Updates on obstetric, pediatric, inflammatory, and severe disease complications:
Publication Date: June 2020
Key Takeaway: This review provides a comprehensive summary of the evidence currently available to guide management of critically ill patients with COVID-19.Authors review COVID-19 pathogenesis, presentation, diagnosis, and potential therapeutics, with a focus on management of COVID-19–associated respiratory failure. The authors draw on literature from other viral epidemics, treatment of acute respiratory distress syndrome, and recent publications on COVID-19, as well as guidelines from major health organizations.
Title: Routine Venous Thromboembolism Prophylaxis May Be Inadequate in the Hypercoagulable State of Severe Coronavirus Disease 2019
Publisher: Critical Care Medicine Publication Date: May 27, 2020 URL:
Key Takeaway: This is an observational study of 109 critically ill Covid-19 patients admitted to the ICU to determine the frequency of venous thromboembolism and the degree of inflammatory and coagulation marker elevation associated with venous thromboembolism. VTE was diagnosed in 31 patients (28%) 8 ± 7 days after hospital admission. Twelve patients (11%) had thromboelastography performed and 58% of these patients had a hypercoagulable study. The calculated coagulation index was hypercoagulable in 50% of patients with thromboelastography. This study confirms that Covid-19 results in a hypercoagulable state and that routine chemical venous thromboembolism prophylaxis may be inadequate in preventing venous thromboembolism in severe Covid-19.
Key Takeaway: The authors propose detailed management algorithms treatment and prevention of venous thromboembolism for patients with and without Covid-19 infection.
Title: Venous Thrombosis Among Critically Ill Patients With Coronavirus Disease 2019 Publisher: Critical Care Medicine
Publication Date: March 29, 2020
Key Takeaway: This study from French critical care physicians prospectively performed a venous ultrasonogram of the inferior limbs for 34 consecutive patients admitted to their ICU for Covid-19 disease and found deep vein thrombosis in 22 patients (65%) at admission and in 27 patients (79%) when the venous ultrasonograms performed 48 hours after ICU admission with 26% proximal, 68% distal and 53% bilateral. In view of the high rate (ie, 79%) of deep vein thrombosis reported in this study, prognosis might be improved with early detection and a prompt start of anticoagulant therapy. Despite anticoagulant prophylaxis, 15% of patients in this study developed deep vein thrombosis only 2 days after ICU admission.
Publisher: The Lancet Publication Date: May 27, 2020
URL: https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30243-5/fulltext Key Takeaway: This is a report on the cardiopulmonary findings of the first autopsy series of ten African Americans with recorded cause of death of COVID-19. The distinctive pathological findings are likely to have important implications for treatment of severe disease in this patient population. The authors state, “We believe that effective therapy for this patient demographic—and probably patients with severe infection across demographics— should target not only the viral pathogen, but also the thrombotic and microangiopathic effects of the virus, and possibly a maladaptive immune response to viral infection.”
Publisher: Angiogenesis Publication Date: May 27, 2020
Key Takeaway: The authors propose angiopoietin-2 is a relevant predictive factor for ICU direct admission in COVID-19 patients. This is a prospective cohort study that enrolled 40 consecutive COVID-19 patients admitted to the emergency department that fulfilled criteria for hospitalization; 20 were admitted in conventional wards without any ICU transfer during hospitalization and 20 others were directly transferred to ICU. Angiopoietin-2 cut-off of 5000 pg/mL was the best predictor for ICU outcome further confirmed in multivariate analysis after adjustment for creatinine, CRP or D-dimers. This result showing an endothelial activation reinforces the hypothesis of a COVID-19-associated microvascular dysfunction.
Title: Is the Prone Position Helpful During Spontaneous Breathing in Patients With COVID-19?
Publication Date: May 15, 2020
Key Takeaway: Two studies are discussed in this editorial comment:
Study 1: 24 patients with acute hypoxemic respiratory failure and infiltrates on chest CT scans, 6 of 15 patients who tolerated prone position showed a mean (SD) increase in Pao2 of more than 20% from baseline (74  to 95  mm Hg; P = .006) but 3 patients returned to baseline Pao2 after supination.
Study 2: Awake patients with mild and moderate ARDS. Proned in 3 hour sessions, median of 2 NIV sessions. 12 of 15 had improved oxygenation (Pa O 2 :FiO 2 100 to 122) and respiratory rate (28 /min to 24 /min) during and for 1 hour after NIV session. At 14 days, 1 patient was intubated and 1 other died.
Conclusion: many but not all patients with hypoxemic respiratory failure tolerate the prone position while awake, breathing spontaneously or while receiving NIV. Among patients who tolerated a session of prone positioning, improvement in oxygenation and decrease in respiratory rate occurred. The effects were transient, and respiratory rates and oxygenation often returned to baseline after supination.
