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Duve K, Petakh P, Kamyshnyi O. COVID-19-associated encephalopathy: connection between neuroinflammation and microbiota-gut-brain axis. Front Microbiol 2024; 15:1406874. [PMID: 38863751 PMCID: PMC11165208 DOI: 10.3389/fmicb.2024.1406874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 05/16/2024] [Indexed: 06/13/2024] Open
Abstract
While neurological complications of COVID-19, such as encephalopathy, are relatively rare, their potential significant impact on long-term morbidity is substantial, especially given the large number of infected patients. Two proposed hypotheses for the pathogenesis of this condition are hypoxia and the uncontrolled release of proinflammatory cytokines. The gut microbiota plays an important role in regulating immune homeostasis and overall gut health, including its effects on brain health through various pathways collectively termed the gut-brain axis. Recent studies have shown that COVID-19 patients exhibit gut dysbiosis, but how this dysbiosis can affect inflammation in the central nervous system (CNS) remains unclear. In this context, we discuss how dysbiosis could contribute to neuroinflammation and provide recent data on the features of neuroinflammation in COVID-19 patients.
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Affiliation(s)
- Khrystyna Duve
- Department of Neurology, I. Horbachevsky Ternopil National Medical University, Ternopil, Ukraine
| | - Pavlo Petakh
- Department of Biochemistry and Pharmacology, Uzhhorod National University, Uzhhorod, Ukraine
- Department of Microbiology, Virology, and Immunology, I. Horbachevsky Ternopil National Medical University, Ternopil, Ukraine
| | - Oleksandr Kamyshnyi
- Department of Biochemistry and Pharmacology, Uzhhorod National University, Uzhhorod, Ukraine
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2
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Strickland B, Stuart Harris N. Adapting nitric oxide: A review of its foundation, uses in austere medical conditions, and emerging applications. Nitric Oxide 2024; 146:58-63. [PMID: 38583684 DOI: 10.1016/j.niox.2024.04.003] [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: 01/29/2024] [Revised: 04/01/2024] [Accepted: 04/03/2024] [Indexed: 04/09/2024]
Abstract
Nitric oxide was first identified as a novel and effective treatment for persistent pulmonary hypertension of the newborn (PPHN), and has since been found to be efficacious in treating acute respiratory distress syndrome (ARDS) and pulmonary hypertension. Physicians and researchers have also found it shows promise in resource-constrained settings, both within and outside of the hospital, such as in high altitude pulmonary edema (HAPE) and COVID-19. The treatment has been well tolerated in these settings, and is both efficacious and versatile when studied across a variety of clinical environments. Advancements in inhaled nitric oxide continue, and the gas is worthy of investigation as physicians contend with new respiratory and cardiovascular illnesses, as well as unforeseen logistical challenges.
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Affiliation(s)
- Brian Strickland
- Department of Emergency Medicine, University of Colorado, Aurora, CO, USA.
| | - N Stuart Harris
- Division of Wilderness Medicine, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
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Masood M, Singh P, Hariss D, Khan F, Yameen D, Siraj S, Islam A, Dohare R, Mahfuzul Haque M. Nitric oxide as a double-edged sword in pulmonary viral infections: Mechanistic insights and potential therapeutic implications. Gene 2024; 899:148148. [PMID: 38191100 DOI: 10.1016/j.gene.2024.148148] [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: 09/19/2023] [Revised: 12/21/2023] [Accepted: 01/05/2024] [Indexed: 01/10/2024]
Abstract
In the face of the global pandemic caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), researchers are tirelessly exploring novel therapeutic approaches to combat coronavirus disease 2019 (COVID-19) and its associated complications. Nitric oxide (NO) has appeared as a multifaceted signaling mediator with diverse and often contrasting biological activities. Its intricate biochemistry renders it a crucial regulator of cardiovascular and pulmonary functions, immunity, and neurotransmission. Perturbations in NO production, whether excessive or insufficient, contribute to the pathogenesis of various diseases, encompassing cardiovascular disease, pulmonary hypertension, asthma, diabetes, and cancer. Recent investigations have unveiled the potential of NO donors to impede SARS-CoV- 2 replication, while inhaled NO demonstrates promise as a therapeutic avenue for improving oxygenation in COVID-19-related hypoxic pulmonary conditions. Interestingly, NO's association with the inflammatory response in asthma suggests a potential protective role against SARS-CoV-2 infection. Furthermore, compelling evidence indicates the benefits of inhaled NO in optimizing ventilation-perfusion ratios and mitigating the need for mechanical ventilation in COVID-19 patients. In this review, we delve into the molecular targets of NO, its utility as a diagnostic marker, the mechanisms underlying its action in COVID-19, and the potential of inhaled NO as a therapeutic intervention against viral infections. The topmost significant pathway, gene ontology (GO)-biological process (BP), GO-molecular function (MF) and GO-cellular compartment (CC) terms associated with Nitric Oxide Synthase (NOS)1, NOS2, NOS3 were arginine biosynthesis (p-value = 1.15 x 10-9) regulation of guanylate cyclase activity (p-value = 7.5 x 10-12), arginine binding (p-value = 2.62 x 10-11), vesicle membrane (p-value = 3.93 x 10-8). Transcriptomics analysis further validates the significant presence of NOS1, NOS2, NOS3 in independent COVID-19 and pulmonary hypertension cohorts with respect to controls. This review investigates NO's molecular targets, diagnostic potentials, and therapeutic role in COVID-19, employing bioinformatics to identify key pathways and NOS isoforms' significance.
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Affiliation(s)
- Mohammad Masood
- Department of Biotechnology, Faculty of Natural Sciences, Jamia Millia Islamia, New Delhi 110025, India.
| | - Prithvi Singh
- Centre for Interdisciplinary Research in Basic Sciences, Jamia Millia Islamia, New Delhi 110025, India.
| | - Daaniyaal Hariss
- Department of Biosciences, Faculty of Natural Sciences, Jamia Millia Islamia, New Delhi 110025, India.
| | - Faizya Khan
- Department of Biotechnology, Faculty of Natural Sciences, Jamia Millia Islamia, New Delhi 110025, India.
| | - Daraksha Yameen
- Department of Biotechnology, Faculty of Natural Sciences, Jamia Millia Islamia, New Delhi 110025, India.
| | - Seerat Siraj
- Department of Biotechnology, Faculty of Natural Sciences, Jamia Millia Islamia, New Delhi 110025, India.
| | - Asimul Islam
- Centre for Interdisciplinary Research in Basic Sciences, Jamia Millia Islamia, New Delhi 110025, India.
| | - Ravins Dohare
- Centre for Interdisciplinary Research in Basic Sciences, Jamia Millia Islamia, New Delhi 110025, India.
| | - Mohammad Mahfuzul Haque
- Department of Biotechnology, Faculty of Natural Sciences, Jamia Millia Islamia, New Delhi 110025, India.
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Sanfilippo F, Uryga A, Ball L, Battaglini D, Iavarone IG, Smielewski P, Beqiri E, Czosnyka M, Patroniti N, Robba C. The Effect of Recruitment Maneuvers on Cerebrovascular Dynamics and Right Ventricular Function in Patients with Acute Brain Injury: A Single-Center Prospective Study. Neurocrit Care 2024:10.1007/s12028-024-01939-x. [PMID: 38351299 DOI: 10.1007/s12028-024-01939-x] [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: 10/18/2023] [Accepted: 01/03/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Optimization of ventilatory settings is challenging for patients in the neurointensive care unit, requiring a balance between precise gas exchange control, lung protection, and managing hemodynamic effects of positive pressure ventilation. Although recruitment maneuvers (RMs) may enhance oxygenation, they could also exert profound undesirable systemic impacts. METHODS The single-center, prospective study investigated the effects of RMs (up-titration of positive end-expiratory pressure) on multimodal neuromonitoring in patients with acute brain injury. Our primary focus was on intracranial pressure and secondarily on cerebral perfusion pressure (CPP) and other neurological parameters: cerebral autoregulation [pressure reactivity index (PRx)] and regional cerebral oxygenation (rSO2). We also assessed blood pressure and right ventricular (RV) function evaluated using tricuspid annular plane systolic excursion. Results are expressed as the difference (Δ) from baseline values obtained after completing the RMs. RESULTS Thirty-two patients were enrolled in the study. RMs resulted in increased intracranial pressure (Δ = 4.8 mm Hg) and reduced CPP (ΔCPP = -12.8 mm Hg) and mean arterial pressure (difference in mean arterial pressure = -5.2 mm Hg) (all p < 0.001). Cerebral autoregulation worsened (ΔPRx = 0.31 a.u.; p < 0.001). Despite higher systemic oxygenation (difference in partial pressure of O2 = 4 mm Hg; p = 0.001) and unchanged carbon dioxide levels, rSO2 marginally decreased (ΔrSO2 = -0.5%; p = 0.031), with a significant drop in arterial content and increase in the venous content. RV systolic function decreased (difference in tricuspid annular plane systolic excursion = -0.1 cm; p < 0.001) with a tendency toward increased RV basal diameter (p = 0.06). Grouping patients according to ΔCPP or ΔPRx revealed that those with poorer tolerance to RMs had higher CPP (p = 0.040) and a larger RV basal diameter (p = 0.034) at baseline. CONCLUSIONS In patients with acute brain injury, RMs appear to have adverse effects on cerebral hemodynamics. These findings might be partially explained by RM's impact on RV function. Further advanced echocardiography monitoring is required to prove this hypothesis.
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Affiliation(s)
- Filippo Sanfilippo
- Department of General Surgery and Medico-Surgical Specialties, School of Anaesthesia and Intensive Care, University of Catania, Catania, Italy
| | - Agnieszka Uryga
- Department of Biomedical Engineering, Wroclaw University of Science and Technology, Wrocław, Poland
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
- Anesthesia and Intensive Care, IRCCS Policlinico San Martino, Largo Rosanna Benzi, 16100, Genoa, Italy
| | - Denise Battaglini
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Ida Giorgia Iavarone
- Anesthesia and Intensive Care, IRCCS Policlinico San Martino, Largo Rosanna Benzi, 16100, Genoa, Italy
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Nicolò Patroniti
- Department of Biomedical Engineering, Wroclaw University of Science and Technology, Wrocław, Poland
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.
- Anesthesia and Intensive Care, IRCCS Policlinico San Martino, Largo Rosanna Benzi, 16100, Genoa, Italy.
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Battaglini D, De Rosa S, Godoy DA. Crosstalk Between the Nervous System and Systemic Organs in Acute Brain Injury. Neurocrit Care 2024; 40:337-348. [PMID: 37081275 DOI: 10.1007/s12028-023-01725-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 03/29/2023] [Indexed: 04/22/2023]
Abstract
Organ crosstalk is a complex biological communication between distal organs mediated via cellular, soluble, and neurohormonal actions, based on a two-way pathway. The communication between the central nervous system and peripheral organs involves nerves, endocrine, and immunity systems as well as the emotional and cognitive centers of the brain. Particularly, acute brain injury is complicated by neuroinflammation and neurodegeneration causing multiorgan inflammation, microbial dysbiosis, gastrointestinal dysfunction and dysmotility, liver dysfunction, acute kidney injury, and cardiac dysfunction. Organ crosstalk has become increasingly popular, although the information is still limited. The present narrative review provides an update on the crosstalk between the nervous system and systemic organs after acute brain injury. Future research might help to target this pathophysiological process, preventing the progression toward multiorgan dysfunction in critically ill patients with brain injury.
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Affiliation(s)
- Denise Battaglini
- Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Policlinico San Martino, Genoa, Italy
| | - Silvia De Rosa
- Centre for Medical Sciences, University of Trento, Via S. Maria Maddalena 1, 38122, Trento, Italy.
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS Trento, Trento, Italy.
