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Evidence Check - Symptoms, diagnosis and treatment

Asymptomatic, disease progression, ambulance, drugs, community, hospitalisation, recovery, palliative care, death.

Vascular dysfunction and COVID-19 evidence check

Added: 5 Aug 2020

What are the symptoms and incidence for vascular events in patients with COVID-19?
  • Thrombotic vasculopathy - A systematic review of 11 studies including 1,765 COVID-19 positive patients reported the occurrence of venous thromboembolism (VTE) in approximately 20% of patients.
  • Cerebrovascular manifestations - A systematic review has reported occurrence of stroke in 3.5% of patients based on a pooled analysis of five studies including 973 patients. Many patients with cerebrovascular complications have cerebrovascular risk factors, such as hypertension, diabetes mellitus, hyperlipidaemia, high BMI, smoking or previous stroke history.
  • Systemic vasculitis - An association between COVID-19 infection and novel paediatric vasculitis, named later as multisystem inflammatory syndrome in children (MIS-C) has not yet been established, due to inconsistent testing of COVID-19, although it seems plausible, given the temporal association. In adults, the spectrum of complications following COVID-19 is broader than in children and includes autoimmune diseases, but their incidence is low. Case reports describe a wide range of clinical presentations of COVID-19 related to systemic vasculitis including cutaneous manifestations, and possible vascular involvement in remote tissues.
  • Neurovascular involvement - In a retrospective study of 214 patients with COVID-19, neurologic symptoms were seen in 36% of patients and were more common in patients with severe infection. Apart from cerebrovascular disease and impaired consciousness, most neurologic manifestations occurred early in the illness. Involvement of vascular endothelium in hyperinflammatory pro-thrombotic state has been proposed as a possible mechanism for neurologic manifestations in patients with severe COVID-19.

Risks associated with surgery in people with COVID-19 evidence check

Added: 20 Jul 2020

Are patients with COVID-19 or who have previously had COVID-19 at risk of adverse post-operative outcomes? If so, what is the duration of the heightened risk?
  • There were no studies reporting empirical data on recovered COVID-19 patients undergoing surgery. One study reported recommendations without data, advising to follow the precautionary principle and undertake the same precautions in the operating room as for a confirmed patient.
  • The main surgical outcomes reported in literature for COVID-19 patients were clinical complications from surgery (e.g. pulmonary, thrombotic), including COVID-19 specific ICU admission requiring post-operative supplemental oxygenation, the impact on length of hospital stay and death (i.e. 30 day mortality)
  • Studies have reported the risk factors that are associated with adverse surgical outcomes in COVID-19 patients undergoing surgery which include, age (e.g. being 70 years or older), being male, positive smoking status, presence of multi- and co-morbidities, having cancer surgery, needing emergency surgery and needing major surgery.
  • Researchers from the COVIDSurg Collaborative conducted an international, multicentre, cohort at 235 hospitals in 24 countries, which included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The analysis included 1,128 patients, who had surgery between January and March 2020. The authors found that post-operative pulmonary complications occurred in half of the patients with perioperative SARS-CoV-2 infection (577 of 1128, 51.2%). The infection was also associated with high mortality, with the 30 day mortality of 38.0% (219 of 577) in these patients, accounting for 81.7% (219 of 268) of all deaths.
  • Based on their findings, authors from the studies included in this evidence check advise the following: Testing and appropriate diagnosis of all patients before surgical treatment to determine COVID-19 status, especially as it is difficult to distinguish between non-COVID-19, asymptomatic, or pre-symptomatic cases. To balance the increased risks associated with SARS-CoV-2 infection against the risks of delaying surgery in individual patients. Rapid evidence checks are based on a simplified review method and may not be entirely exhaustive, but aim to provide a balanced assessment of what is already known about a specific problem or issue. This brief has not been peer-reviewed and should not be a substitute for individual clinical judgement, nor is it an endorsed position of NSW Health. COVID-19 Critical Intelligence Unit 20 July 2020 To consider postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery in COVID-19 patients. This is recommended especially for those with increased vulnerability for adverse outcomes, including elderly patients and those with comorbidities, and in various types of surgeries and procedures, including: adjuvant chemotherapy or elective surgery for stable cancer thoracic operations urological surgery orthopaedic surgery neurosurgery.
  • Only one study reported that patients with asymptomatic or mild COVID-19 infection can safely undergo early surgical intervention for hip fracture after appropriate medical optimisation.

