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Hajjar LA, Costa IBSDS, Rizk SI, Biselli B, Gomes BR, Bittar CS, de Oliveira GQ, de Almeida JP, de Oliveira Bello MV, Garzillo C, Leme AC, Elena M, Val F, de Almeida Lopes M, Lacerda MVG, Ramires JAF, Kalil Filho R, Teboul JL, Landoni G. Intensive care management of patients with COVID-19: a practical approach. Ann Intensive Care 2021; 11:36. [PMID: 33604873 PMCID: PMC7891474 DOI: 10.1186/s13613-021-00820-w] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 01/29/2021] [Indexed: 02/06/2023] Open
Abstract
SARS-CoV-2, the causative agent of coronavirus disease 2019 (COVID-19), is responsible for the largest pandemic facing humanity since the Spanish flu pandemic in the early twentieth century. Since there is no specific antiviral treatment, optimized support is the most relevant factor in the patient's prognosis. In the hospital setting, the identification of high-risk patients for clinical deterioration is essential to ensure access to intensive treatment of severe conditions in a timely manner. The initial management of hypoxemia includes conventional oxygen therapy, high-flow nasal canula oxygen, and non-invasive ventilation. For patients requiring invasive mechanical ventilation, lung-protective ventilation with low tidal volumes and plateau pressure is recommended. Cardiovascular complications are frequent and include myocardial injury, thrombotic events, myocarditis, and cardiogenic shock. Acute renal failure is a common complication and is a marker of poor prognosis, with significant impact in costs and resources allocation. Regarding promising therapies for COVID-19, the most promising drugs until now are remdesivir and corticosteroids although further studies may be needed to confirm their effectiveness. Other therapies such as, tocilizumab, anakinra, other anti-cytokine drugs, and heparin are being tested in clinical trials. Thousands of physicians are living a scenario that none of us have ever seen: demand for hospital exceed capacity in most countries. Until now, the certainty we have is that we should try to decrease the number of infected patients and that an optimized critical care support is the best strategy to improve patient's survival.
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Affiliation(s)
- Ludhmila Abrahão Hajjar
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil.
- Instituto Do Câncer, Universidade de São Paulo, São Paulo, Brazil.
| | | | - Stephanie Itala Rizk
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
- Instituto Do Câncer, Universidade de São Paulo, São Paulo, Brazil
- Hospital Sírio Libanês, São Paulo, SP, Brazil
| | - Bruno Biselli
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
| | - Brenno Rizerio Gomes
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
| | - Cristina Salvadori Bittar
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
- Instituto Do Câncer, Universidade de São Paulo, São Paulo, Brazil
| | | | - Juliano Pinheiro de Almeida
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
| | | | - Cibele Garzillo
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
| | - Alcino Costa Leme
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
| | - Moizo Elena
- IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fernando Val
- Instituto Leônidas & Maria Deane, Fiocruz, Manaus, Brazil
| | | | | | - José Antonio Franchini Ramires
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
| | - Roberto Kalil Filho
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
- Instituto Do Câncer, Universidade de São Paulo, São Paulo, Brazil
- Hospital Sírio Libanês, São Paulo, SP, Brazil
| | - Jean-Louis Teboul
- Medical Intensive Care Unit, Bicêtre Hospital, Paris-Sud University Hospitals, Le Kremlin Bicêtre, France
| | - Giovanni Landoni
- IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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Franco RA, de Almeida JP, Landoni G, Scheeren TWL, Galas FRBG, Fukushima JT, Zefferino S, Nardelli P, de Albuquerque Piccioni M, Arita ECTC, Park CHL, Cunha LCC, de Oliveira GQ, Costa IBSDS, Kalil Filho R, Jatene FB, Hajjar LA. Dobutamine-sparing versus dobutamine-to-all strategy in cardiac surgery: a randomized noninferiority trial. Ann Intensive Care 2021; 11:15. [PMID: 33496877 PMCID: PMC7838231 DOI: 10.1186/s13613-021-00808-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 01/13/2021] [Indexed: 12/16/2022] Open
Abstract