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Battaglini D, Delpiano L, Masuello D, Leme Silva P, Rocco PRM, Matta B, Pelosi P, Robba C. Effects of positive end-expiratory pressure on brain oxygenation, systemic oxygen cascade and metabolism in acute brain injured patients: a pilot physiological cross-sectional study. J Clin Monit Comput 2024; 38:165-175. [PMID: 37453007 DOI: 10.1007/s10877-023-01042-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 06/02/2023] [Indexed: 07/18/2023]
Abstract
Patients with acute brain injury (ABI) often require the application of positive end-expiratory pressure (PEEP) to optimize mechanical ventilation and systemic oxygenation. However, the effect of PEEP on cerebral function and metabolism is unclear. The primary aim of this study was to evaluate the effects of PEEP augmentation test (from 5 to 15 cmH2O) on brain oxygenation, systemic oxygen cascade and metabolism in ABI patients. Secondary aims include to determine whether changes in regional cerebral oxygenation are reflected by changes in oxygenation cascade and metabolism, and to assess the correlation between brain oxygenation and mechanical ventilation settings. Single center, pilot cross-sectional observational study in an Academic Hospital. Inclusion criteria were: adult (> 18 y/o) patients with ABI and stable intracranial pressure, available gas exchange and indirect calorimetry (IC) monitoring. Cerebral oxygenation was monitored with near-infrared spectroscopy (NIRS) and different derived parameters were collected: variation (Δ) in oxy (O2)-hemoglobin (Hb) (ΔO2Hbi), deoxy-Hb(ΔHHbi), total-Hb(ΔcHbi), and total regional oxygenation (ΔrSO2). Oxygen cascade and metabolism were monitored with arterial/venous blood gas analysis [arterial partial pressure of oxygen (PaO2), arterial saturation of oxygen (SaO2), oxygen delivery (DO2), and lactate], and IC [energy expenditure (REE), respiratory quotient (RQ), oxygen consumption (VO2), and carbon dioxide production (VCO2)]. Data were measured at PEEP 5 cmH2O and 15 cmH2O and expressed as delta (Δ) values. Ten patients with ABI [median age 70 (IQR 62-75) years, 6 (60%) were male, median Glasgow Coma Scale at ICU admission 5.5 (IQR 3-8)] were included. PEEP augmentation from 5 to 15 cmH2O did not affect cerebral oxygenation, systemic oxygen cascade parameters, and metabolism. The arterial component of cerebral oxygenation was significantly correlated with DO2 (ΔO2HBi, rho = 0.717, p = 0.037). ΔrSO2 (rho = 0.727, p = 0.032), ΔcHbi (rho = 0.797, p = 0.013), and ΔHHBi (rho = 0.816, p = 0.009) were significantly correlated with SaO2, but not ΔO2Hbi. ΔrSO2 was significantly correlated with VCO2 (rho = 0.681, p = 0.049). No correlation between brain oxygenation and ventilatory parameters was found. PEEP augmentation test did not affect cerebral and systemic oxygenation or metabolism. Changes in cerebral oxygenation significantly correlated with DO2, SaO2, and VCO2. Cerebral oxygen monitoring could be considered for individualization of mechanical ventilation setting in ABI patients without high or instable intracranial pressure.
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Affiliation(s)
| | - Lara Delpiano
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genoa, Italy
| | - Denise Masuello
- Hospital Donaciòn Francisco Santojanni, Buenos Aires, Argentina
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Centro de Ciências da Saúde, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Centro de Ciências da Saúde, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- Rio de Janeiro Network on Neuroinflammation, Carlos Chagas Filho Foundation for Supporting Research in the State of Rio de Janeiro (FAPERJ), Rio de Janeiro, Brazil
| | - Basil Matta
- Neurocritical Care Unit, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Paolo Pelosi
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genoa, Italy
| | - Chiara Robba
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genoa, Italy
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Xiao S, Yuan Z, Huang Y. The Potential Role of Nitric Oxide as a Therapeutic Agent against SARS-CoV-2 Infection. Int J Mol Sci 2023; 24:17162. [PMID: 38138990 PMCID: PMC10742813 DOI: 10.3390/ijms242417162] [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: 10/27/2023] [Revised: 11/28/2023] [Accepted: 12/04/2023] [Indexed: 12/24/2023] Open
Abstract
The global coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become the greatest worldwide public health threat of this century, which may predispose multi-organ failure (especially the lung) and death despite numerous mild and moderate symptoms. Recent studies have unraveled the molecular and clinical characteristics of the infectivity, pathogenicity, and immune evasion of SARS-CoV-2 and thus improved the development of many different therapeutic strategies to combat COVID-19, including treatment and prevention. Previous studies have indicated that nitric oxide (NO) is an antimicrobial and anti-inflammatory molecule with key roles in pulmonary vascular function in the context of viral infections and other pulmonary disease states. This review summarized the recent advances of the pathogenesis of SARS-CoV-2, and accordingly elaborated on the potential application of NO in the management of patients with COVID-19 through antiviral activities and anti-inflammatory properties, which mitigate the propagation of this disease. Although there are some limits of NO in the treatment of COVID-19, it might be a worthy candidate in the multiple stages of COVID-19 prevention or therapy.
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Affiliation(s)
| | | | - Yi Huang
- National Biosafety Laboratory, Chinese Academy of Sciences, Wuhan 430020, China
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Battaglini D, Premraj L, Huth S, Fanning J, Whitman G, Arora RC, Bellapart J, Porto DB, Taccone FS, Suen JY, Bassi GL, Fraser JF, Cho SM, Robba C. The Use of Noninvasive Multimodal Neuromonitoring in Adult Critically Ill Patients With COVID-19 Infection. J Neurosurg Anesthesiol 2023; 35:423-428. [PMID: 35695738 PMCID: PMC9729386 DOI: 10.1097/ana.0000000000000859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 05/12/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Noninvasive neuromonitoring could be a valuable option for bedside assessment of cerebral dysfunction in patients with coronavirus disease-2019 (COVID-19) admitted to intensive care units (ICUs). This systematic review aims to investigate the use of noninvasive multimodal neuromonitoring in critically ill adult patients with COVID-19 infection. METHODS MEDLINE/PubMed, Scopus, Cochrane, and EMBASE databases were searched for studies investigating noninvasive neuromonitoring in patients with COVID-19 admitted to ICUs. The monitoring included transcranial Doppler ultrasonography (TCD), the Brain4care Corp. cerebral compliance monitor (B4C), optic nerve sheath diameter (ONSD), near infrared spectroscopy, automated pupillometry, and electroencephalography (EEG). RESULTS Thirty-two studies that investigated noninvasive neuromonitoring techniques in patients with COVID-19 in the ICU were identified from a systematic search of 7001 articles: 1 study investigating TCD, ONSD and pupillometry; 2 studies investigating the B4C device and TCD; 3 studies investigating near infrared spectroscopy and TCD; 4 studies investigating TCD; 1 case series investigating pupillometry, and 21 studies investigating EEG. One hundred and nineteen patients underwent TCD monitoring, 47 pupillometry, 49 ONSD assessment, 50 compliance monitoring with the B4C device, and 900 EEG monitoring. Alterations in cerebral hemodynamics, brain compliance, brain oxygenation, pupillary response, and brain electrophysiological activity were common in patients with COVID-19 admitted to the ICU; these abnormalities were not clearly associated with worse outcome or the development of new neurological complications. CONCLUSIONS The use of noninvasive multimodal neuromonitoring in critically ill COVID-19 patients could be considered to facilitate the detection of neurological derangements. Determining whether such findings allow earlier detection of neurological complications or guide appropriate therapy requires additional studies.
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Affiliation(s)
- Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for oncology and neuroscience, Genoa, Italy
- Department of Medicine, University of Barcelona, Spain
| | | | - Samuel Huth
- Critical Care Research Group (CCRG), Australia
- Faculty of Medicine, The University of Queensland, Australia
| | - Jonathon Fanning
- Critical Care Research Group (CCRG), Australia
- Faculty of Medicine, The University of Queensland, Australia
- St. Andrew’s War Memorial Hospital, Uniting Care Health, Australia
| | - Glenn Whitman
- Department of Surgery, Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, United States
| | - Rakesh C. Arora
- Department of Surgery, Section of Cardiac Surgery, Max Rady College of Medicine, University of Manitoba, Canada
| | - Judith Bellapart
- Critical Care Research Group (CCRG), Australia
- Royal Brisbane and Women’s Hospital, Australia
| | - Diego Bastos Porto
- Department of Critical Care, Sao Camilo Cura D’ars Hospital, Fortaleza, Cearà, Brazil
| | | | - Jacky Y. Suen
- Critical Care Research Group (CCRG), Australia
- Faculty of Medicine, The University of Queensland, Australia
| | - Gianluigi Li Bassi
- Critical Care Research Group (CCRG), Australia
- Faculty of Medicine, The University of Queensland, Australia
- Queensland University of Technology, Australia
- Institut de Ricerca Biomedica August Pi i Sunyer (IDIBAPS), Spain
| | - John F. Fraser
- Critical Care Research Group (CCRG), Australia
- Faculty of Medicine, The University of Queensland, Australia
- St. Andrew’s War Memorial Hospital, Uniting Care Health, Australia
- Queensland University of Technology, Australia
| | - Sung-Min Cho
- Department of Surgery, Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, United States
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for oncology and neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
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Burzyńska M, Uryga A, Kasprowicz M, Czosnyka M, Goździk W, Robba C. Cerebral Autoregulation, Cerebral Hemodynamics, and Injury Biomarkers, in Patients with COVID-19 Treated with Veno-Venous Extracorporeal Membrane Oxygenation. Neurocrit Care 2023; 39:425-435. [PMID: 36949359 PMCID: PMC10033181 DOI: 10.1007/s12028-023-01700-w] [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: 12/08/2022] [Accepted: 02/14/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND This study aimed to describe the cerebrovascular dynamics, in particular cerebral autoregulation (CA), and cerebral biomarkers as neuron-specific enolase (NSE) in patients with a diagnosis of coronavirus disease 2019 and acute respiratory distress syndrome as well as undergoing veno-venous extracorporeal membrane treatment. METHODS This was a single center, observational study conducted in the intensive care unit of the University Hospital in Wroclaw from October 2020 to February 2022. Transcranial Doppler recordings of the middle cerebral artery conducted for at least 20 min were performed. Cerebral autoregulation (CA) was estimated by using the mean velocity index (Mxa), calculated as the moving correlation coefficient between slow-wave oscillations in cerebral blood flow velocity and arterial blood pressure. Altered CA was defined as a positive Mxa. Blood samples for the measurement of NSE were obtained at the same time as transcranial Doppler measurements. RESULTS A total of 16 patients fulfilled the inclusion criteria and were enrolled in the study. The median age was 39 (34-56) years. Altered CA was found in 12 patients, and six out of seven patients who died had altered CA. A positive Mxa was a significant predictor of mortality, with a sensitivity of 85.7%. We found that three out of five patients with pathological changes in brain computed tomography and six out of ten patients with neurological complications had altered CA. NSE was a significant predictor of mortality (cutoff value: 28.9 µg/L); area under the curve = 0.83, p = 0.006), with a strong relationship between increased level of NSE and altered CA, χ2 = 6.24; p = 0.035; φ = 0.69. CONCLUSIONS Patients with coronavirus disease 2019-related acute respiratory distress syndrome, requiring veno-venous extracorporeal membrane treatment, are likely to have elevated NSE levels and altered CA. The CA was associated with NSE values in this group. This preliminary analysis suggests that advanced neuromonitoring and evaluation of biomarkers should be considered in this population.
