BACKGROUND: Anticoagulation during extracorporeal membrane oxygenation (ECMO) might still lead to severe bleeding complications. Heparin is the most frequently used anticoagulant, but novel drugs could be promising. Argatroban is a new alternative to heparin. To date, no robust studies have confirmed the clear superiority of argatroban (AG) over heparin, although it has some advantages and may be safer. STUDY DESIGN AND METHODS: An observational study was conducted in all adult veno-venous ECMO patients with COVID-19-associated acute respiratory distress syndrome admitted to the University Hospital Ostrava (n = 63). They were anticoagulated with heparin in the first period and with AG in the second period, targeting the same activated partial thromboplastin time (aPTT; 45-60 s). Bleeding complications requiring transfusion and life-threatening bleeding events were evaluated. The primary objective was to compare heparin and AG in terms of bleeding, transfusion requirements and mortality-related bleeding. RESULTS: The total time on ECMO per patient was 16 days with an in-hospital mortality of 55.6%. The red blood cell consumption in the AG group (median 2.7 transfusions/week) was significantly lower than in the heparin group (median 4.2 transfusions/week, p = 0.011). Life-threatening bleeding complications were higher in the heparin group compared to the AG group (35.7% vs. 10.2%, p = 0.035), and mortality-related bleeding complications were also higher in the heparin group (21.4% vs. 2.0%, p = 0.032). DISCUSSION: Argatroban is an interesting alternative to heparin with less bleeding, less need for red blood cell transfusions and improved safety of ECMO with less mortality-related bleeding.
- MeSH
- antikoagulancia * škodlivé účinky terapeutické užití MeSH
- arginin * analogy a deriváty MeSH
- COVID-19 komplikace MeSH
- dospělí MeSH
- heparin * škodlivé účinky MeSH
- krvácení * chemicky indukované terapie MeSH
- kyseliny pipekolové * terapeutické užití aplikace a dávkování MeSH
- lidé středního věku MeSH
- lidé MeSH
- mimotělní membránová oxygenace * MeSH
- mortalita v nemocnicích MeSH
- SARS-CoV-2 MeSH
- senioři MeSH
- sulfonamidy * MeSH
- syndrom dechové tísně terapie MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- pozorovací studie MeSH
- srovnávací studie MeSH
Rationale: Early detection, standardized therapy, adequate infrastructure, and strategies for quality improvement should constitute essential components of every hospital's sepsis plan. Objectives: To investigate the extent to which recommendations from the sepsis guidelines are implemented and the availability of infrastructure for the care of patients with sepsis in acute-care hospitals. Methods: A multidisciplinary cross-sectional questionnaire was used to investigate sepsis care in hospitals. This included the use of sepsis definitions, the implementation of sepsis guideline recommendations, diagnostic and therapeutic infrastructure, antibiotic stewardship, and quality improvement initiatives (QIIs) in hospitals. Measurements and Main Results: A total of 1,023 hospitals in 69 countries were included. Most of them, 835 (81.6%), were in Europe. Sepsis screening was used in 54.2% of emergency departments (EDs), 47.9% of wards, and 61.7% of ICUs. Sepsis management was standardized in 57.3% of EDs, 45.2% of wards, and 70.7% of ICUs. The implementation of comprehensive QIIs was associated with increased screening (EDs, +33.3%; wards, +44.4%; ICUs, +23.8% absolute difference) and increased standardized sepsis management (EDs, +33.6%; wards, +40.0%; ICUs, +17.7% absolute difference) compared with hospitals without QIIs. A total of 9.8% of hospitals had implemented ongoing QIIs, and 4.6% had invested in sepsis programs. Conclusions: The findings indicate that there is considerable room for improvement in a large number of mainly European hospitals, particularly with regard to early identification and standardized management of sepsis, the availability of guidelines, diagnostic and therapeutic infrastructure, and the implementation of QIIs. Further efforts are required to implement a more comprehensive and appropriate quality of care.