Background The detrimental effects of inotropes are well-known, and in many fields they are only used within a goal-directed therapy approach. Nevertheless, standard management in many centers includes administering inotropes to all patients undergoing cardiac surgery to prevent low cardiac output syndrome and its implications. Randomized evidence in favor of a patient-tailored, inotrope-sparing approach is still lacking. We designed a randomized controlled noninferiority trial in patients undergoing cardiac surgery with normal ejection fraction to assess whether an dobutamine-sparing strategy (in which the use of dobutamine was guided by hemodynamic evidence of low cardiac output associated with signs of inadequate tissue perfusion) was noninferior to an inotrope-to-all strategy (in which all patients received dobutamine). Results A total of 160 patients were randomized to the dobutamine-sparing strategy (80 patients) or to the dobutamine-to-all approach (80 patients). The primary composite endpoint of 30-day mortality or occurrence of major cardiovascular complications (arrhythmias, acute myocardial infarction, low cardiac output syndrome and stroke or transient ischemic attack) occurred in 25/80 (31%) patients of the dobutamine-sparing group (p = 0.74) and 27/80 (34%) of the dobutamine-to-all group. There were no significant differences between groups regarding the incidence of acute kidney injury, prolonged mechanical ventilation, intensive care unit or hospital length of stay. Discussion Although it is common practice in many centers to administer inotropes to all patients undergoing cardiac surgery, a dobutamine-sparing strategy did not result in an increase of mortality or occurrence of major cardiovascular events when compared to a dobutamine-to-all strategy. Further research is needed to assess if reducing the administration of inotropes can improve outcomes in cardiac surgery. Trial registration ClinicalTrials.gov, NCT02361801. Registered Feb 2nd, 2015. https://clinicaltrials.gov/ct2/show/NCT02361801
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Affiliation(s)
- Rafael Alves Franco
- Intensive Care Unit, Cancer Institute (ICESP), University of Sao Paulo, São Paulo, Brazil
| | | | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Thomas W L Scheeren
- Department of Anesthesiology, University Medical Center, Groningen, The Netherlands
| | | | - Julia Tizue Fukushima
- Intensive Care Unit, Cancer Institute (ICESP), University of Sao Paulo, São Paulo, Brazil
| | - Suely Zefferino
- Department of Anesthesiology, Heart Institute, University of Sao Paulo, São Paulo, Brazil
| | - Pasquale Nardelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | | | | | | | | | | | - Roberto Kalil Filho
- Department of Cardiology, Heart Institute (InCor), University of Sao Paulo, São Paulo, Brazil
| | - Fabio Biscegli Jatene
- Division of Cardiovascular Surgery, Heart Institute (InCor), University of Sao Paulo, São Paulo, Brazil
| | - Ludhmila Abrahão Hajjar
- Intensive Care Unit, Cancer Institute (ICESP), University of Sao Paulo, São Paulo, Brazil. .,Department of Cardiopneumology, Instituto Do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Enéas de Carvalho Aguiar, 44-05403-900, São Paulo, SP, Brazil.
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Crivelari NC, Oliveira GQD, Park CHL, Riemma GDC, Costa IBSDS, Lacerda MVGD, Oliveira GMMD, Darrieux FCDC, Sacilotto L, Hajjar LA. Severe Cardiovascular Complications of COVID-19: a Challenge for the Physician. International Journal of Cardiovascular Sciences 2020. [DOI: 10.36660/ijcs.20200125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Gerent ARM, Almeida JP, Fominskiy E, Landoni G, de Oliveira GQ, Rizk SI, Fukushima JT, Simoes CM, Ribeiro U, Park CL, Nakamura RE, Franco RA, Cândido PI, Tavares CR, Camara L, Dos Santos Rocha Ferreira G, de Almeida EPM, Filho RK, Galas FRBG, Hajjar LA. Effect of postoperative goal-directed therapy in cancer patients undergoing high-risk surgery: a randomized clinical trial and meta-analysis. Crit Care 2018; 22:133. [PMID: 29792232 PMCID: PMC5964647 DOI: 10.1186/s13054-018-2055-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 05/02/2018] [Indexed: 01/18/2023]
Abstract