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Affiliation(s)
- Małgorzata Burzyńska
- Department of Anaesthesiology and Intensive Care, Wroclaw Medical University, Wroclaw, Poland
| | - Agnieszka Uryga
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, Wybrzeze Wyspianskiego 27, 50-370, Wroclaw, Poland.
| | - Magdalena Kasprowicz
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, Wybrzeze Wyspianskiego 27, 50-370, Wroclaw, Poland
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
- Institute of Electronic Systems, Faculty of Electronics and Information Technology, Warsaw University of Technology, Warsaw, Poland
| | - Waldemar Goździk
- Department of Anaesthesiology and Intensive Care, Wroclaw Medical University, Wroclaw, Poland
| | - Chiara Robba
- IRCCS, Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Viale Benedetto XV 16, Genoa, Italy
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10
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Mekontso Dessap A, Papazian L, Schaller M, Nseir S, Megarbane B, Haudebourg L, Timsit JF, Teboul JL, Kuteifan K, Gainnier M, Slama M, Houeto P, Lecourt L, Mercat A, Vieillard-Baron A. Inhaled nitric oxide in patients with acute respiratory distress syndrome caused by COVID-19: treatment modalities, clinical response, and outcomes. Ann Intensive Care 2023; 13:57. [PMID: 37368036 DOI: 10.1186/s13613-023-01150-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 06/07/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Inhaled nitric oxide (iNO) has been widely used in patients with COVID-19-related acute respiratory distress syndrome (C-ARDS), though its physiological effects and outcome are debated in this setting. The objective of this cohort study was to describe the modalities of iNO use, clinical response, and outcomes in a large cohort of C-ARDS patients. METHODS Multicentre, retrospective cohort study conducted in France. RESULTS From end February to December 2020, 300 patients (22.3% female) were included, 84.5% were overweight and 69.0% had at least one comorbidity. At ICU admission, their median (IQR) age, SAPS II, and SOFA score were 66 (57-72) years, 37 (29-48), and 5 (3-8), respectively. Patients were all ventilated according to a protective ventilation strategy, and 68% were prone positioned before iNO initiation. At iNO initiation, 2%, 37%, and 61% of patients had mild, moderate, and severe ARDS, respectively. The median duration of iNO treatment was 2.8 (1.1-5.5) days with a median dosage of 10 (7-13) ppm at initiation. Responders (PaO2/FiO2 ratio improving by 20% or more) represented 45.7% of patients at 6 h from iNO initiation. The severity of ARDS was the only predictive factor associated with iNO response. Among all evaluable patients, the crude mortality was not significantly different between responders at 6 h and their counterparts. Of the 62 patients with refractory ARDS (who fulfilled extracorporeal membrane oxygenation criteria before iNO initiation), 32 (51.6%) no longer fulfilled these criteria after 6 h of iNO. The latter showed significantly lower mortality than the other half (who remained ECMO eligible), including after confounder adjustment (adjusted OR: 0.23, 95% CI 0.06, 0.89, p = 0.03). CONCLUSIONS Our study reports the benefits of iNO in improving arterial oxygenation in C-ARDS patients. This improvement seems more relevant in the most severe cases. In patients with ECMO criteria, an iNO-driven improvement in gas exchange was associated with better survival. These results must be confirmed in well-designed prospective studies.
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Affiliation(s)
- Armand Mekontso Dessap
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri-Mondor, AP-HP, 94010, Créteil, France.
- CARMAS research group, Univ Paris Est Créteil, Faculté de Santé, 94010, Créteil, France.
- IMRB, INSERM, Univ Paris Est Créteil, 94010, Créteil, France.
| | - Laurent Papazian
- Médecine Intensive Réanimation, Centre d'Etudes et de Recherches sur les Services de Santé et Qualité de vie EA 3279, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille University, 13015, Marseille, France
| | | | - Saad Nseir
- Department of Intensive Care Medicine, Critical Care Center, CHU of Lille, 59000, Lille, France
| | - Bruno Megarbane
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, INSERM MURS-1144, University of Paris, AP-HP, 2 Rue Ambroise Paré, 75010, Paris, France
| | - Luc Haudebourg
- Service de Pneumologie et Réanimation Médicale du Département R3S, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, AP-HP, Paris, France
| | - Jean-François Timsit
- Medical and Infectious Diseases Intensive Care Unit, Bichat-Claude Hospital and U1137, IAME Université Paris-Cité, AP-HP, 75018, Paris, France
| | - Jean-Louis Teboul
- Service de Medecine Intensive-Reanimation, Hôpital de Bicêtre, AP-HP, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Khaldoun Kuteifan
- Service de Réanimation Médicale, Groupe Hospitalier de la Région Mulhouse Sud Alsace, 68100, Mulhouse, France
| | - Marc Gainnier
- Réanimation des Urgences, Hôpital de La Timone, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Michel Slama
- Medical Intensive Care Unit, CHU Sud Amiens, Amiens, France
| | | | | | - Alain Mercat
- Department of Intensive Care, University of Angers, Angers, France
| | - Antoine Vieillard-Baron
- Medical Intensive Care Unit, Ambroise Paré Hospital, AP-HP, Boulogne-Billancourt, France
- Inserm UMR 1018, Équipe 5, CESP, Villejuif, France
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Rodrigues de Moraes L, Robba C, Battaglini D, Pelosi P, Rocco PRM, Silva PL. New and personalized ventilatory strategies in patients with COVID-19. Front Med (Lausanne) 2023; 10:1194773. [PMID: 37332761 PMCID: PMC10273276 DOI: 10.3389/fmed.2023.1194773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/09/2023] [Indexed: 06/20/2023] Open
Abstract
Coronavirus disease (COVID-19) is caused by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) virus and may lead to severe respiratory failure and the need for mechanical ventilation (MV). At hospital admission, patients can present with severe hypoxemia and dyspnea requiring increasingly aggressive MV strategies according to the clinical severity: noninvasive respiratory support (NRS), MV, and the use of rescue strategies such as extracorporeal membrane oxygenation (ECMO). Among NRS strategies, new tools have been adopted for critically ill patients, with advantages and disadvantages that need to be further elucidated. Advances in the field of lung imaging have allowed better understanding of the disease, not only the pathophysiology of COVID-19 but also the consequences of ventilatory strategies. In cases of refractory hypoxemia, the use of ECMO has been advocated and knowledge on handling and how to personalize strategies have increased during the pandemic. The aims of the present review are to: (1) discuss the evidence on different devices and strategies under NRS; (2) discuss new and personalized management under MV based on the pathophysiology of COVID-19; and (3) contextualize the use of rescue strategies such as ECMO in critically ill patients with COVID-19.
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Affiliation(s)
- Lucas Rodrigues de Moraes
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Chiara Robba
- Unit of Anaesthesia and Intensive Care, San Martino Hospital (IRCCS), Genoa, Italy
| | - Denise Battaglini
- Unit of Anaesthesia and Intensive Care, San Martino Hospital (IRCCS), Genoa, Italy
| | - Paolo Pelosi
- Unit of Anaesthesia and Intensive Care, San Martino Hospital (IRCCS), Genoa, Italy
| | - Patricia R. M. Rocco
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Battaglini D, Parodi L, Cinotti R, Asehnoune K, Taccone FS, Orengo G, Zona G, Uccelli A, Ferro G, Robba M, Pelosi P, Robba C. Ventilator-associated pneumonia in neurocritically ill patients: insights from the ENIO international prospective observational study. Respir Res 2023; 24:146. [PMID: 37259054 DOI: 10.1186/s12931-023-02456-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/21/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND Acute brain injured (ABI) patients are at high risk of developing ventilator-associated pneumonia (VAP). However, incidence, risk factors and effects on outcome of VAP are not completely elucidated in this population. The primary aim of this study was to determine the incidence of VAP in a cohort of ABI patients. The secondary objectives included the identification of risk factors for development of VAP, and the impact of VAP on clinical outcomes. Clinical outcomes were defined as intensive care unit length of stay (ICU-LOS), duration of invasive mechanical ventilation (IMV), and ICU mortality. METHODS Pre-planned sub-analysis of the Extubation strategies in Neuro-Intensive care unit (ICU) patients and associations with Outcomes (ENIO) international multi-center prospective observational study. Patients with available data on VAP, who received at least 48 h of IMV and ICU-LOS ≥ 72 h were included. RESULTS Out of 1512 patients included in the ENIO study, 1285 were eligible for this analysis. The prevalence of VAP was 39.5% (33.7 cases /1000 ventilator-days), with a high heterogeneity across countries and according to the type of brain injury. VAP was significantly more frequent in male patients, in those with smoke habits and when intraparenchymal probe (IP), external ventricular drain (EVD) or hypothermia (p < 0.001) were used. Independent risk factors for VAP occurrence were male gender, the use of IP, hypothermia, and the occurrence of tracheobronchitis during ICU stay. VAP was not an independent risk factor for ICU mortality (Hazard Ratio, HR = 0.71 95%CI 0.43-1.16, p = 0.168), but was independently associated with longer ICU stay (OR = 2.55 95%CI 2.01-3.23, p < 0.001). CONCLUSIONS VAP is common in ABI patients. Male gender, IP and EVD insertion, tracheobronchitis, and the use of therapeutic hypothermia were significantly associated with VAP occurrence. VAP did not affect mortality but increased ICU-LOS.
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Affiliation(s)
| | - Luca Parodi
- Department of Informatics, Bioengineering, Robotics and Systems Engineering, DIBRIS, Via Opera Pia 13, 16145, Genoa, Italy
| | - Raphael Cinotti
- Department of Anaesthesia and Critical Care, CHU Nantes, Nantes Université, Hôtel Dieu, 44000, Nantes, France
| | - Karim Asehnoune
- Department of Anaesthesia and Critical Care, CHU Nantes, Nantes Université, Hôtel Dieu, 44000, Nantes, France
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | | | - Gianluigi Zona
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- DINOGMI, University of Genoa, Genoa, Italy
| | - Antonio Uccelli
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- DINOGMI, University of Genoa, Genoa, Italy
| | - Giulio Ferro
- Department of Informatics, Bioengineering, Robotics and Systems Engineering, DIBRIS, Via Opera Pia 13, 16145, Genoa, Italy
| | - Michela Robba
- Department of Informatics, Bioengineering, Robotics and Systems Engineering, DIBRIS, Via Opera Pia 13, 16145, Genoa, Italy
| | - Paolo Pelosi
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Chiara Robba
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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Robba C, Battaglini D, Rasulo F, Lobo FA, Matta B. The importance of monitoring cerebral oxygenation in non brain injured patients. J Clin Monit Comput 2023:10.1007/s10877-023-01002-8. [PMID: 37043157 PMCID: PMC10091334 DOI: 10.1007/s10877-023-01002-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/22/2023] [Indexed: 04/13/2023]
Abstract
Over the past few years, the use of non-invasive neuromonitoring in non-brain injured patients has increased, as a result of the recognition that many of these patients are at risk of brain injury in a wide number of clinical scenarios and therefore may benefit from its application which allows interventions to prevent injury and improve outcome. Among these, are post cardiac arrest syndrome, sepsis, liver failure, acute respiratory failure, and the perioperative settings where in the absence of a primary brain injury, certain groups of patients have high risk of neurological complications. While there are many neuromonitoring modalities utilized in brain injured patients, the majority of those are either invasive such as intracranial pressure monitoring, require special skill such as transcranial Doppler ultrasonography, or intermittent such as pupillometry and therefore unable to provide continuous monitoring. Cerebral oximetry using Near infrared Spectroscopy, is a simple non invasive continuous measure of cerebral oxygenation that has been shown to be useful in preventing cerebral hypoxemia both within the intensive care unit and the perioperative settings. At present, current recommendations for standard monitoring during anesthesia or in the general intensive care concentrate mainly on hemodynamic and respiratory monitoring without specific indications regarding the brain, and in particular, brain oximetry. The aim of this manuscript is to provide an up-to-date overview of the pathophysiology and applications of cerebral oxygenation in non brain injured patients as part of non-invasive multimodal neuromonitoring in the early identification and treatment of neurological complications in this population.
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Affiliation(s)
- Chiara Robba
- Anesthesia and Intensive Care, IRCCS Policlinico San Martino, Genoa, Italy.
- Department of Surgical Science and Integrated Diagnostics, University of Genoa, Genoa, Italy.
| | - Denise Battaglini
- Anesthesia and Intensive Care, IRCCS Policlinico San Martino, Genoa, Italy
| | - Francesco Rasulo
- Department of Anesthesia and Intensive Care, Spedali Civili University Affiliated Hospital of Brescia, Brescia, Italy
| | - Francisco A Lobo
- Institute of Anesthesiology, Cleveland Clinic, Abu Dhabi, United Arab Emirates
| | - Basil Matta
- Neurocritical Care Unit, Cambridge University Hospitals, Cambridge, UK
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Beloncle FM. Is COVID-19 different from other causes of acute respiratory distress syndrome? JOURNAL OF INTENSIVE MEDICINE 2023:S2667-100X(23)00008-7. [PMID: 37362866 PMCID: PMC10085872 DOI: 10.1016/j.jointm.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/30/2023] [Accepted: 02/03/2023] [Indexed: 06/28/2023]
Abstract
Coronavirus disease 2019 (COVID-19) pneumonia can lead to acute hypoxemic respiratory failure. When mechanical ventilation is needed, almost all patients with COVID-19 pneumonia meet the criteria for acute respiratory distress syndrome (ARDS). The question of the specificities of COVID-19-associated ARDS compared to other causes of ARDS is of utmost importance, as it may justify changes in ventilatory strategies. This review aims to describe the pathophysiology of COVID-19-associated ARDS and discusses whether specific ventilatory strategies are required in these patients.
