Fattori di rischio per un supporto ventilatorio invasivo o non invasivo nel paziente con polmonite da COVID-19

INTRODUCTION In December 2019 a novel coronavirus (COVID19) appeared in Wuhan (China) and rapidly spread worldwide leading to a pandemic scenario. The average reported mortality is 6.89%, and it is even higher in Italy (13.35%). Facing a life-threatening infection, reliable risk factors recognition is warranted in order to guarantee a fast and appropriate medical response. METHODS We included all consecutive adult patients presenting to the Emergency Department (ED) of Santa Maria Annunziata Hospital in Florence between February 25th to April 25th 2020 (60 days) with a confirmed diagnosis of COVID-19. All patients were admitted on Intensive Care Unit (ICU), or Infectious Disease Unit (IDU), basing on their clinical status. NI/I-VS was defined as need for continuous positive airway pressure (CPAP) or bilevel positive pressure non-invasive ventilation (BPAP) or mechanical ventilation (MV) rather than venturi-mask (VM) or low-flow (LF) oxygen-therapy. Data included baseline characteristics, clinical features, symptoms history and Sequential Organ Failure Assessment, and laboratory findings performed upon arrival at the ED, chest radiology, admission ward (IDU or ICU), supplemental oxygen requirement and type of administration during the in-hospital stay, antiretroviral therapy (lopinavir/ritonavir or darunavir based drugs), hydroxychloroquine, antibiotic therapy, immunomodulating therapy with corticosteroids or tocilizumab. RESULTS Ninety-seven patients were enrolled; 61,9% (60/97) were male, median age was 64 years; intra- hospital mortality was 9.3%. Thirty five out of 97 (36%) patients required ICU admission and 94.8% (92/97) were prescribed oxygen-therapy: 10.8% (10/92) with LF, 44.5% (41/92) with VM, 31.5% (29/92) with CPAP, 2.2% (2/92) with BPAP and 10.8% (10/92) underwent intubation for MV. Patients with body mass index >30, type II diabetes mellitus and presenting at the admission with dyspnoea, asthenia, SOFA score ≥2 points, PaO2/FiO2 38°C, increased levels of lactate dehydrogenase (LDH), alanine aminotransferase, C-reactive protein and a d-dimer >1000 ng/ml underwent more frequently NI/I-VS at the univariate analysis. Multivariate logistic regression analysis confirmed temperature >38°C (odds ratio [OR] 21.2, 95% confidential interval [95%CI] 3.5- 124.5, p=0.001), LDH >250 U/L (OR 15.2, 95%CI 1.8-128.8, p=0.012) and d- dimer >1000 ng/ml (OR 4.5, 95%CI 1.2-17, p=0.027) as significantly associated with NI/I-VS requirement. A non-significant trend (p=0.051) was described for PaO2/FiO2 <300. CONCLUSIONS Temperature >38°C, LDH >250 U/L and d-dimer >1000 ng/ml resulted to be indipendent risk factors for non invasive/invasive-ventilatory support requirement. An inflammatory marker screening could be useful to quickly identify patients prone to develop a severe illness and to perform an appropriate treatment management. Nel dicembre 2019 è apparso a Wuhan in Cina un nuovo Coronavirus, che si è rapidamente diffuso in tutto il mondo tanto che il 30 gennaio 2020 l'OMS ha dichiarato l'epidemia di Coronavirus Emergenza internazionale di salute pubblica e l'11 marzo 2020 lo stato di pandemia. L’infezione causata dal nuovo coronavirus fu chiamata Coronavirus Disease (COVID-19). Gli studi di biologia molecolare hanno evidenziato che il virus COVID-2019 usa il recettore ACE 2 (enzima di conversione dell’angiotensina) per entrare nelle cellule, sempre espresso sulle cellule endoteliali, per lo più sulle cellule alveolari di tipo II del tratto respiratorio (pneumociti), ma anche sull’epitelio gastrointestinale e altri