Background Perioperative goal-directed hemodynamic therapy (GDHT) has been advocated in high-risk patients undergoing noncardiac surgery to reduce postoperative morbidity and mortality. We hypothesized that using cardiac index (CI)-guided GDHT in the postoperative period for patients undergoing high-risk surgery for cancer treatment would reduce 30-day mortality and postoperative complications. Methods A randomized, parallel-group, superiority trial was performed in a tertiary oncology hospital. All adult patients undergoing high-risk cancer surgery who required intensive care unit admission were randomly allocated to a CI-guided GDHT group or to a usual care group. In the GDHT group, postoperative therapy aimed at CI ≥ 2.5 L/min/m2 using fluids, inotropes and red blood cells during the first 8 postoperative hours. The primary outcome was a composite endpoint of 30-day all-cause mortality and severe postoperative complications during the hospital stay. A meta-analysis was also conducted including all randomized trials of postoperative GDHT published from 1966 to May 2017. Results A total of 128 patients (64 in each group) were randomized. The primary outcome occurred in 34 patients of the GDHT group and in 28 patients of the usual care group (53.1% vs 43.8%, absolute difference 9.4 (95% CI, − 7.8 to 25.8); p = 0.3). During the 8-h intervention period more patients in the GDHT group received dobutamine when compared to the usual care group (55% vs 16%, p < 0.001). A meta-analysis of nine randomized trials showed no differences in postoperative mortality (risk ratio 0.85, 95% CI 0.59–1.23; p = 0.4; p for heterogeneity = 0.7; I2 = 0%) and in the overall complications rate (risk ratio 0.88, 95% CI 0.71–1.08; p = 0.2; p for heterogeneity = 0.07; I2 = 48%), but a reduced hospital length of stay in the GDHT group (mean difference (MD) – 1.6; 95% CI – 2.75 to − 0.46; p = 0.006; p for heterogeneity = 0.002; I2 = 74%). Conclusions CI-guided hemodynamic therapy in the first 8 postoperative hours does not reduce 30-day mortality and severe complications during hospital stay when compared to usual care in cancer patients undergoing high-risk surgery. Trial registration www.clinicaltrials.gov, NCT01946269. Registered on 16 September 2013. Electronic supplementary material The online version of this article (10.1186/s13054-018-2055-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Aline Rejane Muller Gerent
- Intensive Care Unit and Department of Anesthesiology, Instituto do Cancer, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Juliano Pinheiro Almeida
- Intensive Care Unit and Department of Anesthesiology, Instituto do Cancer, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Evgeny Fominskiy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gisele Queiroz de Oliveira
- Intensive Care Unit and Department of Anesthesiology, Instituto do Cancer, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Stephanie Itala Rizk
- Intensive Care Unit and Department of Anesthesiology, Instituto do Cancer, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Julia Tizue Fukushima
- Intensive Care Unit and Department of Anesthesiology, Instituto do Cancer, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Claudia Marques Simoes
- Intensive Care Unit and Department of Anesthesiology, Instituto do Cancer, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Ulysses Ribeiro
- Department of Surgery, Instituto do Cancer, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Clarice Lee Park
- Intensive Care Unit and Department of Anesthesiology, Instituto do Cancer, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Rosana Ely Nakamura
- Intensive Care Unit and Department of Anesthesiology, Instituto do Cancer, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Rafael Alves Franco
- Intensive Care Unit and Department of Anesthesiology, Instituto do Cancer, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Patricia Inês Cândido
- Intensive Care Unit and Department of Anesthesiology, Instituto do Cancer, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Cintia Rosa Tavares
- Intensive Care Unit and Department of Anesthesiology, Instituto do Cancer, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Ligia Camara
- Intensive Care Unit and Department of Anesthesiology, Instituto do Cancer, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Graziela Dos Santos Rocha Ferreira
- Intensive Care Unit and Department of Anesthesiology, Instituto do Cancer, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Elisangela Pinto Marinho de Almeida
- Intensive Care Unit and Department of Anesthesiology, Instituto do Cancer, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Roberto Kalil Filho
- Department of Cardiopneumology, Instituto do Coracao, Hospital das Clinicas, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Filomena Regina Barbosa Gomes Galas
- Intensive Care Unit and Department of Anesthesiology, Instituto do Cancer, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Ludhmila Abrahão Hajjar
- Department of Cardiopneumology, Instituto do Coracao, Hospital das Clinicas, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil.
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