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Affiliation(s)
- François M Beloncle
- Medical ICU, University Hospital of Angers, Vent'Lab, University of Angers, Angers 49033, France
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15
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Sonneville R, Dangayach NS, Newcombe V. Neurological complications of critically ill COVID-19 patients. Curr Opin Crit Care 2023; 29:61-67. [PMID: 36880556 DOI: 10.1097/mcc.0000000000001029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
PURPOSE OF REVIEW COVID-19 and systemic critical illness are both associated with neurological complications. We provide an update on the diagnosis and critical care management of adult patients with neurological complications of COVID-19. RECENT FINDINGS Large prospective multicentre studies conducted in the adult population over the last 18 months improved current knowledge on severe neurological complications of COVID-19. In COVID-19 patients presenting with neurological symptoms, a multimodal diagnostic workup (including CSF analysis, brain MRI, and EEG) may identify different syndromes associated with distinct trajectories and outcomes. Acute encephalopathy, which represents the most common neurological presentation of COVID-19, is associated with hypoxemia, toxic/metabolic derangements, and systemic inflammation. Other less frequent complications include cerebrovascular events, acute inflammatory syndromes, and seizures, which may be linked to more complex pathophysiological processes. Neuroimaging findings include infarction, haemorrhagic stroke, encephalitis, microhaemorrhages and leukoencephalopathy. In the absence of structural brain injury, prolonged unconsciousness is usually fully reversible, warranting a cautious approach for prognostication. Advanced quantitative MRI may provide useful insights into the extent and pathophysiology of the consequences of COVID-19 infection including atrophy and functional imaging changes in the chronic phase. SUMMARY Our review highlights the importance of a multimodal approach for the accurate diagnosis and management of complications of COVID-19, both at the acute phase and in the long-term.
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Affiliation(s)
- Romain Sonneville
- Université Paris Cité, IAME, INSERM UMR1137
- AP-HP, Hôpital Bichat - Claude Bernard, Department of Intensive Care Medicine, F-75018 Paris, France
| | - Neha S Dangayach
- Neurocritical Care Division, Departments of Neurosurgery and Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Virginia Newcombe
- University Division of Anaesthesia, Department of Medicine, University of Cambridge, United Kingdom
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Battaglini D, Ciaravolo E, Caiffa S, Delpiano L, Ball L, Vena A, Giacobbe DR, Bassetti M, Matta B, Pelosi P, Robba C. Systemic and Cerebral Effects of Physiotherapy in Mechanically Ventilated Subjects. Respir Care 2023; 68:452-461. [PMID: 36810363 PMCID: PMC10173117 DOI: 10.4187/respcare.10227] [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] [Indexed: 02/24/2023]
Abstract
BACKGROUND Physiotherapy may result in better functional outcomes, shorter duration of delirium, and more ventilator-free days. The effects of physiotherapy on different subpopulations of mechanically ventilated patients on respiratory and cerebral function are still unclear. We evaluated the effect of physiotherapy on systemic gas exchange and hemodynamics as well as on cerebral oxygenation and hemodynamics in mechanically ventilated subjects with and without COVID-19 pneumonia. METHODS This was an observational study in critically ill subjects with and without COVID-19 who underwent protocolized physiotherapy (including respiratory and rehabilitation physiotherapy) and neuromonitoring of cerebral oxygenation and hemodynamics. PaO2 /FIO2 , PaCO2 , hemodynamics (mean arterial pressure [MAP], mm Hg; heart rate, beats/min), and cerebral physiologic parameters (noninvasive intracranial pressure, cerebral perfusion pressure using transcranial Doppler, and cerebral oxygenation using near-infrared spectroscopy) were assessed before (T0) and immediately after physiotherapy (T1). RESULTS Thirty-one subjects were included (16 with COVID-19 and 15 without COVID-19). Physiotherapy improved PaO2 /FIO2 in the overall population (T1 = 185 [108-259] mm Hg vs T0 = 160 [97-231] mm Hg, P = .02) and in the subjects with COVID-19 (T1 = 119 [89-161] mm Hg vs T0 = 110 [81-154] mm Hg, P = .02) and decreased the PaCO2 in the COVID-19 group only (T1 = 40 [38-44] mm Hg vs T0 = 43 [38-47] mm Hg, P = .03). Physiotherapy did not affect cerebral hemodynamics, whereas increased the arterial oxygen part of hemoglobin both in the overall population (T1 = 3.1% [-1.3 to 4.9] vs T0 = 1.1% [-1.8 to 2.6], P = .007) and in the non-COVID-19 group (T1 = 3.7% [0.5-6.3] vs T0 = 0% [-2.2 to 2.8], P = .02). Heart rate was higher after physiotherapy in the overall population (T1 = 87 [75-96] beats/min vs T0 = 78 [72-92] beats/min, P = .044) and in the COVID-19 group (T1 = 87 [81-98] beats/min vs T0 = 77 [72-91] beats/min, P = .01), whereas MAP increased in the COVID-19 group only (T1 = 87 [82-83] vs T0 = 83 [76-89], P = .030). CONCLUSIONS Protocolized physiotherapy improved gas exchange in subjects with COVID-19, whereas it improved cerebral oxygenation in non-COVID-19 subjects.
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Affiliation(s)
- Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy; and Department of Medicine, University of Barcelona, Barcelona, Spain.
| | - Elena Ciaravolo
- Anesthesia and Emergency Department, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy; and Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Salvatore Caiffa
- Intensive Care Respiratory Physiotherapy, Rehabilitation and Functional Education, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Lara Delpiano
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy; and Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Lorenzo Ball
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy; and Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Antonio Vena
- Department of Health Sciences, University of Genoa, Genoa, Italy; and Infectious Diseases Unit, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Daniele R Giacobbe
- Department of Health Sciences, University of Genoa, Genoa, Italy; and Infectious Diseases Unit, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Matteo Bassetti
- Department of Health Sciences, University of Genoa, Genoa, Italy; and Infectious Diseases Unit, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Basil Matta
- Neurocritical Care Unit, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy; and Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy; and Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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Ciliberti P, Cardim D, Giardina A, Groznik M, Ball L, Giovannini M, Battaglini D, Beqiri E, Matta B, Smielewski P, Czosnyka M, Pelosi P, Robba C. Effects of short-term hyperoxemia on cerebral autoregulation and tissue oxygenation in acute brain injured patients. Front Physiol 2023; 14:1113386. [PMID: 36846344 PMCID: PMC9944047 DOI: 10.3389/fphys.2023.1113386] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 01/25/2023] [Indexed: 02/10/2023] Open
Abstract
Introduction: Potential detrimental effects of hyperoxemia on outcomes have been reported in critically ill patients. Little evidence exists on the effects of hyperoxygenation and hyperoxemia on cerebral physiology. The primary aim of this study is to assess the effect of hyperoxygenation and hyperoxemia on cerebral autoregulation in acute brain injured patients. We further evaluated potential links between hyperoxemia, cerebral oxygenation and intracranial pressure (ICP). Methods: This is a single center, observational, prospective study. Acute brain injured patients [traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), intracranial hemorrhage (ICH)] undergoing multimodal brain monitoring through a software platform (ICM+) were included. Multimodal monitoring consisted of invasive ICP, arterial blood pressure (ABP) and near infrared spectrometry (NIRS). Derived parameters of ICP and ABP monitoring included the pressure reactivity index (PRx) to assess cerebral autoregulation. ICP, PRx, and NIRS-derived parameters (cerebral regional saturation of oxygen, changes in concentration of regional oxy- and deoxy-hemoglobin), were evaluated at baseline and after 10 min of hyperoxygenation with a fraction of inspired oxygen (FiO2) of 100% using repeated measures t-test or paired Wilcoxon signed-rank test. Continuous variables are reported as median (interquartile range). Results: Twenty-five patients were included. The median age was 64.7 years (45.9-73.2), and 60% were male. Thirteen patients (52%) were admitted for TBI, 7 (28%) for SAH, and 5 (20%) patients for ICH. The median value of systemic oxygenation (partial pressure of oxygen-PaO2) significantly increased after FiO2 test, from 97 (90-101) mm Hg to 197 (189-202) mm Hg, p < 0.0001. After FiO2 test, no changes were observed in PRx values (from 0.21 (0.10-0.43) to 0.22 (0.15-0.36), p = 0.68), nor in ICP values (from 13.42 (9.12-17.34) mm Hg to 13.34 (8.85-17.56) mm Hg, p = 0.90). All NIRS-derived parameters reacted positively to hyperoxygenation as expected. Changes in systemic oxygenation and the arterial component of cerebral oxygenation were significantly correlated (respectively ΔPaO2 and ΔO2Hbi; r = 0.49 (95% CI = 0.17-0.80). Conclusion: Short-term hyperoxygenation does not seem to critically affect cerebral autoregulation.
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Affiliation(s)
- Pietro Ciliberti
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Danilo Cardim
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, United States,Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, TX, United States
| | - Alberto Giardina
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Matjaž Groznik
- Traumatology Department of the University Clinical Center Ljubljana, Ljubljana, Slovenia
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy,Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Martina Giovannini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Basil Matta
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom,Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy,Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy,Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy,*Correspondence: Chiara Robba,
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Quaresima V, Scholkmann F, Ferrari M. Skin pigmentation bias in regional brain oximetry measurements? Crit Care 2023; 27:10. [PMID: 36627689 PMCID: PMC9830604 DOI: 10.1186/s13054-022-04295-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 12/25/2022] [Indexed: 01/12/2023] Open
Affiliation(s)
- V. Quaresima
- grid.158820.60000 0004 1757 2611Department of Life, Health and Environmental Science, University of L’Aquila, L’Aquila, Italy
| | - F. Scholkmann
- grid.7400.30000 0004 1937 0650Biomedical Optics Research Laboratory, Department of Neonatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - M. Ferrari
- grid.158820.60000 0004 1757 2611Department of Life, Health and Environmental Science, University of L’Aquila, L’Aquila, Italy
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Ellenberger C, Pelosi P, de Abreu MG, Wrigge H, Diaper J, Hagerman A, Adam Y, Schultz MJ, Licker M. Distribution of ventilation and oxygenation in surgical obese patients ventilated with high versus low positive end-expiratory pressure: A substudy of a randomised controlled trial. Eur J Anaesthesiol 2022; 39:875-884. [PMID: 36093886 PMCID: PMC9553219 DOI: 10.1097/eja.0000000000001741] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
BACKGROUND Intra-operative ventilation using low/physiological tidal volume and positive end-expiratory pressure (PEEP) with periodic alveolar recruitment manoeuvres (ARMs) is recommended in obese surgery patients. OBJECTIVES To investigate the effects of PEEP levels and ARMs on ventilation distribution, oxygenation, haemodynamic parameters and cerebral oximetry. DESIGN A substudy of a randomised controlled trial. SETTING Tertiary medical centre in Geneva, Switzerland, between 2015 and 2018. PATIENTS One hundred and sixty-two patients with a BMI at least 35 kg per square metre undergoing elective open or laparoscopic surgery lasting at least 120 min. INTERVENTION Patients were randomised to PEEP of 4 cmH 2 O ( n = 79) or PEEP of 12 cmH 2 O with hourly ARMs ( n = 83). MAIN OUTCOME MEASURES The primary endpoint was the fraction of ventilation in the dependent lung as measured by electrical impedance tomography. Secondary endpoints were the oxygen saturation index (SaO 2 /FIO 2 ratio), respiratory and haemodynamic parameters, and cerebral tissue oximetry. RESULTS Compared with low PEEP, high PEEP was associated with smaller intra-operative decreases in dependent lung ventilation [-11.2%; 95% confidence interval (CI) -8.7 to -13.7 vs. -13.9%; 95% CI -11.7 to -16.5; P = 0.029], oxygen saturation index (-49.6%; 95% CI -48.0 to -51.3 vs. -51.3%; 95% CI -49.6 to -53.1; P < 0.001) and a lower driving pressure (-6.3 cmH 2 O; 95% CI -5.7 to -7.0). Haemodynamic parameters did not differ between the groups, except at the end of ARMs when arterial pressure and cardiac index decreased on average by -13.7 mmHg (95% CI -12.5 to -14.9) and by -0.54 l min -1 m -2 (95% CI -0.49 to -0.59) along with increased cerebral tissue oximetry (3.0 and 3.2% on left and right front brain, respectively). CONCLUSION In obese patients undergoing abdominal surgery, intra-operative PEEP of 12 cmH 2 O with periodic ARMs, compared with intra-operative PEEP of 4 cmH 2 O without ARMs, slightly redistributed ventilation to dependent lung zones with minor improvements in peripheral and cerebral oxygenation. TRIAL REGISTRATION NCT02148692, https://clinicaltrials.gov/ct2.
