Neurological and neuropsychiatric symptoms that persist or develop three months after the onset of COVID-19 pose a significant threat to the global healthcare system. These symptoms are yet to be ...synthesized and quantified via meta-analysis.
To determine the prevalence of neurological and neuropsychiatric symptoms reported 12 weeks (3 months) or more after acute COVID-19 onset in adults.
A systematic search of PubMed, EMBASE, Web of Science, Google Scholar and Scopus was conducted for studies published between January 1st, 2020 and August 1st, 2021. The systematic review was guided by Preferred Reporting Items for Systematic Review and Meta-Analyses.
Studies were included if the length of follow-up satisfied the National Institute for Healthcare Excellence (NICE) definition of post-COVID-19 syndrome (symptoms that develop or persist ≥3 months after the onset of COVID-19). Additional criteria included the reporting of neurological or neuropsychiatric symptoms in individuals with COVID-19.
Two authors independently extracted data on patient characteristics, hospital and/or ICU admission, acute-phase COVID-19 symptoms, length of follow-up, and neurological and neuropsychiatric symptoms.
The primary outcome was the prevalence of neurological and neuropsychiatric symptoms reported ≥3 months post onset of COVID-19. We also compared post-COVID-19 syndrome in hospitalised vs. non-hospitalised patients, with vs. without ICU admission during the acute phase of infection, and with mid-term (3 to 6 months) and long-term (>6 months) follow-up.
Of 1458 articles, 18 studies, encompassing a total of 10,530 patients, were analysed. Overall prevalence for neurological post-COVID-19 symptoms were: fatigue (37%, 95% CI: 25%–48%), brain fog (32%, 10%–54%), memory issues (28%, 22%–35%), attention disorder (22%, 7%–36%), myalgia (17%, 9%–25%), anosmia (12%, 8%–16%), dysgeusia (10%, 6%–14%) and headache (15%, 4%–26%). Neuropsychiatric conditions included sleep disturbances (31%, 19%–42%), anxiety (23%, 14%–32%) and depression (17%, 10%–24%). Neuropsychiatric symptoms substantially increased in prevalence between mid- and long-term follow-up. Compared to non-hospitalised patients, patients hospitalised for acute COVID-19 had reduced frequency of anosmia, anxiety, depression, dysgeusia, fatigue, headache, myalgia, and sleep disturbance at three (or more) months post-infection. Cohorts with >20% of patients admitted to the ICU during acute COVID-19 experienced higher prevalence of fatigue, anxiety, depression, and sleep disturbances than cohorts with <20% of ICU admission.
Fatigue, cognitive dysfunction (brain fog, memory issues, attention disorder) and sleep disturbances appear to be key features of post-COVID-19 syndrome. Psychiatric manifestations (sleep disturbances, anxiety, and depression) are common and increase significantly in prevalence over time. Randomised controlled trials are necessary to develop intervention strategy to reduce disease burden.
•Question: How commonly are neurological and neuropsychiatric symptoms reported three months or more after acute COVID-19 onset in adults?•Findings: In a meta-analysis of 18 studies encompassing 10,530 patients (hospitalised and non-hospitalised), overall prevalence for neurological symptoms three months after COVID-19 onset was: fatigue (37%), brain fog (32%), memory issues (28%), attention disorder (22%), myalgia (17%), anosmia (12%), dysgeusia (10%), and headache (15%). The prevalence of neuropsychiatric symptoms was sleep disturbances (31%), anxiety (23%), and depression (17%).•Meaning: Given the high prevalence of neurological and neuropsychiatric post-COVID-19 syndrome, randomised controlled trials are necessary to develop intervention strategy to reduce disease burden.