organi. La disfunzione endoteliale è uno dei principali fattori determinanti della disfunzione microvascolare, in quanto sposta l'equilibrio vascolare verso una maggiore vasocostrizione con conseguente ischemia d'organo, infiammazione con edema tissutale associato e uno stato procoagulante. Il Covid-19 ha causato e sta causando uno spettro esteso di sintomi e manifestazioni. Le evidenze mostrano come nel 70% dei pazienti la malattia sia asintomatica o con sintomi molto lievi (febbre, raffreddore, dolori muscolari, oculorinite), mentre nel restante 30% si manifesta una sindrome respiratoria con febbre elevata, tosse, fino a raggiungere l’insufficienza respiratoria grave (quadro di ARDS) che può richiedere il ricovero in terapia intensiva. Questo è uno studio osservazionale retrospettivo monocentrico. Sono stati inclusi i pazienti che si sono presentati al Pronto Soccorso dell’ospedale di Santa Maria Annunziata di Firenze tra il 25 febbraio e il 25 aprile del 2020 (60 giorni) e che sono stati ricoverati nel reparto di Malattie Infettive o in Rianimazione con diagnosi di infezione da COVID-19. La diagnosi doveva essere confermata con RT-PCR su tampone nasale e faringeo. Nel nostro studio di coorte abbiamo analizzato le caratteristiche cliniche dei pazienti COVID-19 positivi ospedalizzati, con l’obiettivo di evidenziare i possibili fattori di rischio associati alla richiesta di supporto ventilatorio invasivo o non invasivo. Dall’inizio dello studio si è sviluppato un approccio multidisciplinare tra gli specialisti del reparto di Malattie Infettive e gli Anestesisti della Rianimazione; si è creata una collaborazione condividendo i briefing e cercando le migliori soluzioni per i pazienti in carico; in particolare il tipo di approccio ventilatorio, i trattamenti di supporto, l’uso di farmaci sperimentali e la somministrazione di antibiotici e antivirali sono state decisioni condivise in accordo con le linee guida locali basate sulle migliori evidenze al momento e seguendo il “Vademecum” realizzato dalla sezione della Società di Malattie infettive e tropicali (SIMIT Lombardia). Il tipo di supporto ventilatorio, invasivo o non invasivo (NIV) mediante maschera venturi o casco, è definito come il bisogno di una CPAP (continuous positive airway pressure) o BPAP (bilevel positive pressure), ventilazione meccanica o ossigenoterapia a bassi flussi. I dati dei pazienti analizzati Includono le caratteristiche di base del paziente, le caratteristiche cliniche, i sintomi e il SOFA (Sequential Organ Failure Assessment), i dati di laboratorio all’arrivo in Pronto Soccorso, i reperti della radiografia del torace, il setting di ricovero (reparto di Malattie Infettive o Rianimazione), richiesta di ossigeno supplementare e tipo di approccio ventilatorio (NIV o VM), terapia antiretrovirale e terapia antibiotica, uso di idrossiclorochina, terapia immunomodulante con corticosteroidi o tocilizumab. L’obiettivo primario era quello di investigare i fattori di rischio per la necessità di ventilazione non invasiva o invasiva, ovvero l’utilizzo di maschera Venturi, inteso come il bisogno di una CPAP (continuous positive airway pressure), BiPAP (bilevel positive airway pressure) o ventilazione meccanica invasiva. Abbiamo utilizzato la BPAP esclusivamente con la maschera total face (NIV), mentre la CPAP con l’utilizzo sia della maschera che del casco. In conclusione, il nostro studio conferma che febbre, alti livelli di D-dimero e LDH rappresentano fattori di rischio per la ventilazione. Tutti e tre questi valori possono essere considerati come marker di uno stato iperinfiammatorio che induce lo sviluppo di una patologia severa difficile da trattare

