Intenzivno liječenje bolesnika s Covid-19

master's thesis

• Title (english): Critical care treatment of patients with Covid-19
• Author: Matej Cindrić
• Mentor: Dinko Tonković (mentor)
• Committee member: Daniela Bandić Pavlović (predsjednik povjerenstva)
• Committee member: Slobodan Mihaljević (član povjerenstva)
• Committee member: Dinko Tonković (član povjerenstva)
• Granter: University of Zagreb; School of Medicine; (Cabinet for First Aid); Zagreb
• Defense date and country: 2022-07-15, Croatia
• Scientific / art field, discipline and subdiscipline: BIOMEDICINE AND HEALTHCARE; Clinical Medical Sciences; Intensive Care

Abstract

Intenzivno liječenje COVID-19 pacijenata obuhvaća veliki spektar intenzivne medicine. Pregledom novijih znanstvenih radova i metaanaliza napisan je ovaj rad s najažurnijim podacima o modalitetima intenzivnog liječenja teško i kritično teško bolesnih COVID-19 pacijenata. Obuhvaća ponajprije patofiziologiju te oblike upale pluća COVID-a-19 radi boljeg razumijevanja primjene ventilacijskih strategija. Teška upala pluća s ARDS-om zahtijevat će neinvazivne respiratorne podrške (HFNC i NIV) ili vrlo vjerojatnije invazivnu mehaničku ventilaciju. Od neinvazivne respiratorne podrške više se pažnje pridodaje HFNC-u iako obje tehnike i HFNC i NIV imaju svoje prednosti i nedostatke. Invazivna mehanička ventilacija mora biti jasno prilagođena i titrirana pacijentima s obzirom na njihovo upalno stanje u plućima. Iako se u početku mislilo da je COVID-19 ARDS jednak kao i ARDS svake druge etiologije, nisu svi pacijenti jednaki te predstavljaju jednu vrlo heterogenu skupinu bolesnika s posebnim osvrtom na liječenje L i H tipa pneumonije. Odluka o intubaciji, iako se čini jednostavna, potrebno ju je donijeti proaktivno kako bi se spriječilo pacijentom samonaneseno oštećenje pluća (P-SILI). Pored ventiliranja plućno protektivnim strategijama, bitno je pacijente položiti u pronacijski položaj tijekom većine dana s obzirom da ono donosi vrlo značajna poboljšanja preživljenja. Primjena antiviralnih lijekova poput remdesivira u zadnjim metaanalizama ne donosi obećavajuće rezultate, ali primjena kortikosteroida zajedno s remdesivirom pokazuje značajno smanjenje mortaliteta. Isto tako nije isto primjenjuje li se deksametazon ili metilprednizolom s obzirom da posljednji bolje prodire u pluća te pokazuje još niži mortalitet od klasičnog deksametazona. Isto tako primjena JAK inhibitora i antagonista IL-6 receptora pokazuje značajno smanjenje mortaliteta i progresije na mehaničku ventilaciju. S obzirom da je COVID-19 protrombogena bolest preporuča se profilaktična primjena antikoagulantne terapije. Potrebno je praćenje srčane i renalne funkcije s obzirom da su to druga dva najpogođenija organa u COVID-u-19, pored upale pluća. Svaki pacijent mora biti pravilno analgosediran, dok je primjena neuromuskularne blokade ograničena. Za najteže, ali mlađe pacijente rezerviran je ECMO i „ultra protektivna“ ventilacija pluća.

Abstract (english)

Critical care treatment of COVID-19 patients comprises a broad spectrum of intensive care medicine. This paper was written after searching for newest research papers and meta-analyses containing most updated data about modalities of intensive care and care of criticaly ill COVID-19 patients. First of all it includes pathophysiology and types of COVID pneumonias for better understanding ventiltation strategies. Severe pneumonia with ARDS will require non-invasive respiratory support (HFNC and NIV) or most likely invasive mechanical ventilation. While talking about non-invasive respiratory support more attention is added to HFNC although both tehniques NIV and HFNC have their advantages and disadvantages. Invasive mechanical ventilation must be clearly tapered and titrated to patients considering their inflammatory condition in the lungs. Although at the beginning it was thought that COVID-19 ARDS was the same as ARDS of any other etiology, not all patients are equal and they present a very heterogeneic group of patients with a special consideration on treatment of L and H types of pneumonias. Intubation decision, although seemed simple, must be made proactively so to prevent patient self-inflicted lung injury (P-SILI). Except lung protective ventilation strategies, it is important to prone position the patients throughout most of the day considering it benefits a very significant survival improvement. In latest meta-analyses application of antiviral medication such as remdesivire does not bring promising results, but application of corticosteroids along with remdesivire shows a significant mortality reduction. Also it is not the same whether dexamethasone or metilprednisolone is applied since the last one penetrates the lungs more efficiently and hence has an even lower mortality rate then dexamethasone. Also application of JAK inhibitors and IL-6 receptor antagonists shows significant reduction in mortality and progression to mechanical ventilation. Considering COVID-19 is a prothrombogenic disease a profilactic dose of anticoagulation medication is recommended. Cardiac and renal function monitoring is needed since they are the second two most affected organs in COVID-19, besides pneumonia. Every patient must be properly analgosedated, while application of neuromuscular blockade is limited. For the most severe, but younger patients ECMO with it's „ultra lung-protective“ ventilation is reserved.

• Keywords: COVID-19; intezivno liječenje
• Keywords (english): COVID-19; critical care
• Language: croatian
• URN:NBN: urn:nbn:hr:105:231952
• Study programme: Title: Medicine; Study programme type: university; Study level: integrated undergraduate and graduate; Academic / professional title: doktor/doktorica medicine (doktor/doktorica medicine)
• Type of resource: Text
• File origin: Born digital
• Access conditions: Open access
• Created on: 2023-01-04 10:56:04