Thromboelastography clot strength profiles and effect of systemic anticoagulation in COVID-19 acute respiratory distress syndrome: a prospective, observational study

OBJECTIVE

Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2) infection may yield a hypercoagulable state with fibrinolysis impairment. We conducted a single-center observational study with the aim of analyzing the coagulation patterns of intensive care unit (ICU) COVID-19 patients with both standard laboratory and viscoelastic tests. The presence of coagulopathy at the onset of the infection and after seven days of systemic anticoagulant therapy was investigated.

PATIENTS AND METHODS

Forty consecutive SARS-CoV-2 patients, admitted to the ICU of a University hospital in Italy between 29th February and 30th March 2020 were enrolled in the study, providing they fulfilled the acute respiratory distress syndrome criteria. They received full-dose anticoagulation, including Enoxaparin 0.5 mg·kg-1 subcutaneously twice a day, unfractionated Heparin 7500 units subcutaneously three times daily, or low-intensity Heparin infusion. Thromboelastographic (TEG) and laboratory parameters were measured at admission and after seven days.

RESULTS

At baseline, patients showed elevated fibrinogen activity [rTEG-Ang 80.5° (78.7 to 81.5); TEG-ACT 78.5 sec (69.2 to 87.9)] and an increase in the maximum amplitude of clot strength [FF-MA 42.2 mm (30.9 to 49.2)]. No alterations in time of the enzymatic phase of coagulation [CKH-K and CKH-R, 1.1 min (0.85 to 1.3) and 6.6 min (5.2 to 7.5), respectively] were observed. Absent lysis of the clot at 30 minutes (LY30) was observed in all the studied population. Standard coagulation parameters were within the physiological range: [INR 1.09 (1.01 to 1.20), aPTT 34.5 sec (29.7 to 42.2), antithrombin 97.5% (89.5 to 115)]. However, plasma fibrinogen [512.5 mg·dl-1 (303.5 to 605)], and D-dimer levels [1752.5 ng·ml-1 (698.5 to 4434.5)], were persistently increased above the reference range. After seven days of full-dose anticoagulation, average TEG parameters were not different from baseline (rTEG-Ang p = 0.13, TEG-ACT p = 0.58, FF-MA p = 0.24, CK-R p = 0.19, CKH-R p  = 0.35), and a persistent increase in white blood cell count, platelet count and D-dimer was observed (white blood cell count p < 0.01, neutrophil count p = 0.02, lymphocyte count p < 0.01, platelet count p = 0.13 < 0.01, D-dimer levels p= 0.02).

CONCLUSIONS

SARS-CoV-2 patients with acute respiratory distress syndrome show elevated fibrinogen activity, high D-dimer levels and maximum amplitude of clot strength. Platelet count, fibrinogen, and standard coagulation tests do not indicate a disseminated intravascular coagulation. At seven days, thromboelastographic abnormalities persist despite full-dose anticoagulation.

New membranes for extracorporeal blood purification in septic conditions

Severe sepsis and septic shock are still the leading cause of mortality and morbidity in the intensive care unit. The inflammatory response to infection is associated with an impressive, systemic release of pro- and anti-inflammatory mediators, which results in generalized endothelial damage, multiple organ failure and altered cellular immunological responsiveness. Over the last years, the substantial advances in the understanding of sepsis have led to the development of a large number of new approaches and technologies in the management of septic patients. Extracorporeal blood purification techniques using various membrane materials have been proposed to modulate multiple inflammatory mediators, and seem to be a potential adjuvant in the treatment of sepsis. However, the use of extracorporeal blood purification techniques during sepsis still remains controversial, thus precluding any definitive recommendations on the benefit of these methods. More data are needed to better recognize septic patients who are most likely to benefit from blood purification treatments, and clarify the optimal timing, duration, and number of applications of these techniques in the daily clinical practice.

Successful application of helmet non-invasive ventilation in a parturient with acute respiratory distress syndrome

Acute respiratory distress syndrome (ARDS) is an important cause of morbidity and mortality during pregnancy. The case of a twin pregnant woman in her 28th week who developed infection-related ARDS, undergoing a cesarean section for premature membrane rupture is described. It was performed epidural anaesthesia and helmet non-invasive ventilation (NIV) during the postoperative period. The combination of epidural anesthesia with NIV helped to restore physiological gas-exchange and to prevent common complications associated with a more invasive approach.