Title: Development and Validation of a Clinical Risk Score to Predict the Occurrence of Critical Illness in Hospitalized Patients With COVID-19
Publisher: JAMA Internal Medicine
Publication Date: May 12, 2020
Key Takeaway: Study in China, using 1590 patients and a validation cohort of 710 patients, developed and validated a risk score (COVID-GRAM, http://18.104.22.168/) to predict development of critical illness (ICU admission, mechanical ventilation, or death). The 10 risk score predictors included: chest radiography abnormality, age, hemoptysis, dyspnea, unconsciousness, number of comorbidities, cancer history, neutrophil-to-lymphocyte ratio, lactate dehydrogenase, and direct bilirubin. Limitations include need for further validation, especially in other populations.
Title: Impact of Corticosteroid Therapy on Outcomes of Persons With SARS-CoV-2, SARS-CoV, or MERS-CoV Infection: A Systematic Review and Meta-Analysis
Publisher: Leukemia / Nature
Publication Date: May 5, 2020
Key Takeaways: Corticosteroid use in subjects with SARS-CoV-2, SARS-CoV, and MERS-CoV infections delayed virus clearing and did not convincingly improve survival, reduce hospitalization duration or ICU admission rate and/or use of mechanical ventilation. There were several adverse effects. Because of a preponderance of observational studies in the dataset and selection and publication biases the conclusions, especially regarding [steroid use in] SARS-CoV-2, confirmation is needed in a randomized clinical trial. The authors suggest caution using corticosteroids in persons with COVID-19.
Editor’s Note: This remains a debated topic, and a non-peer reviewed article recently demonstrated conflicting information.
Title: Treating ARDS in the Era of COVID: A Refined Approach
Publisher: John Hopkins Center for Health Security
Publication Date: April 30, 2020
Key Takeaway: Two phenotypes of Corona-ARDS (CARDS) are described - L & H
Title: Rationale for Prolonged Corticosteroid Treatment in the Acute Respiratory Distress Syndrome Caused by Coronavirus Disease 2019
Publisher: Society for Critical Care Medicine
Publication Date: April 2020
Key Takeaway: International critical care group disagrees with WHO recommendations to save steroids for clinical trials. Authors propose 1mg/kg/day for early mod-severe Corona-ARDS.
Title: Respiratory Support in Novel Coronavirus Disease (COVID-19) Patients
Publisher: American Journal of Tropical Medicine and Hygiene
Publication: April 21, 2020
Title: Management of COVID-19 Respiratory Distress
Publisher: JAMA Network
Publication: April 24, 2020
COVID-19 patients initially tend to retain relatively good compliance despite very poor oxygenation (“Type L” lung disease). This may progress in some patients, either because of disease severity, host response, or suboptimal management, to “Type H” disease characterized by low compliance, higher lung weight, and higher PEEP response.
Title: Covid-19 Does Not Lead to a “Typical” Acute Respiratory Distress Syndrome
Publication: Journal of American Thoracic Society, March 30, 2020
Title: Fast Literature Assessment and Reviews (FLARE) from Massachusetts General Hospital
Key Takeaway: A collaborative effort within the Pulmonary and Critical Care Division to review:
Title: Intensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations
Publication: Lancet, April 6, 2020
Key Takeaway: Comprehensive intensive care practice guidelines developed by the Asian Critical Care Clinical Trials Group
Title: COVID-19 pneumonia: different respiratory treatment for different phenotypes?
Publication: Intensive Care Medicine, 2020
Key Takeaway: This editorial describes two primary “phenotypes” of Covid-19 related pneumonia:
Title: Swivel-HEPA-ETT (SHE) Bougie and HEPA-ETT (HE) Methods for Safe Intubation While Managing Patients With COVID-19
Publication: Journal of Emergency Medicine, April 15, 2020
Key Takeaway: This article reports on methods to reduce aerosolization during intubation. The authors utilized two methods that incorporated HEPA filters (HEPA-ETT and Swivel-HEPA-ETT) that they believe helped to reduce aerosolization during intubation and allow for confirmation of placement without auscultation.
Title: With ventilators running out, doctors say the machines are overused for Covid-19
Key Takeaway: This is an interesting article by a science reporter about the growing uncertainty of the pulmonary pathophysiology of severe Covid-19 infection and how to best treat it.
Title: High-Dose Intravenous Immunoglobulin as a Therapeutic Option for Deteriorating Patients With Coronavirus Disease 2019
Key Takeaway: This case series reports 3 patients with severe COVID-19 who received high-dose intravenous immunoglobulin (IVIg) with satisfactory recovery. With no definite effective treatments for this novel pathogen, based on these observations high-dose IVIg may be considered for clinical trials or compassionate use in deteriorating patients infected with COVID-19 respiratory failure. March 21, 2020
Updated CDC Webinar slide deck on Covid-19 clinical management
Preliminary Estimates of the Prevalence of Selected Underlying Health Conditions Among Patients with Coronavirus Disease 2019,United States, Feb 12–March 28, 2020
Joint Statement on Multiple Patients Per Ventilator
Care of the Critically Ill and Injured During Pandemics and Disasters
Primer on care of critically-ill patients with Covid-19
Society of Critical Care Medicine Surviving Sepsis Recommendations
Management of Critically Ill Adults with Covid-19
Provided by Hana Akselrod, MD, MPH, GW Division of Infectious Diseases