Tag: Covid-2019

COVID-19 infographics

ECMO in COVID-19 related severe cardiopulmonary failure: visual summary of the recently published ELSO – Extracorporeal Life Support Organization Consensus guideline: unique considerations on when & how to provide ECLS in SARS-CoV-2 Coronavirus pandemic, with potential indications/contraindications. Download full document at https://bit.ly/ELSOCOVID19

Surviving Sepsis Campaign COVID-19 guidelines to support management of critically ill ICU patients with SARS-CoV-2 Coronavirus infection: here a graphic summary!
infection control, diagnosis & testing
hemodynamics support monitoring, fluids & vasoactives
non-invasive ventilatory support: SpO2 targets, conventional oxygen therapy, High Flow Nasal Cannula & Non-Invasive Positive Pressure Ventilation
invasive mechanical ventilation: MV settings, recruitment maneuver, prone posi
tioning, fluids, NMBAs & inhaled vasodilators
therapy: steroids antipyretics, antivirals, IVIg, convalescent plasma, rIFNs, chloroquine, tocilizumab & more!
full open access at https://bit.ly/SSCCOVID19

Basic advices & informal decisional algorithm by a study Group on management of critically ills COVID-19 patients based at Niguarda Ca’ Granda Hospital (Director Prof. R. Fumagalli) & Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico (Director Prof. A. Pesenti) in Milan,  Italy:
hot to set mechanical ventilation (initial acute phase, stabilization, weaning), hot to do recruitment maneuver & notes on porne positioning… to do or (maybe) not?
therapy: antivirals/adjuvants (be careful with lopinavir/ritonavir!) antibiotics, fluids/NE, analgesia & sedation, NMBA
temperature management
monitoring
Aim to stardardize treatments, optimizing outcome & resources consumption, and support physicians, nurses, HCPs dealing with severe respiratory failure related to COVID19, waiting for the response of the immune system, the most effective strategy!
By Thomas Langer & Nicola Bottino
Graphics by @foamecmo available both in English & Italian

Request full document with management advices to the authors
Thomas Langer thomas.langer@unimib.it
& Nicola Bottino bottino.nicola@gmail.com

PS Advices are based on preliminary informations collected during the first experience in China, and during the first week of the emergency in Lombardy, Northern of Italy; additional data ad evidence eventually arising will impose updating the recommendations.

COVID-19 network in Lombardy to early identify, triage & manage SARS-CoV-2 Coronavirus patients: JAMA livestream with Professor Maurizio Cecconi, Here a summary…
Do not underestimate! high percentage of patients will require hospitalization, high percentage will require intensive care: get ready, prepare now, work on protocols and have plans: outbreak could comes near to you! also check related paper by Prof Cecconi, Giacomo Grasselli and Antonio Pesenti just released on JAMA.

COVID19 dedicated GiViTI video conference with intensivists from North of Italy sharing their initial experience with Coronavirus SARSCoV19 epidemics: lung ultrasound LUS, prone positioning, MV, ECMO… it’s like a tsunami, you can’t understand if you are not in.
Recordings of the conference (for the ones speaking in Italian!) available link thanks to Istituto Mario Negri

How to manage critically ills with COVID19? be prepared! be familiar with case definition, ensure strict compliance with IPC, beware of diagnostic testing…
ESICM webinar with Prof Yaseen Arabi moderated by Lennie Derde. Here a graphics, slideset & summary available.

Missed the ESICM COVID-19 webinar with Professor Bin Du from China? here some dedicated notes: data about #Coronavirus pandemic, disease evolution, clinical features, organ failure & need for mechanical ventilation; check ESICM blog at for more data! full open access webinar here. A summary in the graphics.

CSECLS Recommendations on extracorporeal support for critically ills with COVID-19 pneumonia

Recommendations on Extracorporeal Life Support for critically ill patients with Coronavirus Disease 2019 (COVID-19) pneumonia from the Chinese Society of Extracorporeal Life Support. Along with the sharp increase in confirmed cases of novel Coronavirus infection, some of the most critically ills will require ExtraCorporeal Membrane Oxygenation (ECMO) support. Based on the clinical data related to COVID-19, as well as on the data from previous clinical studies and on the recommendations from the Extracorporeal Life Support Organization (ELSO), the Committee Board of the Chinese Society of Extracorporeal Life Support (CSECLS) drafted a series of recommendations to guide implementation of extracorporeal support in patients with confirmed infection developing refractory respiratory or cardio-respiratory failure: here a summary, attached the full original version.