- MeSH
- antibiotická politika MeSH
- dodržování směrnic * statistika a číselné údaje MeSH
- jednotky intenzivní péče normy MeSH
- lidé MeSH
- nemocnice * normy statistika a číselné údaje MeSH
- průřezové studie MeSH
- průzkumy a dotazníky MeSH
- sepse * terapie diagnóza MeSH
- směrnice pro lékařskou praxi jako téma MeSH
- urgentní služby nemocnice normy MeSH
- zlepšení kvality * MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- Geografické názvy
- Evropa MeSH
Unfractionated heparin has long been considered the standard anticoagulation in ECMO, despite some pitfalls such as heparin resistance, heparin induced thrombocytopenia (HIT), etc Recently, some centres started to increasingly use argatroban for this purpose, typically using activated partial thromboplastin time (aPTT) for its monitoring. Direct monitoring of the efficacy of argatroban using Anti-IIa is not yet an established method, although it might be more appropriate as it targets the same pathway.An observational study was performed in adult veno-venous ECMO patients hospitalized with SARS-CoV-2 infection anticoagulated with argatroban to an aPTT target of 40-60 s and Anti-IIa target of 0.4-0.6 μg/mL. Bleeding and thrombotic complications were monitored.Forty-four VV ECMO patients were included, with an overall hospital mortality of approx. 50%. No life-threatening thrombotic events were recorded. The risk of bleeding complications significantly increased with aPTT above 52.7 s and with Anti-IIa values over 0.78 μg/mL. Using the above cut-offs for both the aPTT and Anti-IIa and their combination, the negative predictive value for bleeding was approximately 90%.It seems that the generally recommended limits for Anti-IIa of 1.5 μg/mL may be high. However, further data are needed to confirm lower limits.Trial Registration:retrospectively registered in ClinicalTrials.gov, NCT06038682.
- MeSH
- antikoagulancia * terapeutické užití škodlivé účinky aplikace a dávkování MeSH
- arginin analogy a deriváty MeSH
- COVID-19 * krev terapie mortalita komplikace MeSH
- dospělí MeSH
- farmakoterapie COVID-19 * MeSH
- krvácení chemicky indukované MeSH
- kyseliny pipekolové * terapeutické užití aplikace a dávkování škodlivé účinky MeSH
- lidé středního věku MeSH
- lidé MeSH
- mimotělní membránová oxygenace * metody MeSH
- monitorování léčiv metody MeSH
- parciální tromboplastinový čas MeSH
- SARS-CoV-2 MeSH
- senioři MeSH
- sulfonamidy MeSH
- trombóza prevence a kontrola etiologie MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- pozorovací studie MeSH
BACKGROUND: Dexamethasone 6 mg in patients with severe COVID-19 has been shown to decrease mortality and morbidity. The effects of higher doses of corticosteroid, that would further increase anti-inflammatory effects, are uncertain. The objective of our study was to assess the effect of 20 mg dexamethasone vs. 6 mg dexamethasone intravenously in patients with moderate-to-severe acute respiratory distress syndrome (ARDS) and COVID-19. METHODS: In a multicenter, open-label, randomized trial conducted in nine hospitals in the Czech Republic, we randomized adult patients with ARDS and COVID-19 requiring high-flow oxygen, noninvasive or invasive mechanical ventilation to receive either intravenous high-dose dexamethasone (20 mg/day on days 1-5, 10 mg/day on days 6-10) or standard-dose dexamethasone (6 mg/d, days 1-10). The primary outcome was 28-day ventilator-free days. The five secondary outcomes were 60-day mortality, C-reactive protein dynamics, 14-day WHO (World Health Organization) Clinical Progression Scale score, adverse events and 90-day Barthel index. The long-term outcomes were 180- and 360-day mortality and the Barthel index. The planned sample size was 300, with interim analysis after enrollment of 150 patients. RESULTS: The trial was stopped due to a lack of recruitment, and the follow-up was completed in February 2023. Among 234 randomized patients of 300 planned patients, the primary outcome was available for 224 patients (110 high-dose and 114 standard-dose dexamethasone; median [interquartile range (IQR)] age, 59.0 [48.5-66.0] years; 130 [58.0%] were receiving noninvasive or invasive mechanical ventilation at baseline). The mean number of 28-day ventilator-free days was 8.9 (± 11.5) days for high-dose dexamethasone and 8.0 (± 10.7) days for standard-dose dexamethasone, with an absolute difference of + 0.81 days (95% CI - 2.12-3.73 days). None of the prespecified secondary outcomes, including adverse events, differed between the groups. CONCLUSIONS: Despite not reaching its prespecified enrollment, there was no signal to either benefit or harm high-dose dexamethasone over standard-dose dexamethasone in patients with COVID-19 and moderate-to-severe ARDS. Trial registration Trial registration: ClinicalTrials.gov Identifier: NCT04663555. Registered 10 December 2020, https://clinicaltrials.gov/study/NCT04663555?term=NCT04663555&rank=1 and EudraCT: 2020-005887-70.
