkers
- Dept of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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Chotalia M, Ali M, Alderman JE, Kalla M, Parekh D, Bangash MN, Patel JM. Right Ventricular Dysfunction and Its Association With Mortality in Coronavirus Disease 2019 Acute Respiratory Distress Syndrome. Crit Care Med 2021; 49:1757-1768. [PMID: 34224453 PMCID: PMC8439642 DOI: 10.1097/ccm.0000000000005167] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To assess whether right ventricular dilation or systolic impairment is associated with mortality and/or disease severity in invasively ventilated patients with coronavirus disease 2019 acute respiratory distress syndrome. DESIGN Retrospective cohort study. SETTING Single-center U.K. ICU. PATIENTS Patients with coronavirus disease 2019 acute respiratory distress syndrome undergoing invasive mechanical ventilation that received a transthoracic echocardiogram between March and December 2020. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Right ventricular dilation was defined as right ventricular:left ventricular end-diastolic area greater than 0.6, right ventricular systolic impairment as fractional area change less than 35%, or tricuspid annular plane systolic excursion less than 17 mm. One hundred seventy-two patients were included, 59 years old (interquartile range, 49-67), with mostly moderate acute respiratory distress syndrome (n = 101; 59%). Ninety-day mortality was 41% (n = 70): 49% in patients with right ventricular dilation, 53% in right ventricular systolic impairment, and 72% in right ventricular dilation with systolic impairment. The right ventricular dilation with systolic impairment phenotype was independently associated with mortality (odds ratio, 3.11 [95% CI, 1.15-7.60]), but either disease state alone was not. Right ventricular fractional area change correlated with Pao2:Fio2 ratio, Paco2, chest radiograph opacification, and dynamic compliance, whereas right ventricular:left ventricle end-diastolic area correlated negatively with urine output. CONCLUSIONS Right ventricular systolic impairment correlated with pulmonary pathophysiology, whereas right ventricular dilation correlated with renal dysfunction. Right ventricular dilation with systolic impairment was the only right ventricular phenotype that was independently associated with mortality.
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Affiliation(s)
- Minesh Chotalia
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Muzzammil Ali
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Joseph E Alderman
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Manish Kalla
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Dhruv Parekh
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Mansoor N Bangash
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Jaimin M Patel
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
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Bakker J, Horowitz JM, Hagedorn J, Kozloff S, Kaufman D, Castro R. Blood volume and albumin transudation in critically ill COVID-19 patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:269. [PMID: 34332641 PMCID: PMC8325200 DOI: 10.1186/s13054-021-03699-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/21/2021] [Indexed: 11/10/2022]
Affiliation(s)
- Jan Bakker
- Division of Pulmonary, Critical Care, and Sleep Medicine, New York University School of Medicine, New York, NY, USA. .,Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA. .,Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, Netherlands. .,Department of Intensive Care, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - James M Horowitz
- Division of Cardiology, New York University School of Medicine, New York, NY, USA
| | - Jackie Hagedorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, New York University School of Medicine, New York, NY, USA
| | - Sam Kozloff
- Division of Pulmonary, Critical Care, and Sleep Medicine, New York University School of Medicine, New York, NY, USA
| | - David Kaufman
- Division of Pulmonary, Critical Care, and Sleep Medicine, New York University School of Medicine, New York, NY, USA
| | - Ricardo Castro
- Department of Intensive Care, Pontificia Universidad Católica de Chile, Santiago, Chile
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28
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Akin S, van Hooven D, Ince C, Jansen T. Veno-arterial thrombosis and microcirculation imaging in a patient with COVID-19. Respir Med Case Rep 2021; 33:101428. [PMID: 33996436 PMCID: PMC8110328 DOI: 10.1016/j.rmcr.2021.101428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 05/05/2021] [Accepted: 05/07/2021] [Indexed: 12/16/2022] Open
Abstract
The Coronavirus pandemic has brought new challenges in intensive care medicine. Understanding of the pathophysiology of the vascular complications of SARS-CoV-2 infection could bring new resuscitation and therapeutic options. In this case report, we present a patient with COVID-19 pneumonia, who was admitted to our ICU and treated with high-flow nasal cannula, dexamethasone, remdesivir and high-dose prophylactic low molecular weight heparin. During ICU admission, substantial venous and arterial thrombosis developed. Meanwhile the microcirculation showed more than double amount of organ perfusion with very high total vessel density. We hypothesize that this might be a compensatory mechanism for the generalized prothrombic state in which the microcirculation increases the oxygen extraction capacity preventing multi-organ failure.
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Affiliation(s)
- Sakir Akin
- Dept. of Intensive Care, Haga Teaching Hospital, The Hague, the Netherlands.,Dept. of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.,Dept. of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Daphne van Hooven
- Dept. of Intensive Care, Haga Teaching Hospital, The Hague, the Netherlands
| | - Can Ince
- Dept. of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Tim Jansen
- Dept. of Intensive Care, Haga Teaching Hospital, The Hague, the Netherlands
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29
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Grewal S, Harjo B, Aykut G, Ergin B, Nowitzky R, Ince C, Akin S. Case Report: Sublingual Microcirculatory Alterations in a Covid-19 Patient With Subcutaneous Emphysema, Venous Thrombosis, and Pneumomediastinum. Front Med (Lausanne) 2021; 7:624695. [PMID: 33585518 PMCID: PMC7876339 DOI: 10.3389/fmed.2020.624695] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 12/22/2020] [Indexed: 12/27/2022] Open
Abstract
The Corona virus disease 2019 (Covid-19) has brought a wide range of challenges in intensive care medicine. Understanding of the pathophysiology of Covid-19 relies on interpreting of its impact on the vascular, particularly microcirculatory system. Herein we report on the first use of the latest generation hand-held vital microscope to evaluate the sublingual microcirculation in a Covid-19 patient with subcutaneous emphysema, venous thrombosis and pneumomediastinum. Remarkably, microcirculatory parameters of the patient were increased during the exacerbation period, which is not a usual finding in critically ill patients mostly presenting with a loss of hemodynamic coherence. In contrast, recovery from the disease led to a subsequent amelioration of these parameters. This report clearly shows the importance of microcirculatory monitoring for evaluating the course and the adequacy of therapy in Covid-19 patients.
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Affiliation(s)
- Sanjeev Grewal
- Department of Intensive Care, Haga Teaching Hospital, The Hague, Netherlands
| | - Brita Harjo
- Department of Intensive Care, Haga Teaching Hospital, The Hague, Netherlands
| | - Güclü Aykut
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Bülent Ergin
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Ralph Nowitzky
- Department of Intensive Care, Haga Teaching Hospital, The Hague, Netherlands
| | - Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Sakir Akin
- Department of Intensive Care, Haga Teaching Hospital, The Hague, Netherlands.,Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
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