Cardiac arrest (CA) is a major cause of morbidity and mortality frequently associated with neurological and systemic involvement. Supportive therapeutic strategies such as mechanical ventilation, ...hemodynamic settings, and temperature management have been implemented in the last decade in post-CA patients, aiming at protecting both the brain and the lungs and preventing systemic complications. A lung-protective ventilator strategy is currently the standard of care among critically ill patients since it demonstrated beneficial effects on mortality, ventilator-free days, and other clinical outcomes. The role of protective and personalized mechanical ventilation setting in patients without acute respiratory distress syndrome and after CA is becoming more evident. The individual effect of different parameters of lung-protective ventilation, including mechanical power as well as the optimal oxygen and carbon dioxide targets, on clinical outcomes is a matter of debate in post-CA patients. The management of hemodynamics and temperature in post-CA patients represents critical steps for obtaining clinical improvement. The aim of this review is to summarize and discuss current evidence on how to optimize mechanical ventilation in post-CA patients. We will provide ten tips and key insights to apply a lung-protective ventilator strategy in post-CA patients, considering the interplay between the lungs and other systems and organs, including the brain.
A tribute to Paolo Pelosi Robba, Chiara; Battaglini, Denise; Ball, Lorenzo
Critical care (London, England),
06/2023, Volume:
27, Issue:
1
Journal Article
Peer reviewed
Open access
Prof Pelosi served as President of the European Society of Anaesthesiology (ESA) from 2010 to 2011, and had important roles in the World Federation of Societies of Intensive Care and Critical Care ...Medicine (WFSCCM) and European Respiratory Society (ERS). Professor Pelosi made the difference in the field of mechanical ventilation and acute respiratory distress syndrome (ARDS), in particular through the work of the PROVEnet group, which allowed to create large-scale observational studies and randomized clinical trials, providing high quality evidence which revolutionised the field of anaesthesiology and intensive care medicine. Rights and permissions Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. Copy to clipboard Provided by the Springer Nature SharedIt content-sharing initiative Obituary Open Access Published:27 June 2023 A tribute to Paolo Pelosi Chiara Robba ORCID: orcid.org/0000-0003-1628-38451,2, Denise Battaglini1,2 & Lorenzo Ball1,2 Critical Care volume 27, Article number: 253 (2023) Cite this article 1040 Accesses 4 Altmetric Metrics details figure a On the 30th of May, Professor Paolo Pelosi passed away. Prof Pelosi served as President of the European Society of Anaesthesiology (ESA) from 2010 to 2011, and had important roles in the World Federation of Societies of Intensive Care and Critical Care Medicine (WFSCCM) and European Respiratory Society (ERS).
•Chest CT patterns in COVID-19 may be divided into three main phenotypes with different characteristics o In phenotype 1, respiratory mechanics are consistent with high pulmonary compliance and ...severe hypoxemia.•In phenotype 2, moderate to high PEEP as well as lateral and/or prone positioning may help recruit collapsed areas.•Phenotype 3 resembles typical ARDS and should be managed as such.•Attention should be paid to the risk of pulmonary embolism, regardless of phenotype.
Coronavirus disease 2019 (COVID-19) can cause severe respiratory failure requiring mechanical ventilation. The abnormalities observed on chest computed tomography (CT) and the clinical presentation of COVID-19 patients are not always like those of typical acute respiratory distress syndrome (ARDS) and can change over time. This manuscript aimed to provide brief guidance for respiratory management of COVID-19 patients before, during, and after mechanical ventilation, based on the recent literature and on our direct experience with this population. We identify that chest CT patterns in COVID-19 may be divided into three main phenotypes: 1) multiple, focal, possibly overperfused ground-glass opacities; 2) inhomogeneously distributed atelectasis; and 3) a patchy, ARDS-like pattern. Each phenotype can benefit from different treatments and ventilator settings. Also, peripheral macro- and microemboli are common, and attention should be paid to the risk of pulmonary embolism. We suggest use of personalized mechanical ventilation strategies based on respiratory mechanics and chest CT patterns. Further research is warranted to confirm our hypothesis.