- MeSH
- COVID-19 * mortalita komplikace MeSH
- dexamethason * aplikace a dávkování terapeutické užití MeSH
- farmakoterapie COVID-19 * MeSH
- lidé středního věku MeSH
- lidé MeSH
- SARS-CoV-2 MeSH
- senioři MeSH
- syndrom dechové tísně * farmakoterapie mortalita MeSH
- umělé dýchání * MeSH
- výsledek terapie MeSH
- vztah mezi dávkou a účinkem léčiva MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- multicentrická studie MeSH
- randomizované kontrolované studie MeSH
- Geografické názvy
- Česká republika MeSH
BACKGROUND: The dominant feature of COVID-19-associated ARDS is gas exchange impairment. Extravascular lung water index is a surrogate for lung edema and reflects the level of alveolocapillary disruption. The primary aim was the prediction of extravascular lung water index by the alveolar-arterial oxygen difference. The secondary aims were in determining the relationship between the extravascular lung water index and other oxygenation parameters, the [Formula: see text], end-tidal oxygen concentration, pulmonary oxygen gradient ([Formula: see text] minus end-tidal oxygen concentration), and [Formula: see text]. METHODS: This observational prospective single-center study was performed at the Department of Anaesthesiology and Intensive Care, The University Hospital in Ostrava, The Czech Republic, during the COVID-19 pandemic, from March 20, 2020, until May 24, 2021. RESULTS: The relationship between the extravascular lung water index and alveolar-arterial oxygen difference showed only a mild-to-moderate correlation (r = 0.33, P < .001). Other extravascular lung water index correlations were as follows: [Formula: see text] (r = 0.33, P < .001), end-tidal oxygen concentration (r = 0.26, P = .0032), [Formula: see text] minus end-tidal oxygen concentration (r = 0.15, P = .0624), and [Formula: see text] (r = -0.15, P = .01). CONCLUSIONS: The alveolar-arterial oxygen difference does not reliably correlate with the extravascular lung water index and the degree of lung edema in COVID-19-associated ARDS.
- MeSH
- COVID-19 * komplikace patofyziologie MeSH
- dospělí MeSH
- extravaskulární plicní voda * metabolismus MeSH
- kyslík * metabolismus MeSH
- lidé středního věku MeSH
- lidé MeSH
- plicní alveoly * metabolismus patofyziologie MeSH
- plicní edém etiologie patofyziologie MeSH
- prospektivní studie MeSH
- senioři MeSH
- syndrom dechové tísně * patofyziologie etiologie MeSH
- výměna plynů v plicích MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- pozorovací studie MeSH
- Geografické názvy
- Česká republika MeSH
PURPOSE: Convalescent plasma (CP) collected from people who recovered from COVID-19 became a rapidly available treatment modality in numerous countries, including the Czech Republic. The aims of our study were to evaluate the effectiveness and safety of CP in the treatment of COVID-19. METHODS: This retrospective observational study involved six Czech hospitals. This study enrolled patients with and without CP treatment who were hospitalized between April 2020 and April 2021. Propensity score matching and logistic regression analysis were performed to evaluate the influence of CP administration and its timing on the in-hospital survival of COVID-19 patients. RESULTS: A total of 1,498 patients were enrolled in the study; 406 (27%) were administered CP, and 1,092 (73%) were not treated with CP. The propensity score-matched control group consisted of 1,218 subjects. The survival of patients treated with CP was 79%, while that of patients in the matched control group was 62% (P<0.001). Moreover, the chance of survival was significantly greater when CP was administered within three days after the onset of COVID-19 symptoms than when CP was administered after four or more days (87% vs. 76%, P <0.001). In addition, adverse effects related to CP administration were recorded in only 2% of patients and were considered mild in all patients. CONCLUSIONS: Our study demonstrated that the administration of CP was safe and possibly associated with positive effects that were more pronounced if CP was administered within the first three days after the onset of COVID-19 symptoms.