Epidemiology, Clinical Features and Prognostic Factors of Pediatric SARS-CoV-2 Infection: Results From an Italian Multicenter Study

Background: Many aspects of SARS-CoV-2 infection in children and adolescents remain unclear and optimal treatment is debated. The objective of our study was to investigate epidemiological, clinical and therapeutic characteristics of pediatric SARS-CoV-2 infection, focusing on risk factors for complicated and critical disease. Methods: The present multicenter Italian study was promoted by the Italian Society of Pediatric Infectious Diseases, involving both pediatric hospitals and general pediatricians/family doctors. All subjects under 18 years of age with documented SARS-CoV-2 infection and referred to the coordinating center were enrolled from March 2020. Results: As of 15 September 2020, 759 children were enrolled (median age 7.2 years, IQR 1.4; 12.4). Among the 688 symptomatic children, fever was the most common symptom (81.9%). Barely 47% of children were hospitalized for COVID-19. Age was inversely related to hospital admission (p < 0.01) and linearly to length of stay (p = 0.014). One hundred forty-nine children (19.6%) developed complications. Comorbidities were risk factors for complications (p < 0.001). Viral coinfections, underlying clinical conditions, age 5-9 years and lymphopenia were statistically related to ICU admission (p < 0.05). Conclusions: Complications of COVID-19 in children are related to comorbidities and increase with age. Viral co-infections are additional risk factors for disease progression and multisystem inflammatory syndrome temporarily related to COVID-19 (MIS-C) for ICU admission

Post-anaesthesia pulmonary complications after use of muscle relaxants (POPULAR): a multicentre, prospective observational study

Background Results from retrospective studies suggest that use of neuromuscular blocking agents during general anaesthesia might be linked to postoperative pulmonary complications. We therefore aimed to assess whether the use of neuromuscular blocking agents is associated with postoperative pulmonary complications. Methods We did a multicentre, prospective observational cohort study. Patients were recruited from 211 hospitals in 28 European countries. We included patients (aged ≥18 years) who received general anaesthesia for any in-hospital procedure except cardiac surgery. Patient characteristics, surgical and anaesthetic details, and chart review at discharge were prospectively collected over 2 weeks. Additionally, each patient underwent postoperative physical examination within 3 days of surgery to check for adverse pulmonary events. The study outcome was the incidence of postoperative pulmonary complications from the end of surgery up to postoperative day 28. Logistic regression analyses were adjusted for surgical factors and patients’ preoperative physical status, providing adjusted odds ratios (ORadj) and adjusted absolute risk reduction (ARRadj). This study is registered with ClinicalTrials.gov, number NCT01865513. Findings Between June 16, 2014, and April 29, 2015, data from 22803 patients were collected. The use of neuromuscular blocking agents was associated with an increased incidence of postoperative pulmonary complications in patients who had undergone general anaesthesia (1658 [7·6%] of 21694); ORadj 1·86, 95% CI 1·53–2·26; ARRadj –4·4%, 95% CI –5·5 to –3·2). Only 2·3% of high-risk surgical patients and those with adverse respiratory profiles were anaesthetised without neuromuscular blocking agents. The use of neuromuscular monitoring (ORadj 1·31, 95% CI 1·15–1·49; ARRadj –2·6%, 95% CI –3·9 to –1·4) and the administration of reversal agents (1·23, 1·07–1·41; –1·9%, –3·2 to –0·7) were not associated with a decreased risk of postoperative pulmonary complications. Neither the choice of sugammadex instead of neostigmine for reversal (ORadj 1·03, 95% CI 0·85–1·25; ARRadj –0·3%, 95% CI –2·4 to 1·5) nor extubation at a train-of-four ratio of 0·9 or more (1·03, 0·82–1·31; –0·4%, –3·5 to 2·2) was associated with better pulmonary outcomes. Interpretation We showed that the use of neuromuscular blocking drugs in general anaesthesia is associated with an increased risk of postoperative pulmonary complications. Anaesthetists must balance the potential benefits of neuromuscular blockade against the increased risk of postoperative pulmonary complications