ECMO Indications

Acute Respiratory Distress Syndrome (ARDS) is one of the most common indications for extracorporeal support in respiratory failure. While providing extracorporeal gas exchange, respiratory ECMO enables lung protective mechanical ventilation settings, allowing the lung to rest, and eventually to recover. In majority of the patients infected with novel Coronavirus, pneumonia were mild and reversible. However, some of these patients became critically ill, with most of them developing dyspnea and/or hypoxemia in 1 week from the onset. Most severe cases rapidly developed ARDS, deteriorating to multiple organ failure. Some patients presented with concurrent cardiac involvement, eventually evolving in circulatory dysfunction in sickest patients. When cardiogenic shock or cardiac arrest occurs, veno-arterial configuration (VA-ECMO) needs to be considered. 

Timing for ECMO support

ECMO could be implemented in patients with ARDS if hypoxemia does not improve despite conventional management strategies, with maximal mechanical ventilation settings (FiO2≥ 0.8, tidal volume 6 ml/kg, PEEP ≥ 10 cmH2O), if no contraindication are present, and when at least one of the following conditions is met:
– PaO2/ FiO2 < 80 mmHg for more than 6 hours
– FiO2 = 1.0,PaO2/FiO< 100 mmHg.
– arterial pH < 7.25, PaCO2 > 60 mmHg for more than 6 hours, and respiratory rate > 35 breaths per minute
– respiratory rate > 35 breaths per minute, and arterial pH < 7.2 with plateau pressure > 30 cmH2O
– coexisting cardiogenic shock or cardiac arrest.

Relative or absolute contraindications for ECMO

  1. combination of irreversible disease, severe damage of central nervous system or advanced stage of malignant tumor.
  2. Mechanical Ventilation at high settings (FiO2> 0.9, plateau pressure > 30 cmH2O) lasting 7 days or longer;
  3. advanced age in not actually considered a contraindication, it is associated to an increased risk of death;
  4. severe multiple organ failure;
  5. moderate to severe aortic regurgitation and acute aortic dissection could be considered contraindications to VA ECMO support;
  6. pharmacologic immunosuppression (absolute neutrophil count < 0.4 × 109/L);
  7. no vascular access available for ECMO cannulation due to anatomy alterations or pathological changes involving target vessels.

ECMO configuration

COVID-19 patients usually present with a normal cardiac function at the early stage, so veno-venous ECMO to support respiratory function has been the preferential configuration; however, right heart function should be closely monitored during the rung. If cardiogenic shock or cardiac arrest occurs, configuration could be shift to veno-arterialIf differently hypoxemia develops on VA-ECMO, establishing a VAV configuration could be considered.

Follow CSECLS on WeChat 中国医师协会体外生命支持专业委员会

Clinical characteristics of Covid-19

Clinical characteristics of patients with 2019nCoV (now properly defined by World Health Organization (WHO) Covid-19) in these 3 papers.

Data extraction on 1,099 patients with laboratory-confirmed #Covid-19 from 552 hospitals in 31 provinces/provincial municipalities through January 29th, 2020. Authors reported 5% of patients admitted to #ICU, 2.18% requiring invasive ventilation, and 1.36% death rate. Extracorporeal membrane oxygenation implemented in 5 severe cases (0.5%). Read additional data (detailed clinical characteristics, radiographic & laboratory findings, complications, treatment & outcome, distribution of patients across China), open access text. Note article is a preprint/not peer-reviewed.

Data from 138 hospitalized patients infected with 2019 novel coronavirus in Wuhan, China also published on JAMA, reporting 26.1% of cases transferred to the intensive care unit, 47.2% received invasive ventilation, 4 patients were switched to #ECMO support; overall mortality 4.3%. Open access text

Clinical characteristics of 137 2019-nCoV-infected patients from tertiary hospitals in Hubei Province, reporting no extracorporeal support (authors relate this finding to the fact that they reported about cases admitted to respiratory departments, with data from ICUs/other departments missing). Open access on Chinese Medical Journal.