- MeSH
- COVID-19 * terapie mortalita MeSH
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- pasivní imunizace * metody MeSH
- protilátky virové krev MeSH
- retrospektivní studie MeSH
- SARS-CoV-2 * imunologie MeSH
- senioři MeSH
- sérologická léčba covidu-19 * MeSH
- výsledek terapie MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- pozorovací studie MeSH
- Geografické názvy
- Česká republika MeSH
PURPOSE: Anticoagulation therapy aims to improve the outcome of critically ill patients with severe COVID-19-associated pneumonia. Activated partial thromboplastin time (aPTT) is commonly used to maintain the target therapeutic range of continuous infusion of unfractionated heparin (UFH). The UFH infusion efficacy can be evaluated by determining the time in therapeutic range (TTR) using a modified Rosendaal method. The present study's primary aim was to evaluate TTR based on the aPTT in critically ill patients with severe forms of COVID-19 pneumonia and its influence on survival. The secondary aim was to evaluate the time spent above (TATR) and below the therapeutic range (TBTR). PATIENTS AND METHODS: We performed a retrospective analysis of critically ill patients with COVID-19-associated pneumonia. All patients received a continuous infusion of UFH from the 2nd to 8th day since admission to the ICU. TTR, TATR, and TBTR were calculated using the modified Rosendaal method, and survival days were analyzed by regression (censored after 60 days). RESULTS: Of 103 patients, the median TTR was 49% (IQR 38-63%), TATR 11% (IQR 5-20%), and TBTR 33% (IQR 22-51%). The regression analysis indicated a positive impact of higher TTR and TATR on the number of survival days [β=0.598 (p=0.0367) and β=1.032 (p=0.0208), respectively] and a negative impact of higher TBTR [β=-0.681 (p=0.0033)] on the number of survival days. CONCLUSION: Higher TTR and TATR were associated with better survival of critically ill patients with a severe course of COVID-19-associated pneumonia. Higher TBTR was associated with worse survival in these patients.
- Publikační typ
- časopisecké články MeSH
- Klíčová slova
- lékařská terminologie,
- MeSH
- lingvistika MeSH
- terminologie jako téma * MeSH
- vtip a humor jako téma * MeSH
BACKGROUND: Maintaining the patient awake and not intubated during the venovenous extracorporeal membrane oxygenation (VV ECMO) reduces the risk of ventilation-induced lung injury in patients with ARDS. Currently, there is a lack of data on outcomes and complications associated with the awake ECMO approach. OBJECTIVES: To evaluate outcomes and the occurrence of complications of awake ECMO approach guided by local safety protocol comprising ultrasound-guided cannulation, argatroban-based anticoagulation, respiratory support, and routine sedation targeted to reduce respiratory effort and keeping nurse-to-patient ratio of 1:1. DESIGN: A single-center retrospective case series analysis. METHODS: Consecutive patients with COVID-19-related acute respiratory distress syndrome (ARDS) (CARDS) treated by full awake VV ECMO approach from April 2019 to December 2023 were eligible. RESULTS: Our center treated 10 patients (mean age 54.7 ± 11.6 years) with CARDS with an awake ECMO approach. The reasons for awake ECMO included the presence of barotrauma in six patients, a team consensus to prefer awake ECMO instead of mechanical ventilation in three patients, and the patient's refusal to be intubated in one case. Before ECMO, patients were severely hypoxemic, with a mean value of Horowitz index of 48.9 ± 9.1 mmHg and a mean respiratory rate of 28.8 ± 7.3 breaths per minute on high-flow nasal cannula or noninvasive ventilation support. The mean duration of awake VV ECMO was 558.0 ± 173.6 h. Seven patients (70%) were successfully disconnected from ECMO and fully recovered. Intubation from respiratory causes was needed in three patients (30%), all of whom died eventually. In total, three episodes of delirium, two episodes of significant bleeding, one pneumothorax requiring chest tube insertion, and one oxygenator acute exchange occurred throughout the 5580 h of awake ECMO. No complications related to cannula displacement or malposition occurred. CONCLUSION: The awake ECMO strategy guided by safety protocol appears to be a safe approach in conscious, severely hypoxemic, non-intubated patients with COVID-19-related ARDS.