Successful treatment of multidrug-resistant Acinetobacter baumannii ventriculitis with intrathecal and intravenous colistin

Acinetobacter baumannii (AB) nosocomial infections, especially those due to multi-drug resistant (MDR) strains, are increasingly detected. We report a case of a 42-year-old male patient affected by low-grade ependymoma who developed AB-MDR post-neurosurgical ventriculitis. Initially, because of in vitro susceptibility, we used a combination of intravenous colistin and tigecycline. This treatment resulted in the improvement of the patient's initial condition. However, soon after, the infection relapsed; tigecycline was stopped and treatment with intrathecal colistin was initiated. Cure was achieved by continuing this treatment for approximately three weeks, without adverse effects.

Diurnal and nocturnal shifts do not influence non-invasive ventilation outcome

AIM

The aim of this study was to assess if diurnal or nocturnal shifts were independent risk factors for non-invasive ventilation (NIV) failure.

METHODS

This was an observational study carried out on 18 patients of the general Intensive Care Unit in Rome. A total number of 189 consecutive patients needing mechanical ventilation for respiratory failure were prospectively enrolled: 82 were treated with NIV as a first line intervention. Of the 107 patients who were initially intubated, 59 patients were extubated; once extubation failed they were treated with NIV. NIV failure was assessed during both the day (between 7 am and 10 pm) and night shifts (between 10 pm and 7 am).

RESULTS

Of the 141 total patients who received NIV, 51 experienced failure during the day shifts and 18 during the night shifts. No difference in the median day and night shift TISS-28 values were observed in any patients who failed NIV during both day and night shifts. Causes of NIV failure were similar during both diurnal and nocturnal shifts. The inability to correct gas exchanges was the main reason for failure.

CONCLUSION

In a center with NIV expertise, notwithstanding nurse understaffing, diurnal and nocturnal shifts did not affect the rate of NIV failure.

Use of corticosteroids in critically ill septic patients : a review of mechanisms of adrenal insufficiency in sepsis and treatment

Adrenal insufficiency has being reported with increased frequency in critical ill patients with sepsis and other inflammatory states. Its incidence varies widely depending on the criteria used to define it and the patient population studied. Increased glucocorticoid action is essential in the stress response to acute injury and even minor degrees of adrenal insufficiency can be fatal. Recently the so-called relative or functional adrenal insufficiency (CIRCI) has been described: in this syndrome cortisol levels may be low or high but nonetheless inadequate to meet the elevated metabolic demand. Since laboratory diagnosis of adrenal insufficiency is still controversial, the diagnosis of ICU associated adrenal insufficiency is essentially a clinical diagnosis. Whether exogenous corticosteroid support may be beneficial in critical illness is still matter of debate: most international guidelines recommend that the decision to treat patients with corticosteroids should be based on clinical criteria (low blood pressure poorly responsive to vasopressor despite adequate fluid resuscitation) rather than on tests of the hypothalamic-pituitary-adrenal axis alone. As regards specifically the role of steroids in the treatment of sepsis and septic shock, at present there are no strong evidence-based recommendations. More studies are needed to reach consensus about several issues: which is the best target population, whether a cosyntropin test should be used to guide treatment, whether fludrocortisones should be given along with hydrocortisone, and how long treatment should continue.

Leptin and perioperative neuroendocrine stress response with two different anaesthetic techniques

BACKGROUND

Stress response to surgery is modulated by several factors, including magnitude of the injury, pain, type of procedure and choice of anaesthesia. Our purpose was to compare intra- and post-operative hormonal changes during total intravenous anaesthesia (TIVA) using propofol and remifentanil vs. sevoflurane anaesthesia in a low stress level surgical model (laparoscopy).

METHODS

We randomly allocated 18 patients undergoing laparoscopic surgery for benign ovarian cysts in two groups to receive either TIVA (group A=9) or sevoflurane anaesthesia (group B=9). Perioperative plasma levels of norepinephrine (NE), epinephrine (E), adrenocorticotropic hormone (ACTH), cortisol and leptin were measured. Blood samples were collected pre-operatively (time 0), 30 min after the beginning of surgery (time 1), after extubation (time 2), and 2 h (time 3) and 4 h after surgery (time 4).

