Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.
IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy.
Crit Care. 2021 Mar 19;25(1):111. doi: 10.1186/s13054-021-03537-1.
In COVID-19 patients with acute respiratory distress syndrome (ARDS), the effectiveness of ventilatory rescue strategies remains uncertain, with controversial efficacy on systemic oxygenation and no data available regarding cerebral oxygenation and hemodynamics.
This is a prospective observational study conducted at San Martino Policlinico Hospital, Genoa, Italy. We included adult COVID-19 patients who underwent at least one of the following rescue therapies: recruitment maneuvers (RMs), prone positioning (PP), inhaled nitric oxide (iNO), and extracorporeal carbon dioxide (CO) removal (ECCOR). Arterial blood gas values (oxygen saturation [SpO], partial pressure of oxygen [PaO] and of carbon dioxide [PaCO]) and cerebral oxygenation (rSO) were analyzed before (T0) and after (T1) the use of any of the aforementioned rescue therapies. The primary aim was to assess the early effects of different ventilatory rescue therapies on systemic and cerebral oxygenation. The secondary aim was to evaluate the correlation between systemic and cerebral oxygenation in COVID-19 patients.
Forty-five rescue therapies were performed in 22 patients. The median [interquartile range] age of the population was 62 [57-69] years, and 18/22 [82%] were male. After RMs, no significant changes were observed in systemic PaO and PaCO values, but cerebral oxygenation decreased significantly (52 [51-54]% vs. 49 [47-50]%, p < 0.001). After PP, a significant increase was observed in PaO (from 62 [56-71] to 82 [76-87] mmHg, p = 0.005) and rSO (from 53 [52-54]% to 60 [59-64]%, p = 0.005). The use of iNO increased PaO (from 65 [67-73] to 72 [67-73] mmHg, p = 0.015) and rSO (from 53 [51-56]% to 57 [55-59]%, p = 0.007). The use of ECCOR decreased PaO (from 75 [75-79] to 64 [60-70] mmHg, p = 0.009), with reduction of rSO values (59 [56-65]% vs. 56 [53-62]%, p = 0.002). In the whole population, a significant relationship was found between SpO and rSO (R = 0.62, p < 0.001) and between PaO and rSO (R0 0.54, p < 0.001).
Rescue therapies exert specific pathophysiological mechanisms, resulting in different effects on systemic and cerebral oxygenation in critically ill COVID-19 patients with ARDS. Cerebral and systemic oxygenation are correlated. The choice of rescue strategy to be adopted should take into account both lung and brain needs. Registration The study protocol was approved by the ethics review board (Comitato Etico Regione Liguria, protocol n. CER Liguria: 23/2020).
在 COVID-19 并发急性呼吸窘迫综合征（ARDS）的患者中，通气抢救策略的有效性仍不确定，其对全身氧合的疗效存在争议，且目前尚无关于脑氧合和血液动力学的数据。
这是一项在意大利热那亚 San Martino 综合医院进行的前瞻性观察性研究。我们纳入了至少接受过以下抢救治疗之一的成年 COVID-19 患者：复张手法（RM）、俯卧位（PP）、吸入一氧化氮（iNO）和体外二氧化碳去除（ECCOR）。在使用上述抢救治疗之前（T0）和之后（T1），分析动脉血气值（氧饱和度[SpO2]、氧分压[PaO]和二氧化碳分压[PaCO]）和脑氧合（rSO）。主要目的是评估不同通气抢救疗法对全身和脑氧合的早期影响。次要目的是评估 COVID-19 患者的全身和脑氧合之间的相关性。
22 例患者共进行了 45 次抢救治疗。人群的中位[四分位数范围]年龄为 62[57-69]岁，18/22[82%]为男性。RM 后，全身 PaO 和 PaCO 值无明显变化，但脑氧合明显下降（52[51-54]% vs. 49[47-50]%，p<0.001）。PP 后，PaO 显著增加（从 62[56-71]增加至 82[76-87]mmHg，p=0.005），rSO 也显著增加（从 53[52-54]%增加至 60[59-64]%，p=0.005）。iNO 的使用增加了 PaO（从 65[67-73]增加至 72[67-73]mmHg，p=0.015）和 rSO（从 53[51-56]%增加至 57[55-59]%，p=0.007）。ECCOR 的使用降低了 PaO（从 75[75-79]降低至 64[60-70]mmHg，p=0.009），同时 rSO 值降低（59[56-65]% vs. 56[53-62]%，p=0.002）。在整个人群中，SpO2 和 rSO2 之间存在显著相关性（R=0.62，p<0.001），PaO2 和 rSO2 之间也存在显著相关性（R=0.54，p<0.001）。
抢救疗法发挥了特定的病理生理机制，对 COVID-19 并发 ARDS 的危重症患者的全身和脑氧合产生了不同的影响。脑和全身氧合是相关的。应根据肺部和脑部的需求选择抢救策略。本研究方案已获得伦理审查委员会的批准（伦巴第大区伦理委员会，协议编号：CER Liguria：23/2020）。