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Affiliation(s)
- Christoph Ellenberger
- From the Department of Anaesthesia, Pharmacology, Intensive Care and Emergency Medicine, University Hospital of Geneva, rue Gabriel-Perret-Gentil (CE, JD, AH, YA, ML), Faculty of Medicine, University of Geneva, Geneva, Switzerland (CE, ML), Department of Surgical Sciences and Integrated Diagnostics, University of Genoa (PP), Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy (PP), Pulmonary Engineering Group, Department of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany (MGdA), Department of Outcomes Research (MGdA), Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA (MGdA), Department of Anaesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital (HW), Medical Faculty, Martin-Luther-University Halle-Wittenberg, Halle, Germany (HW), Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centers, Amsterdam, The Netherlands (MJS)
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20
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Alqahtani JS, Aldhahir AM, Al Ghamdi SS, AlBahrani S, AlDraiwiesh IA, Alqarni AA, Latief K, Raya RP, Oyelade T. Inhaled Nitric Oxide for Clinical Management of COVID-19: A Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12803. [PMID: 36232100 PMCID: PMC9566710 DOI: 10.3390/ijerph191912803] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 09/28/2022] [Accepted: 09/29/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Severe COVID-19 is associated with hypoxemia and acute respiratory distress syndrome (ARDS), which may predispose multiorgan failure and death. Inhaled nitric oxide (iNO) is a clinical vasodilator used in the management of acute respiratory distress syndrome (ARDS). This study evaluated the response rate to iNO in patients with COVID-19-ARDS. METHOD We searched Medline and Embase databases in May 2022, and data on the use of iNO in the treatment of ARDS in COVID-19 patients were synthesized from studies that satisfied predefined inclusion criteria. A systematic synthesis of data was performed followed by meta-analysis. We performed the funnel plot and leave-one-out sensitivity test on the included studies to assess publication bias and possible exaggerated effect size. We compared the effect size of the studies from the Unites States with those from other countries and performed meta-regression to assess the effect of age, year of publication, and concomitant vasodilator use on the effect size. RESULTS A total of 17 studies (including 712 COVID-19 patients) were included in this systematic review of which 8 studies (involving 265 COVID-19 patients) were subjected to meta-analysis. The overall response rate was 66% (95% CI, 47-84%) with significantly high between-studies heterogeneity (I2 = 94%, p < 0.001). The funnel plot showed publication bias, although the sensitivity test using leave-one-out analysis showed that removing any of the study does not remove the significance of the result. The response rate was higher in the Unites States, and meta-regression showed that age, year of publication, and use of concomitant vasodilators did not influence the response rate to iNO. CONCLUSION iNO therapy is valuable in the treatment of hypoxemia in COVID-19 patients and may improve systemic oxygenation in patients with COVID-19-ARDS. Future studies should investigate the mechanism of the activity of iNO in COVID-19 patients to provide insight into the unexplored potential of iNO in general ARDS.
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Affiliation(s)
- Jaber S. Alqahtani
- Department of Respiratory Care, Prince Sultan Military College of Health Sciences, Dammam 34313, Saudi Arabia
| | - Abdulelah M. Aldhahir
- Respiratory Therapy Department, Faculty of Applied Medical Sciences, Jazan University, Jazan 45142, Saudi Arabia
| | - Shouq S. Al Ghamdi
- Anesthesia Technology Department, Prince Sultan Military College of Health Sciences, Dammam 34313, Saudi Arabia
| | - Salma AlBahrani
- Department of Internal Medicine, King Fahad Military Medical Complex, Dhahran 31932, Saudi Arabia
| | - Ibrahim A. AlDraiwiesh
- Department of Respiratory Care, Prince Sultan Military College of Health Sciences, Dammam 34313, Saudi Arabia
| | - Abdullah A. Alqarni
- Department of Respiratory Therapy, Faculty of Medical Rehabilitation Sciences, King Abdulaziz University, Jeddah 22254, Saudi Arabia
| | - Kamaluddin Latief
- Global Health and Health Security Department, College of Public Health, Taipei Medical University, Taipei 11031, Taiwan
- Centre for Family Welfare, Faculty of Public Health, University of Indonesia, Depok 16424, Indonesia
| | - Reynie Purnama Raya
- Institute for Global Health, Faculty of Population Health Sciences, University College London, London NW3 2PF, UK
- Faculty of Science, Universitas ‘Aisyiyah Bandung, Bandung 40264, Indonesia
| | - Tope Oyelade
- Institute for Liver and Digestive Health, Division of Medicine, University College London, London NW3 2PF, UK
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21
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Complications of invasive mechanical ventilation in critically Ill Covid-19 patients - A narrative review. Ann Med Surg (Lond) 2022; 80:104201. [PMID: 35874936 PMCID: PMC9287581 DOI: 10.1016/j.amsu.2022.104201] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 07/12/2022] [Indexed: 01/08/2023] Open
Abstract
Critically ill COVID-19 patients have to undergo positive pressure ventilation, a non-physiological and invasive intervention that can be lifesaving in severe ARDS. Similar to any other intervention, it has its pros and cons. Despite following Lung Protective Ventilation (LPV), some of the complications are frequently reported in these critically ill patients and significantly impact overall mortality. The complications related to invasive mechanical ventilation (IMV) in critically ill COVID-19 patients can be broadly divided into pulmonary and non-pulmonary. Among pulmonary complications, the most frequent is ventilator-associated pneumonia. Others are barotrauma, including subcutaneous emphysema, pneumomediastinum, pneumothorax, bullous lesions, cardiopulmonary effects of right ventricular dysfunction, and pulmonary complications mimicking cardiac failure, including pulmonary edema. Tracheal complications, including full-thickness tracheal lesions (FTTLs) and tracheoesophageal fistulas (TEFs) are serious but rare complications. Non-Pulmonary complications include neurological, nephrological, ocular, and oral complications. The complications related to IMV in critically ill covid 19 patients can be broadly divided into pulmonary and non-pulmonary complications. Among pulmonary complications the most frequent is Ventilator associated pneumonia. Others are Barotrauma, Cardiopulmonary effects of right ventricular dysfunction & Pulmonary complications mimicking cardiac failure including pulmonary edema, tracheal complications including full thickness tracheal lesions & tracheoesophageal fistulas. Non-Pulmonary complications of prolonged IMV include neurological, nephrological, ocular and oral complications.
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22
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More questions than answers for the use of inhaled nitric oxide in COVID-19. Nitric Oxide 2022; 124:39-48. [PMID: 35526702 PMCID: PMC9072755 DOI: 10.1016/j.niox.2022.05.001] [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: 02/25/2022] [Revised: 04/08/2022] [Accepted: 05/03/2022] [Indexed: 12/14/2022]
Abstract
Inhaled nitric oxide (iNO) is a potent vasodilator approved for use in term and near-term neonates, but with broad off-label use in settings including acute respiratory distress syndrome (ARDS). As an inhaled therapy, iNO reaches well ventilated portions of the lung and selectively vasodilates the pulmonary vascular bed, with little systemic effect due to its rapid inactivation in the bloodstream. iNO is well documented to improve oxygenation in a variety of pathological conditions, but in ARDS, these transient improvements in oxygenation have not translated into meaningful clinical outcomes. In coronavirus disease 2019 (COVID-19) related ARDS, iNO has been proposed as a potential treatment due to a variety of mechanisms, including its vasodilatory effect, antiviral properties, as well as anti-thrombotic and anti-inflammatory actions. Presently however, no randomized controlled data are available evaluating iNO in COVID-19, and published data are largely derived from retrospective and cohort studies. It is therefore important to interpret these limited findings with caution, as many questions remain around factors such as patient selection, optimal dosing, timing of administration, duration of administration, and delivery method. Each of these factors may influence whether iNO is indeed an efficacious therapy - or not - in this context. As such, until randomized controlled trial data are available, use of iNO in the treatment of patients with COVID-19 related ARDS should be considered on an individual basis with sound clinical judgement from the attending physician.
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23
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Inhaled nitric oxide as temporary respiratory stabilization in patients with COVID-19 related respiratory failure (INOCOV): Study protocol for a randomized controlled trial. PLoS One 2022; 17:e0268822. [PMID: 35622848 PMCID: PMC9140246 DOI: 10.1371/journal.pone.0268822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 05/06/2022] [Indexed: 12/02/2022] Open
Abstract
Background In March 2020, WHO announced the COVID-19 a pandemic and a major global public health emergency. Mortality from COVID-19 is rapidly increasing globally, with acute respiratory failure as the predominant cause of death. Many patients experience severe hypoxia and life-threatening respiratory failure often requiring mechanical ventilation. To increase safety margins during emergency anaesthesia and rapid sequence intubation (RSI), patients are preoxygenated with a closed facemask with high-flow oxygen and positive end-expiratory pressure (PEEP). Due to the high shunt fraction of deoxygenated blood through the lungs frequently described in COVID-19 however, these measures may be insufficient to avoid harmful hypoxemia. Preoxygenation with inhaled nitric oxide (iNO) potentially reduces the shunt fraction and may thus allow for the necessary margins of safety during RSI. Methods and design The INOCOV protocol describes a phase II pharmacological trial of inhaled nitric oxide (iNO) as an adjunct to standard of care with medical oxygen in initial airway and ventilation management of patients with known or suspected COVID-19 in acute respiratory failure. The trial is parallel two-arm, randomized, controlled, blinded trial. The primary outcome measure is the change in oxygen saturation (SpO2), and the null hypothesis is that there is no difference in the change in SpO2 following initiation of iNO. Trial registration EudraCT number 2020-001656-18; WHO UTN: U1111-1250-1698. Protocol version: 2.0 (June 25th, 2021).
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24
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Silva PL, Ball L, Rocco PRM, Pelosi P. Physiological and Pathophysiological Consequences of Mechanical Ventilation. Semin Respir Crit Care Med 2022; 43:321-334. [PMID: 35439832 DOI: 10.1055/s-0042-1744447] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Mechanical ventilation is a life-support system used to ensure blood gas exchange and to assist the respiratory muscles in ventilating the lung during the acute phase of lung disease or following surgery. Positive-pressure mechanical ventilation differs considerably from normal physiologic breathing. This may lead to several negative physiological consequences, both on the lungs and on peripheral organs. First, hemodynamic changes can affect cardiovascular performance, cerebral perfusion pressure (CPP), and drainage of renal veins. Second, the negative effect of mechanical ventilation (compression stress) on the alveolar-capillary membrane and extracellular matrix may cause local and systemic inflammation, promoting lung and peripheral-organ injury. Third, intra-abdominal hypertension may further impair lung and peripheral-organ function during controlled and assisted ventilation. Mechanical ventilation should be optimized and personalized in each patient according to individual clinical needs. Multiple parameters must be adjusted appropriately to minimize ventilator-induced lung injury (VILI), including: inspiratory stress (the respiratory system inspiratory plateau pressure); dynamic strain (the ratio between tidal volume and the end-expiratory lung volume, or inspiratory capacity); static strain (the end-expiratory lung volume determined by positive end-expiratory pressure [PEEP]); driving pressure (the difference between the respiratory system inspiratory plateau pressure and PEEP); and mechanical power (the amount of mechanical energy imparted as a function of respiratory rate). More recently, patient self-inflicted lung injury (P-SILI) has been proposed as a potential mechanism promoting VILI. In the present chapter, we will discuss the physiological and pathophysiological consequences of mechanical ventilation and how to personalize mechanical ventilation parameters.