RESULTS

The comparative analysis between the groups shows significantly higher values of NE (P<0.001 at time 1 and P<0.01 at time 3), E (P<0.001 at times 1 and 2; P<0.01 at time 3 and P<0.05 at time 4), ACTH (P<0.001 at times 1 and 2; P<0.05 at time 3) and cortisol (P<0.001 at times 1 and 2; P<0.01 at time 3; P<0.05 at time 4) in group B. The serum values of leptin were not significantly different between the two groups.

CONCLUSION

The choice of anaesthesia does not seem to affect the leptin serum levels but influences the release of stress response markers: ACTH, cortisol, NE and E.

[Diagnostic imaging and patient database managing systems: The integration of digital information in the experience of an intensive care center]

AIM

To present our experience with integrating digital information on Intensive Care Unit patients (clinical data, laboratory findings, imaging, etc) to create electronic patient records.

MATERIAL AND METHODS

Using the hospital Intranet, a connection was established between the Local area Network (LAN) of the Intensive Care Unit (ICU) and the Digital Imaging and Communications in Medicine (DICOM(R)) network of the Radiology Department allowing to receive, process and archive digital images locally at the ICU. Using the software RADclient-RADimage, the information received was managed by an electronic patient record system (DIGISTAT by UMS-Unterberger Medical Software, Florence). All the above software runs on Microsoft WindowsNT 4.0 platforms.

RESULTS

Images of various kinds and formats (CT, MRI, etc.) pertaining to the ICU patients were semi-automatically handled and filed on a local server acting as a central databank. The images were then included in the electronic patient record and made available to the end user who could view them using either web technologies (hypertexts were automatically generated that could be viewed through the widely available World Wide Web browsers) or specific viewing utilities supplied with DIGISTAT .

DISCUSSION AND CONCLUSIONS

For the intensivist, the handling and filing of data on hospitalised or discharged patients for treatment or research purposes involves having to process large amounts of information. Furthermore, in the event of patients being re-admitted to the unit, it is crucial to have ready access to all the information regarding previous hospital stays, including diagnostic images, to avoid the need for time-consuming searches through the hospital s paper-based archives. The possibility to access clinical information and diagnostic images using a single computer programme proved to be useful both for evaluating the patient s conditions immediately after the imaging procedure and for monitoring the patient s progress over time by comparing the different diagnostic images and imaging procedures. This pilot experience could be seen to provide the basic know-how for applying the method in the future Emergency Department of the A. Gemelli Hospital in Rome.

[NIV in the treatment of acute exacerbation of COPD and status asthmaticus]

The authors describe the application of NIV as a useful tool to correct hypercarbia, gas exchanges and to reduce the complications caused by mechanical ventilation with ETT in patients with acute exacerbation of COPD and acute asthma attack.

A repository of 14 PCR-loci Italian gene frequencies in the World Wide Web

A collection of 6830 typing results produced by the Immunohematology Laboratory at the UCSC, pertaining to 11 STRs (FES/FPS, vWA31, HUMTH01, F13A1, MBP, D21S11, D7S460, D18S51, CD4, TPOX, CSF1PO) and 3 AmpFLPs (D1S80, APO-B, COL2A1), is publicly available as an electronic archive at a website.

Estimating European admixture in African Americans by using microsatellites and a microsatellite haplotype (CD4/Alu)

We have analyzed 10 unlinked microsatellites and a linked Alu deletion polymorphism at the CD4 locus in an African American population sample from Chicago (USA). Heterozygosity estimates at the microsatellite loci range from 0.727+/-0.025 (D3S1358) to 0.873+/-0.017 (D18S51), with an average of 0.794+/-0.016. These values are comparable to or higher than those reported for Europeans, with only one exception (D3S1358). The CD4/Alu haplotypic diversity (0.887+/-0.012) is comparable to diversity levels observed in sub-Saharan African populations and is higher than the diversity levels reported in European populations. No consistent pattern of within, between, or multi-locus deviations from Hardy-Weinberg expectations is observed, suggesting a low sub-heterogeneity within the sampled population. We have applied a maximum likelihood method and estimated the proportion of European admixture to the African American gene pool to be 0.26+/-0.02. The narrow confidence interval indicates that allele frequency data from multiple microsatellite loci, whether analyzed independently or as haplotypes, are particularly useful for estimating genetic admixture.