COVID-19 patients admitted to our hospital between July 2020 and October 2021 were included in the analysis. The study period corresponds to the second to fifth waves in Japan. We have mainly treated patients with severe respiratory failure (requiring ventilatory assistance) or with potential for severe respiratory failure and patients positive for COVID-19 and requiring emergency care (surgery, endovascular therapy, etc.) [“COVID-19 positive emergency patients”]. We often collaborate with hospitals in charge of mild and moderate illnesses to accommodate patients transferred to the hospital. In some cases, patients with severe respiratory failure are brought directly by ambulance, and hard-to-receive cases are accepted during nights and on public holidays to maintain the emergency medical system.
Institutional COVID-19 Treatment Policy
In principle, the COVID-19 treatment policy was based on the treatment guidelines for coronavirus disease 2019 (COVID-19)17. The Japanese guidelines are publicly available and have been updated. The main drug treatment was remdesivir and dexamethasone (6 mg/day)6. The steroid (methylprednisolone) dose was increased to 2 mg/kg when the patient was deemed critically ill based on CT, oxygenation, and rate of deterioration. Patients without bacterial infection or immunosuppression were treated with tocilizumab or baricitinib, in addition to remdesivir and steroids. Until the third wave, HFNC was only used after extubation. After the fourth wave (May 2021), HFNC was actively introduced before mechanical ventilation9. If excessive inspiratory effort and tachypnea are not resolved even after onset of HFNC, tracheal intubation and mechanical ventilation should be started as soon as possible. In patients with severe obesity18young age, no delirium and severe chronic obstructive pulmonary disease, CNHP with high oxygen concentration could be continued in awake patients11 to avoid artificial respiration. In mechanically ventilated patients, esophageal pressure was monitored to titrate positive end-tidal pressure (PEEP)19. When CT showed a dorsal or unilateral predominant shadow distribution, positional therapy (prone or lateral decubitus) was used. Although the indications for ECMO are very different, such as refractory hypoxia or hypercapnia, VV-ECMO has been introduced.
Patients on ventilators or ECMO received continuous enteral nutrition starting at 20 mL/h with a peptide-based formula (Peptamen AF®, Nestle HealthCare Nutrition, Inc.) and increased the daily injection rate. The target caloric dose (about 1500 kcal/day) is usually reached by day 4. In addition to continuous intravenous insulin, oral hypoglycemic agents (biguanides, dipeptidyl peptidase-4 inhibitors, sodium-glucose-2 cotransporter thiazolidinediones) have been used to control glucose intolerance due to steroid use and frequent complications of diabetes mellitus. To control excessive inspiratory effort, patients with severe COVID-19 often require high doses of opioids. Naldemedine20 has been used in addition to magnesium oxide and sodium picosulfate to promote intestinal peristalsis. Since most severe cases of COVID-19 were hemodynamically stable, we attempted management of fluid restriction. We restricted injection fluid and used diuretics or continuous renal replacement therapy if needed in patients with acute kidney injury or chronic kidney disease.
Patient history (age, sex, height, weight, blood test on admission) and admission route (direct transport by ambulance, A; transfer from outside the hospital, T) were recorded . Severity was defined as oxygen therapy (not intubated, Group 1 [G1]; ventilated, Group 2 [G2]; ECMO, Group 3 [G3]). We collected data on ventilator duration, ECMO duration, drug treatment (total steroid dose, tocilizumab, baricitinib), sequelae, blood transfusion requirements, in-hospital mortality, length of hospital stay. hospital and waiting period (days between extubation and transfer). or discharge).
Patient characteristics, clinical course and weight loss during hospitalization were compared according to disease severity. In the severe group (G2 + G3). We then compared the characteristics, the clinical evolution and the course of admission. We looked at length of hospital stay and waiting period for each severity of illness in patients who were discharged alive.
Scale data is expressed as median (25th-75th percentile) and categorical data as number (percentage). Group comparisons were made using the Jonckheere-Terpstra test or the Mann-Whitney U test for scale data and the chi-square test for categorical data, with P
This study was approved by the Chiba Emergency Medical Center Institutional Review Board (October 11, 2021). This research was conducted in accordance with the Declaration of Helsinki and relevant guidelines/regulations. Informed consent was withdrawn by the ethics committee.