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Affiliation(s)
- Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.,Department of Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.,Department of Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
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25
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Battaglini D, Premraj L, Huth S, Fanning J, Whitman G, Arora RC, Bellapart J, Bastos Porto D, Taccone FS, Suen JY, Li Bassi G, Fraser JF, Badenes R, Cho SM, Robba C. Non-Invasive Multimodal Neuromonitoring in Non-Critically Ill Hospitalized Adult Patients With COVID-19: A Systematic Review and Meta-Analysis. Front Neurol 2022; 13:814405. [PMID: 35493827 PMCID: PMC9047047 DOI: 10.3389/fneur.2022.814405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 03/15/2022] [Indexed: 12/26/2022] Open
Abstract
Introduction Neurological complications are frequent in patients with coronavirus disease-2019 (COVID-19). The use of non-invasive neuromonitoring in subjects without primary brain injury but with potential neurological derangement is gaining attention outside the intensive care unit (ICU). This systematic review and meta-analysis investigates the use of non-invasive multimodal neuromonitoring of the brain in non-critically ill patients with COVID-19 outside the ICU and quantifies the prevalence of abnormal neuromonitoring findings in this population. Methods A structured literature search was performed in MEDLINE/PubMed, Scopus, Cochrane, and EMBASE to investigate the use of non-invasive neuromonitoring tools, including transcranial doppler (TCD); optic nerve sheath diameter (ONSD); near-infrared spectroscopy (NIRS); pupillometry; and electroencephalography (EEG) inpatients with COVID-19 outside the ICU. The proportion of non-ICU patients with CVOID-19 and a particular neurological feature at neuromonitoring at the study time was defined as prevalence. Results A total of 6,593 records were identified through literature searching. Twenty-one studies were finally selected, comprising 368 non-ICU patients, of whom 97 were considered for the prevalence of meta-analysis. The pooled prevalence of electroencephalographic seizures, periodic and rhythmic patterns, slow background abnormalities, and abnormal background on EEG was.17 (95% CI 0.04–0.29), 0.42 (95% CI 0.01–0.82), 0.92 (95% CI 0.83–1.01), and.95 (95% CI 0.088–1.09), respectively. No studies investigating NIRS and ONSD outside the ICU were found. The pooled prevalence for abnormal neuromonitoring findings detected using the TCD and pupillometry were incomputable due to insufficient data. Conclusions Neuromonitoring tools are non-invasive, less expensive, safe, and bedside available tools with a great potential for both diagnosis and monitoring of patients with COVID-19 at risk of brain derangements. However, extensive literature searching reveals that they are rarely used outside critical care settings. Systematic Review Registration:www.crd.york.ac.uk/prospero/display_record.php?RecordID=265617, identifier: CRD42021265617.
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Affiliation(s)
- Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Medicine, University of Barcelona, Barcelona, Spain
| | | | - Samuel Huth
- Critical Care Research Group (CCRG), Herston, QLD, Australia
- Faculty of Medicine, The University of Queensland, Herston, QLD, Australia
| | - Jonathon Fanning
- Critical Care Research Group (CCRG), Herston, QLD, Australia
- Faculty of Medicine, The University of Queensland, Herston, QLD, Australia
- St. Andrew's War Memorial Hospital, Uniting Care Health, Spring Hill, QLD, Australia
| | - Glenn Whitman
- School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Rakesh C. Arora
- Department of Surgery, Section of Cardiac Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Judith Bellapart
- Critical Care Research Group (CCRG), Herston, QLD, Australia
- Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Diego Bastos Porto
- Department of Critical Care, Sao Camilo Cura D'ars Hospital, Fortaleza, Brazil
| | - Fabio Silvio Taccone
- Intensive Care Unit, Erasmus Hospital, Free University of Brussels, Brussels, Belgium
| | - Jacky Y. Suen
- Critical Care Research Group (CCRG), Herston, QLD, Australia
- Faculty of Medicine, The University of Queensland, Herston, QLD, Australia
| | - Gianluigi Li Bassi
- Critical Care Research Group (CCRG), Herston, QLD, Australia
- Faculty of Medicine, The University of Queensland, Herston, QLD, Australia
- Queensland University of Technology, Herston, QLD, Australia
- Institut de Ricerca Biomedica August Pi i Sunyer (IDIBAPS), Valencia, Spain
| | - John F. Fraser
- Critical Care Research Group (CCRG), Herston, QLD, Australia
- Faculty of Medicine, The University of Queensland, Herston, QLD, Australia
- St. Andrew's War Memorial Hospital, Uniting Care Health, Spring Hill, QLD, Australia
- Queensland University of Technology, Herston, QLD, Australia
| | - Rafael Badenes
- Department of Anesthesia and Intensive Care, Hospital Clinic Universitari, INCLIVA Research Health Institute, University of Valencia, Valencia, Spain
- *Correspondence: Rafael Badenes
| | - Sung-Min Cho
- Griffith University School of Medicine, Gold Coast, QLD, Australia
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
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26
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Treating the body to prevent brain injury: lessons learned from the coronavirus disease 2019 pandemic. Curr Opin Crit Care 2022; 28:176-183. [PMID: 35058407 PMCID: PMC8891065 DOI: 10.1097/mcc.0000000000000917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW We aim to provide the current evidence on utility and application of neuromonitoring tools including electroencephalography (EEG), transcranial Doppler (TCD), pupillometry, optic nerve sheath diameter (ONSD), cerebral near-infrared spectroscopy (cNIRS), somatosensory-evoked potentials (SSEPs), and invasive intracranial monitoring in COVID-19. We also provide recent evidence on management strategy of COVID-19-associated neurological complications. RECENT FINDINGS Despite the common occurrence of neurological complications, we found limited use of standard neurologic monitoring in patients with COVID-19. No specific EEG pattern was identified in COVID-19. Frontal epileptic discharge was proposed to be a potential marker of COVID-19 encephalopathy. TCD, ONSD, and pupillometry can provide real-time data on intracranial pressure. Additionally, TCD may be useful for detection of acute large vessel occlusions, abnormal cerebral hemodynamics, cerebral emboli, and evolving cerebral edema at bedside. cNIRS was under-utilized in COVID-19 population and there are ongoing studies to investigate whether cerebral oxygenation could be a more useful parameter than peripheral oxygen saturation to guide clinical titration of permissive hypoxemia. Limited data exists on SSEPs and invasive intracranial monitoring. SUMMARY Early recognition using standardized neuromonitoring and timely intervention is important to reduce morbidity and mortality. The management strategy for neurological complications is similar to those without COVID-19.
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27
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Ball L, Silva PL, Giacobbe DR, Bassetti M, Zubieta-Calleja GR, Rocco PRM, Pelosi P. Understanding the pathophysiology of typical acute respiratory distress syndrome and severe COVID-19. Expert Rev Respir Med 2022; 16:437-446. [PMID: 35341424 PMCID: PMC9115784 DOI: 10.1080/17476348.2022.2057300] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction Typical acute respiratory distress syndrome (ARDS) and severe coronavirus-19 (COVID-19) pneumonia share complex pathophysiology, a high mortality rate, and an unmet need for efficient therapeutics. Areas covered This review discusses the current advances in understanding the pathophysiologic mechanisms underlying typical ARDS and severe COVID-19 pneumonia, highlighting specific aspects of COVID-19-related acute hypoxemic respiratory failure that require attention. Two models have been proposed to describe the mechanisms of respiratory failure associated with typical ARDS and severe COVID-19 pneumonia. Expert opinion ARDS is defined as a syndrome rather than a distinct pathologic entity. There is great heterogeneity regarding the pathophysiologic, clinical, radiologic, and biological phenotypes in patients with ARDS, challenging clinicians, and scientists to discover new therapies. COVID-19 has been described as a cause of pulmonary ARDS and has reopened many questions regarding the pathophysiology of ARDS itself. COVID-19 lung injury involves direct viral epithelial cell damage and thrombotic and inflammatory reactions. There are some differences between ARDS and COVID-19 lung injury in aspects of aeration distribution, perfusion, and pulmonary vascular responses.
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Affiliation(s)
- Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,Anesthesia and Intensive Care, Ospedale Policlinico San Martino, IRCCS per l'Oncologia e le Neuroscienze, Genoa, Italy
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Daniele Roberto Giacobbe
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.,Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS per l'Oncologia e le Neuroscienze, Genoa, Italy
| | - Matteo Bassetti
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.,Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS per l'Oncologia e le Neuroscienze, Genoa, Italy
| | | | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,Anesthesia and Intensive Care, Ospedale Policlinico San Martino, IRCCS per l'Oncologia e le Neuroscienze, Genoa, Italy
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28
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Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2022. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2022. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901.
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Affiliation(s)
- Denise Battaglini
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Paolo Pelosi
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Surgical Science and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Chiara Robba
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy. .,Department of Surgical Science and Integrated Diagnostics, University of Genoa, Genoa, Italy.
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29
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Abstract
PURPOSE OF REVIEW Prone position has been widely used in the COVID-19 pandemic, with an extension of its use in patients with spontaneous breathing ('awake prone'). We herein propose a review of the current literature on prone position in mechanical ventilation and while spontaneous breathing in patients with COVID-19 pneumonia or COVID-19 ARDS. RECENT FINDINGS A literature search retrieved 70 studies separating whether patient was intubated (24 studies) or nonintubated (46 studies). The outcomes analyzed were intubation rate, mortality and respiratory response to prone. In nonintubated patient receiving prone position, the main finding was mortality reduction in ICU and outside ICU setting. SUMMARY The final results of the several randomized control trials completed or ongoing are needed to confirm the trend of these results. In intubated patients, observational studies showed that responders to prone in terms of oxygenation had a better survival than nonresponders.
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Affiliation(s)
- Aileen Kharat
- Service de Pneumologie, Hôpitaux Universitaires de Genève
- Université de Médecine de Genève, Switzerland
| | - Marie Simon
- Médecine Intensive-Réanimation, Hôpital Edouard Herriot, Lyon
| | - Claude Guérin
- Médecine Intensive-Réanimation, Hôpital Edouard Herriot, Lyon
- Université de Lyon, Lyon
- Institut Mondor de Recherches Biomédicales, INSERM 955, CNRS 7200, Créteil, France
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30
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Effects of positive end-expiratory pressure on lung ultrasound patterns and their correlation with intracranial pressure in mechanically ventilated brain injured patients. Crit Care 2022; 26:31. [PMID: 35090525 PMCID: PMC8796179 DOI: 10.1186/s13054-022-03903-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 01/20/2022] [Indexed: 12/30/2022] Open
Abstract
Background The effects of positive end-expiratory pressure (PEEP) on lung ultrasound (LUS) patterns, and their relationship with intracranial pressure (ICP) in brain injured patients have not been completely clarified. The primary aim of this study was to assess the effect of two levels of PEEP (5 and 15 cmH2O) on global (LUStot) and regional (anterior, lateral, and posterior areas) LUS scores and their correlation with changes of invasive ICP. Secondary aims included: the evaluation of the effect of PEEP on respiratory mechanics, arterial partial pressure of carbon dioxide (PaCO2) and hemodynamics; the correlation between changes in ICP and LUS as well as respiratory parameters; the identification of factors at baseline as potential predictors of ICP response to higher PEEP. Methods Prospective, observational study including adult mechanically ventilated patients with acute brain injury requiring invasive ICP. Total and regional LUS scores, ICP, respiratory mechanics, and arterial blood gases values were analyzed at PEEP 5 and 15 cmH2O. Results Thirty patients were included; 19 of them (63.3%) were male, with median age of 65 years [interquartile range (IQR) = 66.7–76.0]. PEEP from 5 to 15 cmH2O reduced LUS score in the posterior regions (LUSp, median value from 7 [5–8] to 4.5 [3.7–6], p = 0.002). Changes in ICP were significantly correlated with changes in LUStot (rho = 0.631, p = 0.0002), LUSp (rho = 0.663, p < 0.0001), respiratory system compliance (rho = − 0.599, p < 0.0001), mean arterial pressure (rho = − 0.833, p < 0.0001) and PaCO2 (rho = 0.819, p < 0.0001). Baseline LUStot score predicted the increase of ICP with PEEP. Conclusions LUS-together with the evaluation of respiratory and clinical variables-can assist the clinicians in the bedside assessment and prediction of the effect of PEEP on ICP in patients with acute brain injury. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03903-7.