Computed tomography use during the COVID-19 pandemic evidence check

Added: 4 Jun 2020

What is evidence for the use of computed tomography (CT) in patients with COVID-19?
2. What alternative imaging/diagnostics are being used if CT is not recommended?
  • Articles published early in the pandemic described the use of CT as a primary or adjunct technique for diagnosing COVID-19. More recently, practice has moved away from the use of CT for primary diagnosis due to poor utility and safety concerns.
  • Practice varies in the use of CT on patients with COVID-19. According to five large systematic reviews, CT has been used to identify various lung complications, including round-glass opacity, bilateral compromise, unilateral compromise, peripheral distribution, multilobular involvement and consolidation.
  • There are no comparative diagnostic imaging studies, no comparative effectiveness research, nor health technology assessments comparing CT with another technique for diagnosing COVID-19.

Large vessel occlusion strokes in COVID-19 patients evidence check

Added: 27 May 2020

Is there evidence of large vessel occlusion stroke in patients with COVID-19?
Are stroke patients with COVID-19 more likely to bleed post alteplase (tPA)?
  • Small series of stroke in COVID-19 patients have been reported: o A letter in the New England Journal of Medicine (NEJM) featured five COVID-19 positive cases of new-onset symptoms of large-vessel stroke in patients younger than 50 years of age, who presented to a New York health system over a two-week period. o A letter in the British Medical Journal (BMJ) describes six consecutive cases of acute ischaemic stroke and COVID-19, all of which had large-vessel occlusion (LVO). o An article published in Brain, Behaviour and Immunity identified four patients with acute stroke and COVID-19 in New York, including two with LVO.
  • Other case series have reported acute ischaemic stroke in patients with COVID-19 suggesting neurological manifestation of COVID-19. In two of these cases, patients had severe COVID-19 infections.
  • A single case report of administration of intravenous rt-PA to an ischemic stroke COVID-19 positive patient has been published, with no bleeding reported.
  • Other than this case report, there are no studies in stroke patients with COVID-19 looking at outcomes post alteplase treatment.
  • Guidance for stroke patients with COVID-19 state that despite the concern of impaired recombinant tissue plasminogen activator (rt-PA) hepatic clearance, no data are available to suggest a greater risk or benefit with intravenous rt-PA.

Renal replacement therapies for COVID-19 positive patients in ICU evidence check

Added: 12 May 2020
Updated: 20 May 2020

What is the current evidence on the use of renal replacement therapies in intensive care units for patients with COVID-19?
  • COVID-19 most frequently presents as mild respiratory illness and can generally be managed outside the hospital. About 20% of patients require hospitalisation, and of those, a quarter require intensive care.
  • ICU patients typically require management of hypoxaemic respiratory failure or hypotension requiring vasopressor support. Acute kidney injury is a less common complication but is associated with a significant risk for mortality.
  • Available data suggests that the prevalence of acute kidney injury in COVID-19 patients is around 3-9% and is more common in patients with severe disease, reported in up to 30% of critically ill or deceased patients.