Most patients with ischaemic stroke are managed on the ward or in specialty stroke units, but a significant number requires higher-acuity care and, consequently, admission to the intensive care unit. ...Mechanical ventilation is frequently performed in these patients due to swallowing dysfunction and airway or respiratory system compromise. Experimental studies have focused on stroke-induced immunosuppression and brain-lung crosstalk, leading to increased pulmonary damage and inflammation, as well as reduced alveolar macrophage phagocytic capability, which may increase the risk of infection. Pulmonary complications, such as respiratory failure, pneumonia, pleural effusions, acute respiratory distress syndrome, lung oedema, and pulmonary embolism from venous thromboembolism, are common and found to be among the major causes of death in this group of patients. Furthermore, over the past two decades, tracheostomy use has increased among stroke patients, who can have unique indications for this procedure-depending on the location and type of stroke-when compared to the general population. However, the optimal mechanical ventilator strategy remains unclear in this population. Although a high tidal volume (V
) strategy has been used for many years, the latest evidence suggests that a protective ventilatory strategy (V
= 6-8 mL/kg predicted body weight, positive end-expiratory pressure and rescue recruitment manoeuvres) may also have a role in brain-damaged patients, including those with stroke. The aim of this narrative review is to explore the pathophysiology of brain-lung interactions after acute ischaemic stroke and the management of mechanical ventilation in these patients.
Early detection of cardiovascular dysfunctions directly caused by acute ischemic stroke (AIS) has become paramount. Researchers now generally agree on the existence of a bidirectional interaction ...between the brain and the heart. In support of this theory, AIS patients are extremely vulnerable to severe cardiac complications. Sympathetic hyperactivity, hypothalamic-pituitary-adrenal axis, the immune and inflammatory responses, and gut dysbiosis have been identified as the main pathological mechanisms involved in brain-heart axis dysregulation after AIS. Moreover, evidence has confirmed that the main causes of mortality after AIS include heart attack, congestive heart failure, hemodynamic instability, left ventricular systolic dysfunction, diastolic dysfunction, arrhythmias, electrocardiographic anomalies, and cardiac arrest, all of which are more or less associated with poor outcomes and death. Therefore, intensive care unit admission with continuous hemodynamic monitoring has been proposed as the standard of care for AIS patients at high risk for developing cardiovascular complications. Recent trials have also investigated possible therapies to prevent secondary cardiovascular accidents after AIS. Labetalol, nicardipine, and nitroprusside have been recommended for the control of hypertension during AIS, while beta blockers have been suggested both for preventing chronic remodeling and for treating arrhythmias. Additionally, electrolytic imbalances should be considered, and abnormal rhythms must be treated. Nevertheless, therapeutic targets remain challenging, and further investigations might be essential to complete this complex multi-disciplinary puzzle. This review aims to highlight the pathophysiological mechanisms implicated in the interaction between the brain and the heart and their clinical consequences in AIS patients, as well as to provide specific recommendations for cardiovascular management after AIS.
Severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) causes a wide spectrum of clinical manifestations, with progression to multiorgan failure in the most severe cases. Several biomarkers can ...be altered in coronavirus disease 2019 (COVID-19), and they can be associated with diagnosis, prognosis, and outcomes. The most used biomarkers in COVID-19 include several proinflammatory cytokines, neuron-specific enolase (NSE), lactate dehydrogenase (LDH), aspartate transaminase (AST), neutrophil count, neutrophils-to-lymphocytes ratio, troponins, creatine kinase (MB), myoglobin, D-dimer, brain natriuretic peptide (BNP), and its N-terminal pro-hormone (NT-proBNP). Some of these biomarkers can be readily used to predict disease severity, hospitalization, intensive care unit (ICU) admission, and mortality, while others, such as metabolomic and proteomic analysis, have not yet translated to clinical practice. This narrative review aims to identify laboratory biomarkers that have shown significant diagnostic and prognostic value for risk stratification in COVID-19 and discuss the possible clinical application of novel analytic strategies, like metabolomics and proteomics. Future research should focus on identifying a limited but essential number of laboratory biomarkers to easily predict prognosis and outcome in severe COVID-19.