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Petit M, Jullien E, Vieillard-Baron A. Right Ventricular Function in Acute Respiratory Distress Syndrome: Impact on Outcome, Respiratory Strategy and Use of Veno-Venous Extracorporeal Membrane Oxygenation. Front Physiol 2022; 12:797252. [PMID: 35095561 PMCID: PMC8795709 DOI: 10.3389/fphys.2021.797252] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 12/21/2021] [Indexed: 12/16/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is characterized by protein-rich alveolar edema, reduced lung compliance and severe hypoxemia. Despite some evidence of improvements in mortality over recent decades, ARDS remains a major public health problem with 30% 28-day mortality in recent cohorts. Pulmonary vascular dysfunction is one of the pivot points of the pathophysiology of ARDS, resulting in a certain degree of pulmonary hypertension, higher levels of which are associated with morbidity and mortality. Pulmonary hypertension develops as a result of endothelial dysfunction, pulmonary vascular occlusion, increased vascular tone, extrinsic vessel occlusion, and vascular remodeling. This increase in right ventricular (RV) afterload causes uncoupling between the pulmonary circulation and RV function. Without any contractile reserve, the right ventricle has no adaptive reserve mechanism other than dilatation, which is responsible for left ventricular compression, leading to circulatory failure and worsening of oxygen delivery. This state, also called severe acute cor pulmonale (ACP), is responsible for excess mortality. Strategies designed to protect the pulmonary circulation and the right ventricle in ARDS should be the cornerstones of the care and support of patients with the severest disease, in order to improve prognosis, pending stronger evidence. Acute cor pulmonale is associated with higher driving pressure (≥18 cmH2O), hypercapnia (PaCO2 ≥ 48 mmHg), and hypoxemia (PaO2/FiO2 < 150 mmHg). RV protection should focus on these three preventable factors identified in the last decade. Prone positioning, the setting of positive end-expiratory pressure, and inhaled nitric oxide (INO) can also unload the right ventricle, restore better coupling between the right ventricle and the pulmonary circulation, and correct circulatory failure. When all these strategies are insufficient, extracorporeal membrane oxygenation (ECMO), which improves decarboxylation and oxygenation and enables ultra-protective ventilation by decreasing driving pressure, should be discussed in seeking better control of RV afterload. This review reports the pathophysiology of pulmonary hypertension in ARDS, describes right heart function, and proposes an RV protective approach, ranging from ventilatory settings and prone positioning to INO and selection of patients potentially eligible for veno-venous extracorporeal membrane oxygenation (VV ECMO).
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Affiliation(s)
- Matthieu Petit
- Medical Intensive Care Unit, University Hospital Ambroise Paré, APHP, Boulogne-Billancourt, France
- UFR des Sciences de la Santé Simone Veil, Université Paris-Saclay, Montigny-le-Bretonneux, France
| | - Edouard Jullien
- Medical Intensive Care Unit, University Hospital Ambroise Paré, APHP, Boulogne-Billancourt, France
- UFR des Sciences de la Santé Simone Veil, Université Paris-Saclay, Montigny-le-Bretonneux, France
| | - Antoine Vieillard-Baron
- Medical Intensive Care Unit, University Hospital Ambroise Paré, APHP, Boulogne-Billancourt, France
- UFR des Sciences de la Santé Simone Veil, Université Paris-Saclay, Montigny-le-Bretonneux, France
- *Correspondence: Antoine Vieillard-Baron,
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Robba C, Cardim D, Ball L, Battaglini D, Dabrowski W, Bassetti M, Giacobbe DR, Czosnyka M, Badenes R, Pelosi P, Matta B. The Use of Different Components of Brain Oxygenation for the Assessment of Cerebral Haemodynamics: A Prospective Observational Study on COVID-19 Patients. Front Neurol 2021; 12:735469. [PMID: 34987461 PMCID: PMC8722102 DOI: 10.3389/fneur.2021.735469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 10/29/2021] [Indexed: 11/10/2022] Open
Abstract
Introduction: The role of near-infrared spectroscopy (NIRS) for the evaluation of cerebral haemodynamics is gaining increasing popularity because of its noninvasive nature. The aim of this study was to evaluate the role of the integral components of regional cerebral oxygenation (rSO2) measured by NIRS [i.e., arterial-oxyhemoglobin (O2Hbi) and venous-deoxyhemoglobin (HHbi)-components], as indirect surrogates of cerebral blood flow (CBF) in a cohort of critically ill patients with coronavirus disease 2019 (COVID-19). We compared these findings to the gold standard technique for noninvasive CBF assessment, Transcranial Doppler (TCD). Methods: Mechanically ventilated patients with COVID-19 admitted to the Intensive Care Unit (ICU) of Policlinico San Martino Hospital, Genova, Italy, who underwent multimodal neuromonitoring (including NIRS and TCD), were included. rSO2 and its components [relative changes in O2Hbi, HHbi, and total haemoglobin (cHbi)] were compared with TCD (cerebral blood flow velocity, CBFV). Changes (Δ) in CBFV and rSO2, ΔO2Hbi, ΔHHbi, and ΔcHbi after systemic arterial blood pressure (MAP) modifications induced by different manoeuvres (e.g., rescue therapies and haemodynamic manipulation) were assessed using mixed-effect linear regression analysis and repeated measures correlation coefficients. All values were normalised as percentage changes from the baseline (Δ%). Results: One hundred and four measurements from 25 patients were included. Significant effects of Δ%MAP on Δ%CBF were observed after rescue manoeuvres for CBFV, ΔcHbi, and ΔO2Hbi. The highest correlation was found between ΔCBFV and ΔΔO2Hbi (R = 0.88, p < 0.0001), and the poorest between ΔCBFV and ΔΔHHbi (R = 0.34, p = 0.002). Conclusions: ΔO2Hbi had the highest accuracy to assess CBF changes, reflecting its role as the main component for vasomotor response after changes in MAP. The use of indexes derived from the different components of rSO2 can be useful for the bedside evaluation of cerebral haemodynamics in mechanically ventilated patients with COVID-19.
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Affiliation(s)
- Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy,San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Danilo Cardim
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy,San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Denise Battaglini
- San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy,Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Wojciech Dabrowski
- Department of Anesthesiology and Intensive Care, Medical University of Lublin, Lublin, Poland
| | - Matteo Bassetti
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy,Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Daniele Roberto Giacobbe
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy,Infectious Diseases Unit, Ospedale Policlinico San Martino, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Marek Czosnyka
- Brain Physics Laboratory, Department of Clinical Neurosciences, Neurosurgery Unit, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Rafael Badenes
- Department of Anesthesia and Intensive Care, Hospital Clinic Universitari, INCLIVA Research Health Institute, University of Valencia, Valencia, Spain,*Correspondence: Rafael Badenes
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy,San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Basil Matta
- Neurocritical Care Unit, Addenbrooke's Hospital, Cambridge, United Kingdom
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Valk CMA, Tsonas AM, Botta M, Bos LDJ, Pillay J, Serpa Neto A, Schultz MJ, Paulus F. Association of early positive end-expiratory pressure settings with ventilator-free days in patients with coronavirus disease 2019 acute respiratory distress syndrome: A secondary analysis of the Practice of VENTilation in COVID-19 study. Eur J Anaesthesiol 2021; 38:1274-1283. [PMID: 34238782 PMCID: PMC8630930 DOI: 10.1097/eja.0000000000001565] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND There is uncertainty about how much positive end-expiratory pressure (PEEP) should be used in patients with acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19). OBJECTIVE To investigate whether a higher PEEP strategy is superior to a lower PEEP strategy regarding the number of ventilator-free days (VFDs). DESIGN Multicentre observational study conducted from 1 March to 1 June 2020. SETTING AND PATIENTS Twenty-two ICUs in The Netherlands and 933 invasively ventilated COVID-19 ARDS patients. INTERVENTIONS Patients were categorised retrospectively as having received invasive ventilation with higher (n=259) or lower PEEP (n=674), based on the high and low PEEP/FiO2 tables of the ARDS Network, and using ventilator settings and parameters in the first hour of invasive ventilation, and every 8 h thereafter at fixed time points during the first four calendar days. We also used propensity score matching to control for observed confounding factors that might influence outcomes. MAIN OUTCOMES AND MEASURES The primary outcome was the number of VFDs. Secondary outcomes included distant organ failures including acute kidney injury (AKI) and use of renal replacement therapy (RRT), and mortality. RESULTS In the unmatched cohort, the higher PEEP strategy had no association with the median [IQR] number of VFDs (2.0 [0.0 to 15.0] vs. 0.0 [0.0 to 16.0] days). The median (95% confidence interval) difference was 0.21 (-3.34 to 3.78) days, P = 0.905. In the matched cohort, the higher PEEP group had an association with a lower median number of VFDs (0.0 [0.0 to 14.0] vs. 6.0 [0.0 to 17.0] days) a median difference of -4.65 (-8.92 to -0.39) days, P = 0.032. The higher PEEP strategy had associations with higher incidence of AKI (in the matched cohort) and more use of RRT (in the unmatched and matched cohorts). The higher PEEP strategy had no association with mortality. CONCLUSION In COVID-19 ARDS, use of higher PEEP may be associated with a lower number of VFDs, and may increase the incidence of AKI and need for RRT. TRIAL REGISTRATION Practice of VENTilation in COVID-19 is registered at ClinicalTrials.gov, NCT04346342.
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Affiliation(s)
- Christel M A Valk
- From the Department of Intensive Care & Laboratory of Experimental Intensive Care and Anaesthesiology (LEICA), Amsterdam UMC, Location AMC, Amsterdam (CMAV, AMT, MB, LDJB, ASN, MJS, FP), Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands (JP), Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil (ASN), Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University (ASN), Data Analytics Research & Evaluation (DARE) Centre, Austin Hospital and University of Melbourne, Melbourne, Victoria, Australia (ASN), Nuffield Department of Medicine, Oxford University, Oxford, UK (MJS), Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand (MJS) and ACHIEVE Centre of Expertise, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands (FP)
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Davies DA, Adlimoghaddam A, Albensi BC. The Effect of COVID-19 on NF-κB and Neurological Manifestations of Disease. Mol Neurobiol 2021; 58:4178-4187. [PMID: 34075562 PMCID: PMC8169418 DOI: 10.1007/s12035-021-02438-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/21/2021] [Indexed: 12/15/2022]
Abstract
The coronavirus disease that presumably began in 2019 (COVID-19) is a highly infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and has resulted in a pandemic. Initially, COVID-19 was thought to only affect respiration. However, accumulating evidence shows a wide range of neurological symptoms are also associated with COVID-19, such as anosmia/ageusia, headaches, seizures, demyelination, mental confusion, delirium, and coma. Neurological symptoms in COVID-19 patients may arise due to a cytokine storm and a heighten state of inflammation. The nuclear factor kappa-light-chain enhancer of activated B cells (NF-κB) is a central pathway involved with inflammation and is shown to be elevated in a dose-dependent matter in response to coronaviruses. NF-κB has a role in cytokine storm syndrome, which is associated with greater severity in COVID-19-related symptoms. Therefore, therapeutics that reduce the NF-κB pathway should be considered in the treatment of COVID-19. Neuro-COVID-19 units have been established across the world to examine the neurological symptoms associated with COVID-19. Neuro-COVID-19 is increasingly becoming an accepted term among scientists and clinicians, and interdisciplinary teams should be created to implement strategies for treating the wide range of neurological symptoms observed in COVID-19 patients.
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Affiliation(s)
- Don A Davies
- Division of Neurodegenerative Disorders, St. Boniface Hospital Research, Winnipeg, MB, Canada.
| | - Aida Adlimoghaddam
- Division of Neurodegenerative Disorders, St. Boniface Hospital Research, Winnipeg, MB, Canada
| | - Benedict C Albensi
- Division of Neurodegenerative Disorders, St. Boniface Hospital Research, Winnipeg, MB, Canada.
- Department of Pharmacology & Therapeutics, University of Manitoba, Winnipeg, MB, Canada.
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Brasil S, Solla DJF, Nogueira RDC, Jacobsen Teixeira M, Malbouisson LMS, Paiva WS. Intracranial Compliance Assessed by Intracranial Pressure Pulse Waveform. Brain Sci 2021; 11:brainsci11080971. [PMID: 34439590 PMCID: PMC8392489 DOI: 10.3390/brainsci11080971] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/06/2021] [Accepted: 07/20/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Morphological alterations in intracranial pressure (ICP) pulse waveform (ICPW) secondary to intracranial hypertension (ICP >20 mmHg) and a reduction in intracranial compliance (ICC) are well known indicators of neurological severity. The exclusive exploration of modifications in ICPW after either the loss of skull integrity or surgical procedures for intracranial hypertension resolution is not a common approach studied. The present study aimed to assess the morphological alterations in ICPW among neurocritical care patients with skull defects and decompressive craniectomy (DC) by comparing the variations in ICPW features according to elevations in mean ICP values. METHODS Patients requiring ICP monitoring because of acute brain injury were included. A continuous record of 10 min-length for the beat-by-beat analysis of ICPW was performed, with ICP elevation produced by means of ultrasound-guided manual internal jugular vein compression at the end of the record. ICPW features (peak amplitude ratio (P2/P1), time interval to pulse peak (TTP) and pulse amplitude) were counterweighed between baseline and compression periods. Results were distributed for three groups: intact skull (exclusive burr hole for ICP monitoring), craniotomy/large fractures (group 2) or DC (group 3). RESULTS 57 patients were analyzed. A total of 21 (36%) presented no skull defects, 21 (36%) belonged to group 2, whereas 15 (26%) had DC. ICP was not significantly different between groups: ±15.11 for intact, 15.33 for group 2 and ±20.81 mmHg for group 3, with ICP-induced elevation also similar between groups (p = 0.56). Significant elevation was observed for the P2/P1 ratio for groups 1 and 2, whereas a reduction was observed in group 3 (elevation of ±0.09 for groups 1 and 2, but a reduction of 0.03 for group 3, p = 0.01), and no significant results were obtained for TTP and pulse amplitudes. CONCLUSION In the present study, intracranial pressure pulse waveform analysis indicated that intracranial compliance was significantly more impaired among decompressive craniectomy patients, although ICPW indicated DC to be protective for further influences of ICP elevations over the brain. The analysis of ICPW seems to be an alternative to real-time ICC assessment.