Immunosuppression and COVID-19 evidence check

Added: 30 Apr 2020
Updated: 19 May 2020

What is the evidence for the risk and management of people with immunosuppression and COVID-19?
  • A systematic review showed that people with immunosuppression showed favourable disease course when compared to the general population. Cancer patients experienced more severe COVID-19 infections but did not necessarily have a poor prognosis. The review is subject to bias due to the limited number of included papers and small sample size.
  • Additional small case series suggest that patients with immunosuppression generally have similar risk profiles to the general population in terms of COVID-19 outcomes and severity, however patients with cancer have been shown in some studies to have more severe disease. Results for transplant patients regarding disease severity varies and is based on small numbers.
  • People with cancer provide the majority of the evidence on immunosuppression during COVID- 19. Expert opinion varies on whether cancer patients with a diagnosis of COVID-19 should continue cancer treatment. However there is agreement that decisions should be based on balancing risks and benefits of treatment in the context of the pandemic and infection control principles.
  • A systematic review showed that there is no definitive evidence that specific cytotoxic drugs, low-dose methotrexate for autoimmune disease, NSAIDs, Janus kinase (JAK) kinase inhibitors or anti-TNF╬▒ agents are contraindicated in people with COVID-19.
  • The National Institute for Health and Care Excellence (NICE) recommends continuing systemic anticancer treatment only if it is needed for urgent control of the cancer, and if possible, defer treatment until the patient has at least one negative test for COVID-19.
  • NICE have also released guidance on children and young people who are immunocompromised with COVID-19.

NIPPV and requirements evidence check

Added: 11 May 2020
Updated: 14 May 2020

Has the increasing use of NIPPV to manage suspected or confirmed COVID-19 patients led to any additional guidance regarding the physical requirements and engineering services (e.g. negative pressure rooms or where positive pressure rooms vent to)?
  • In negative pressure rooms, consider using NIV therapy for patients with hypoxaemia associated with COVID-19, ensuring it is used with caution and strict attention is paid to staff safety.
  • In single rooms or shared ward spaces with a cohort of confirmed COVID-19 patients only, consider using NIV therapy for patients with hypoxaemia associated with COVID-19, ensuring it is used with caution and strict attention is paid to staff safety.
  • In shared wards or emergency department cubicles, do not use NIV therapy for patients with hypoxaemia associated with COVID-19.
  • During inter-hospital patient transfer and/or retrieval, do not use NIV therapy for patients with hypoxaemia associated with COVID-19.
  • In patients with COVID-19 who are deteriorating, consider endotracheal intubation and invasive mechanical ventilation. In patients with COVID-19 for whom NIV is appropriate for an alternate clinical presentation (e.g. concomitant chronic obstructive pulmonary disease with type 2 respiratory failure and hypercapnoea), ensure airborne and other infection control precautions are optimised.
  • In adults with COVID-19 on high-level respiratory support, monitor for worsening respiratory status. If worsening occurs, undertake early in the disease course endotracheal intubation in a controlled setting. Patients can deteriorate rapidly 5-10 days after symptom onset.

Fibrinolysis and PCI for STEMI evidence check

Added: 8 May 2020
Updated: 12 May 2020

What is the evidence for fibrinolysis versus primary percutaneous coronary intervention in the treatment of ST-Elevation Myocardial Infarction (STEMI)?
Is there evidence for safety and efficacy of tenecteplase use as fibrinolytic to treat STEMI?
What are the current models of care for treatment of STEMI in COVID-19 and non-COVID-19 patient population during the current pandemic?
  • It is well established that most patients with acute STEMI benefit from reperfusion therapy.(
  • Primary PCI has been shown to achieve better outcomes than fibrinolysis. Better outcomes are achieved when PCI is performed within 90 minutes of first medical contact.
  • When timely PCI cannot be performed, fibrinolysis is indicated in STEMI patients whose onset of ischaemic symptoms were within the previous 12 hours.
  • Primary PCI may be preferred for some patients even when the procedure cannot be performed in a timely manner. This includes patients at high risk of bleeding and those in cardiogenic shock.
  • Fibrinolytic agents include streptokinase, alteplase, reteplase, and tenecteplase. Tenecteplase has a lower rate of non-cerebral bleeding events and is given as a single bolus and is often the preferred agent.

Daily Evidence Digest

Rapid evidence checks are based on a simplified review method and may not be entirely exhaustive, but aim to provide a balanced assessment of what is already known about a specific problem or issue. This brief has not been peer-reviewed and should not be a substitute for individual clinical judgement, nor is it an endorsed position of NSW Health.

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