- MeSH
- antikoagulancia aplikace a dávkování škodlivé účinky terapeutické užití MeSH
- arginin analogy a deriváty MeSH
- bdění * MeSH
- COVID-19 * komplikace terapie MeSH
- dospělí MeSH
- intervenční ultrasonografie MeSH
- kyseliny pipekolové MeSH
- lidé středního věku MeSH
- lidé MeSH
- mimotělní membránová oxygenace * škodlivé účinky metody MeSH
- retrospektivní studie MeSH
- senioři MeSH
- sulfonamidy MeSH
- syndrom dechové tísně * terapie etiologie MeSH
- výsledek terapie MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
V dosavadním průběhu roku 2023 bylo publikováno jen málo originálních prací s respirační tematikou. Převážná většina je charakteru systematických review a metaanalýz již publikovaných studií. V březnu 2023 vydala Evropská společnost pro Intenzivní medicínu (ESICM) doporučení pro management syndromu akutní dechové tísně (acute respiratory distress syndrome, ARDS). V první části tohoto textu je základní shrnutí základních doporučení podle jednotlivých domén. Extrakorporální membránová oxygenace (ECMO) je intervence, která má v posledních letech, především díky pandemii covid-19, velkou pozornost. Poslední randomizovaná studie (EOLIA trial) sice nepotvrdila mortalitní benefit [1], nicméně následná Bayesiánská analýza dat této práce přinesla posteriorní pravděpodobnost mortalitního benefitu ECMO podpory oproti konvenční terapii u vybrané podskupiny pacientů s časným použitím ECMO u pacientů s těžkou formou ARDS [2]. Ve druhé části článku shrnujeme publikace týkající se vlivu ECMO podpory na několik konkrétních skupin onemocnění. Jde o pacienty s polytraumatem, život ohrožujícím astma bronchiale, popáleninovým traumatem a pacienty po transplantaci ledvin. Třetí část článku se zabývá různými aspekty antikoagulační terapie používané u ECMO podpory, včetně její monitorace a srovnání efektu heparinu a bivalirudinu. Ve čtvrté části je popsána publikace hodnotící efektivitu extrakorporální eliminace CO2 (extracorporeal CO2 removal, ECCO2R) z pohledu umožnění ultraprotektivity umělé plicní ventilace u pacientů se středně závažnou až závažnou formou ARDS. V páté část se věnujeme vztahu vybraných patofyziologických aspektů ke klinické praxi a výsledkům. Jedná se o zjišťování významu analýzy vydechovaného vzduchu pro stanovení klinického výsledku pacientů s ventilátorovou pneumonií (VAP). Dále pak o popis vztahu míry ventilace mrtvého prostoru a prognózy pacientů s ARDS. Šestá část se týká optimalizace nastavení umělé plicní ventilace na podkladě použití měření transpulmonálního tlaku. Další, sedmá část článku se zabývá metaanalýzou srovnání efektivity neinvaziní formy mechanické ventilace a dalších metod, jako jsou vysokoprůtoková oxygenoterapie a konvenční kyslíková léčba. Předposlední sekce se zabývá efektem různých forem nebulizační terapie, jako například použití heparinu u pacientů s covid-19 pneumonií, a u obecné populace pacientů na umělé plicní ventilaci, a dále použití volatilních anestetik u pacientů s refrakterním bronchospasmem. V závěru se text věnuje různým aspektům intervencí u pacientů s těžkou formou respiračního selhání ponechaných při vědomí. Jedná se o efekt tzv. awake pronační polohy a awake extrakorporální oxygenační podpory
Only a few original papers on respiratory issues have been published so far in 2023. The vast majority are systematic reviews and meta-analyses of already published studies. In March 2023, the European Society for Intensive Care Medicine (ESICM) issued recommendations for the management of acute respiratory distress syndrome (ARDS). In the first part of this text, a very basic summary of recommendations according to individual domains is described. Extracorporeal membrane oxygenation (ECMO) is an intervention that has received much attention in recent years, mainly due to the COVID-19 pandemic. The last randomized trial (EOLIA trial) did not confirm a mortality benefit [1]. However, the subsequent Bayesian analysis of the data of this study brought a posterior probability of a mortality benefit of ECMO support compared to conventional therapy in a selected subgroup of patients with early use of ECMO in patients with severe ARDS [2]. In the second part of the article, we summarize publications related to the effect of ECMO support on several specific groups of diseases. These are patients with polytrauma, life-threatening bronchial asthma, burn trauma, and kidney transplant patients. The third part of the article deals with various aspects of anticoagulant therapy used in ECMO support, including its monitoring and comparison of the effect of heparin and bivalirudin. The fourth part describes a publication evaluating the effectiveness of extracorporeal CO2 removal (ECCO2R) from the point of view of enabling ultraprotective mechanical ventilation in patients with moderate to severe ARDS. The fifth part deals with the relationship of selected pathophysiological aspects to clinical practice and results. It is an investigation of exhaled air analysis for determining the clinical outcome of patients with ventilator-associated pneumonia (VAP). Furthermore, there is also a description of the relationship between dead space ventilation and the prognosis of patients with ARDS. The sixth part deals with the optimization of artificial lung ventilation settings based on the use of transpulmonary pressure measurement. The next part of the article, the seventh, deals with a meta-analysis of the comparison of the effectiveness of non-invasive forms of mechanical ventilation and other methods, such as high-flow oxygen therapy and conventional oxygen therapy. The penultimate section relates to the effect of various forms of nebulization therapy, such as the use of heparin in patients with COVID-19 pneumonia, and in the general population of patients on mechanical ventilation, and the use of volatile anesthetics in patients with refractory bronchospasm. In the last section, the text deals with various aspects of interventions in patients with severe respiratory failure who remain conscious. This invloves the effect of the so-called awake prone position and awake extracorporeal oxygenation support.