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Affiliation(s)
- Sérgio Brasil
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 05508-070, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.S.P.)
- Correspondence:
| | - Davi Jorge Fontoura Solla
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 05508-070, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.S.P.)
| | - Ricardo de Carvalho Nogueira
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 05508-070, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.S.P.)
| | - Manoel Jacobsen Teixeira
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 05508-070, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.S.P.)
| | | | - Wellingson Silva Paiva
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 05508-070, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.S.P.)
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Prakash A, Kaur S, Kaur C, Prabha PK, Bhatacharya A, Sarma P, Medhi B. Efficacy and safety of inhaled nitric oxide in the treatment of severe/critical COVID-19 patients: A systematic review. Indian J Pharmacol 2021; 53:236-243. [PMID: 34169911 PMCID: PMC8262415 DOI: 10.4103/ijp.ijp_382_21] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE: Present systematic review aimed to analyze the effect of inhaled nitric oxide (iNO) in the treatment of severe COVID-19 and to compare it to standard of care (SOC), antiviral medications, and other medicines. MATERIALS AND METHODS: Medline (PubMed), Scopus, Embase, Ovid, Web of Science, Science Direct, Wiley Online Library, BioRxiv and MedRxiv, and Cochrane (up to April 20, 2021) were the search databases. Two reviewers (SK and CK) independently selected the electronic published literature that studied the effect of nitric oxide with SOC or control. The clinical and physiological outcomes such as prevention of progressive systemic de-oxygenation/clinical improvement, mortality, duration of mechanical ventilation, improvement in pulmonary arterial pressure, and adverse events were assessed. RESULTS: The 14 retrospective/protective studies randomly assigning 423 patients met the inclusion criteria. Cumulative study of the selected articles showed that iNO has a mild impact on ventilation time or ventilator-free days. iNO has increased the partial pressure of oxygen/fraction of inspired oxygen ratio of fraction of inspired oxygen in a few patients as compared to baseline. However, in most of the studies, it does not have better outcome when compared to the baseline improvement. CONCLUSIONS: In patients with COVID-19 with acute respiratory distress syndrome, nitric oxide is linked to a slight increase in oxygenation but has no effect on mortality.
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Affiliation(s)
- Ajay Prakash
- Department of Pharmacology, Experimental Pharmacology Laboratory, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sukhmeet Kaur
- Department of Pharmacology, Experimental Pharmacology Laboratory, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Charanjeet Kaur
- Department of Pharmacology, Experimental Pharmacology Laboratory, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Praisy K Prabha
- Department of Pharmacology, Experimental Pharmacology Laboratory, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Phulen Sarma
- Department of Pharmacology, Experimental Pharmacology Laboratory, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Bikash Medhi
- Department of Pharmacology, Experimental Pharmacology Laboratory, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Barbosa-Silva MC, Lima MN, Battaglini D, Robba C, Pelosi P, Rocco PRM, Maron-Gutierrez T. Infectious disease-associated encephalopathies. Crit Care 2021; 25:236. [PMID: 34229735 PMCID: PMC8259088 DOI: 10.1186/s13054-021-03659-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 06/28/2021] [Indexed: 02/07/2023] Open
Abstract
Infectious diseases may affect brain function and cause encephalopathy even when the pathogen does not directly infect the central nervous system, known as infectious disease-associated encephalopathy. The systemic inflammatory process may result in neuroinflammation, with glial cell activation and increased levels of cytokines, reduced neurotrophic factors, blood-brain barrier dysfunction, neurotransmitter metabolism imbalances, and neurotoxicity, and behavioral and cognitive impairments often occur in the late course. Even though infectious disease-associated encephalopathies may cause devastating neurologic and cognitive deficits, the concept of infectious disease-associated encephalopathies is still under-investigated; knowledge of the underlying mechanisms, which may be distinct from those of encephalopathies of non-infectious cause, is still limited. In this review, we focus on the pathophysiology of encephalopathies associated with peripheral (sepsis, malaria, influenza, and COVID-19), emerging therapeutic strategies, and the role of neuroinflammation.
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Affiliation(s)
- Maria C Barbosa-Silva
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Fiocruz, Av. Brasil, 4365, Pavilhão 108, sala 45, Manguinhos, Rio de Janeiro, RJ, 21040-360, Brazil
| | - Maiara N Lima
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Fiocruz, Av. Brasil, 4365, Pavilhão 108, sala 45, Manguinhos, Rio de Janeiro, RJ, 21040-360, Brazil
| | - Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- National Institute of Science and Technology for Regenerative Medicine, Rio de Janeiro, Rio de Janeiro, Brazil
- Rio de Janeiro Network on Neuroinflammation, Carlos Chagas Filho Foundation for Supporting Research in the State of Rio de Janeiro (FAPERJ), Rio de Janeiro, Brazil
| | - Tatiana Maron-Gutierrez
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Fiocruz, Av. Brasil, 4365, Pavilhão 108, sala 45, Manguinhos, Rio de Janeiro, RJ, 21040-360, Brazil.
- Rio de Janeiro Network on Neuroinflammation, Carlos Chagas Filho Foundation for Supporting Research in the State of Rio de Janeiro (FAPERJ), Rio de Janeiro, Brazil.
- National Institute of Science and Technology on Neuroimmunomodulation, Rio de Janeiro, Rio de Janeiro, Brazil.
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Robba C, Messina A, Battaglini D, Ball L, Brunetti I, Bassetti M, Giacobbe DR, Vena A, Patroniti N, Cecconi M, Matta BF, Liu X, Rocco PRM, Czosnyka M, Pelosi P. Early Effects of Passive Leg-Raising Test, Fluid Challenge, and Norepinephrine on Cerebral Autoregulation and Oxygenation in COVID-19 Critically Ill Patients. Front Neurol 2021; 12:674466. [PMID: 34220684 PMCID: PMC8242251 DOI: 10.3389/fneur.2021.674466] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/29/2021] [Indexed: 12/28/2022] Open
Abstract
Background: Coronavirus disease 2019 (COVID-19) patients are at high risk of neurological complications consequent to several factors including persistent hypotension. There is a paucity of data on the effects of therapeutic interventions designed to optimize systemic hemodynamics on cerebral autoregulation (CA) in this group of patients. Methods: Single-center, observational prospective study conducted at San Martino Policlinico Hospital, Genoa, Italy, from October 1 to December 15, 2020. Mechanically ventilated COVID-19 patients, who had at least one episode of hypotension and received a passive leg raising (PLR) test, were included. They were then treated with fluid challenge (FC) and/or norepinephrine (NE), according to patients' clinical conditions, at different moments. The primary outcome was to assess the early effects of PLR test and of FC and NE [when clinically indicated to maintain adequate mean arterial pressure (MAP)] on CA (CA index) measured by transcranial Doppler (TCD). Secondary outcomes were to evaluate the effects of PLR test, FC, and NE on systemic hemodynamic variables, cerebral oxygenation (rSo2), and non-invasive intracranial pressure (nICP). Results: Twenty-three patients were included and underwent PLR test. Of these, 22 patients received FC and 14 were treated with NE. The median age was 62 years (interquartile range = 57-68.5 years), and 78% were male. PLR test led to a low CA index [58% (44-76.3%)]. FC and NE administration resulted in a CA index of 90.8% (74.2-100%) and 100% (100-100%), respectively. After PLR test, nICP based on pulsatility index and nICP based on flow velocity diastolic formula was increased [18.6 (17.7-19.6) vs. 19.3 (18.2-19.8) mm Hg, p = 0.009, and 12.9 (8.5-18) vs. 15 (10.5-19.7) mm Hg, p = 0.001, respectively]. PLR test, FC, and NE resulted in a significant increase in MAP and rSo2. Conclusions: In mechanically ventilated severe COVID-19 patients, PLR test adversely affects CA. An individualized strategy aimed at assessing both the hemodynamic and cerebral needs is warranted in patients at high risk of neurological complications.
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Affiliation(s)
- Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico for Oncology and Neuroscience, Genoa, Italy
| | - Antonio Messina
- Humanitas Clinical and Research Center-Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Denise Battaglini
- San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico for Oncology and Neuroscience, Genoa, Italy
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico for Oncology and Neuroscience, Genoa, Italy
| | - Iole Brunetti
- San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico for Oncology and Neuroscience, Genoa, Italy
| | - Matteo Bassetti
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.,Infectious Diseases Unit, San Martino Policlinico Hospital, Genoa, Italy
| | - Daniele R Giacobbe
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.,Infectious Diseases Unit, San Martino Policlinico Hospital, Genoa, Italy
| | - Antonio Vena
- Infectious Diseases Unit, San Martino Policlinico Hospital, Genoa, Italy
| | - Nicolo' Patroniti
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico for Oncology and Neuroscience, Genoa, Italy
| | - Maurizio Cecconi
- Humanitas Clinical and Research Center-Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Basil F Matta
- Neurocritical Care Unit, Addenbrookes Hospital, Cambridge, United Kingdom
| | - Xiuyun Liu
- Department of Anesthesiology and Critical Care Medicine, John Hopkins University, Baltimore, MD, United States
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Rio de Janeiro, Brazil
| | - Marek Czosnyka
- Brain Physics Laboratory, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico for Oncology and Neuroscience, Genoa, Italy
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39
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Bonnemain J, Ltaief Z, Liaudet L. The Right Ventricle in COVID-19. J Clin Med 2021; 10:jcm10122535. [PMID: 34200990 PMCID: PMC8230058 DOI: 10.3390/jcm10122535] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 05/31/2021] [Accepted: 06/03/2021] [Indexed: 12/15/2022] Open
Abstract
Infection with the novel severe acute respiratory coronavirus-2 (SARS-CoV2) results in COVID-19, a disease primarily affecting the respiratory system to provoke a spectrum of clinical manifestations, the most severe being acute respiratory distress syndrome (ARDS). A significant proportion of COVID-19 patients also develop various cardiac complications, among which dysfunction of the right ventricle (RV) appears particularly common, especially in severe forms of the disease, and which is associated with a dismal prognosis. Echocardiographic studies indeed reveal right ventricular dysfunction in up to 40% of patients, a proportion even greater when the RV is explored with strain imaging echocardiography. The pathophysiological mechanisms of RV dysfunction in COVID-19 include processes increasing the pulmonary vascular hydraulic load and others reducing RV contractility, which precipitate the acute uncoupling of the RV with the pulmonary circulation. Understanding these mechanisms provides the fundamental basis for the adequate therapeutic management of RV dysfunction, which incorporates protective mechanical ventilation, the prevention and treatment of pulmonary vasoconstriction and thrombotic complications, as well as the appropriate management of RV preload and contractility. This comprehensive review provides a detailed update of the evidence of RV dysfunction in COVID-19, its pathophysiological mechanisms, and its therapy.
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Affiliation(s)
- Jean Bonnemain
- Department of Adult Intensive Care Medicine, Lausanne University Hospital, 1011 Lausanne, Switzerland; (J.B.); (Z.L.)
| | - Zied Ltaief
- Department of Adult Intensive Care Medicine, Lausanne University Hospital, 1011 Lausanne, Switzerland; (J.B.); (Z.L.)
| | - Lucas Liaudet
- Department of Adult Intensive Care Medicine, Lausanne University Hospital, 1011 Lausanne, Switzerland; (J.B.); (Z.L.)
- Division of Pathophysiology, Faculty of Biology and Medicine, University of Lausanne, 1011 Lausanne, Switzerland
- Correspondence: ; Tel.: +41-79-556-4278
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