Severe acute respiratory disease coronavirus 2 (SARS-CoV-2, formerly 2019-nCoV) is a novel coronavirus that has rapidly disseminated worldwide, causing the coronavirus disease 2019 (COVID-19) ...pandemic. As of January 6th, 2021, there were over 86 million global confirmed cases, and the disease has claimed over 1.87 million lives (a ∼2.2% case fatality rate). SARS-CoV-2 is able to infect human cells by binding its spike (S) protein to angiotensin-conversing enzyme 2 (ACE2), which is expressed abundantly in several cell types and tissues. ACE2 has extensive biological activities as a component of the renin-angiotensin-aldosterone system (RAAS) and plays a pivotal role as counter-regulator of angiotensin II (Ang II) activity by converting the latter to Ang (1-7). Virion binding to ACE2 for host cell entry leads to internalization of both via endocytosis, as well as activation of ADAM17/TACE, resulting in downregulation of ACE2 and loss of its protective actions in the lungs and other organs. Although COVID-19 was initially described as a purely respiratory disease, it is now known that infected individuals can rapidly progress to a multiple organ dysfunction syndrome. In fact, all human structures that express ACE2 are susceptible to SARS-CoV-2 infection and/or to the downstream effects of reduced ACE2 levels, namely systemic inflammation and injury. In this review, we aim to summarize the major features of SARS-CoV-2 biology and the current understanding of COVID-19 pathogenesis, as well as its clinical repercussions in the lung, heart, kidney, bowel, liver, and brain. We also highlight potential therapeutic targets and current global efforts to identify safe and effective therapies against this life-threatening condition.
Given our findings, we commend future efforts to protocolise reporting of additional patient-centred outcomes such as speech (Time to Vocalisation), swallowing (Functional Dysphagia Scale) 5 and ...psychological outcomes (Hospital Anxiety and Depression Scale) in future randomised controlled trials, to better inform patient-centred clinical decision-making. Effect of early vs standard approach to tracheostomy on functional outcome at 6 months among patients with severe stroke receiving mechanical ventilation: the SETPOINT2 randomized clinical trial. Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial.
Appropriate perioperative fluid management is of pivotal importance to reduce postoperative complications, which impact on early and long-term patient outcome. The so-called perioperative ...goal-directed therapy (GDT) approach aims at customizing perioperative fluid management on the individual patients' hemodynamic response. Whether or not the overall amount of perioperative volume infused in the context of GDT could influence postoperative surgical outcomes is unclear.
We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing the efficacy of GDT approach between study population and control group in reducing postoperative complications and perioperative mortality, using MEDLINE, EMBASE and the Cochrane Controlled Clinical trials register. The enrolled studies were grouped considering the amount infused intraoperatively and during the first 24 h after the admission in the critical care unit (perioperative fluid).
The metanalysis included 21 RCTs enrolling 2729 patients with a median amount of perioperative fluid infusion of 4500 ml. In the studies reporting an overall amount below or above this threshold, the differences in postoperative complications were not statically significant between controls and GDT subgroup 43.4% vs. 34.2%, p value = 0.23 and 54.8% vs. 39.8%; p value = 0.09, respectively. Overall, GDT reduced the overall rate of postoperative complications, as compared to controls pooled risk difference (95% CI) = - 0.10 (- 0.14, - 0.07); Chi
= 30.97; p value < 0.0001, but not to a reduction of perioperative mortality pooled risk difference (95%CI) = - 0.016 (- 0.0334; 0.0014); p value = 0.07. Considering the rate of organ-related postoperative events, GDT did not reduce neither renal (p value = 0.52) nor cardiovascular (p value = 0.86) or pulmonary (p value = 0.14) or neurological (p value = 0.44) or infective (p value = 0.12) complications.
Irrespectively to the amount of perioperative fluid administered, GDT strategy reduces postoperative complications, but not perioperative mortality.
CRD42020168866; Registration: February 2020 https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=168866.
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