By Ahmad Abdussalam, MD, MRCP UK, neuro intensivist, UCNS Certified; Dana Bakdach, BSC, PharmD, clinical pharmacist; Sundus Sardar, MBBS, medical resident; Nadir Kharma, pulmonary critical care and sleep medicine; Ali Ait Hssain, MD, DESAR, ECMO consultant; Adel Royce Mangodato, senior RN; and Ashraf Molokhia, MD, consultant intensivist and anesthetist
In Qatar, the first case of COVID-19 was confirmed on Feb. 27, 2020. While the global death toll continues to climb, Qatar stands out with a low mortality rate of 0.14%, and 150 deaths to date.1
The state of Qatar is located in West Asia in the Arabian Peninsula, with a population of less than 3 million. It has invested in an excellent health service and had ranked in the top five worldwide in 2018 according to the UK-based Legatum Prosperity Index™.2 With more than three months into the uncharted territory of the COVID-19 pandemic, Qatar has risen to the challenge with innovative multidisciplinary strategies to navigate through this crisis.
Amidst the myriad clinical presentations of COVID-19, predominantly with respiratory, gastrointestinal, renal or cardiac involvement, recent emerging data on neurological manifestations of SARS-CoV-2 have incited significant interest. In patients exposed to SARS-CoV-2, approximately one-third may present with neurological manifestations, including dizziness, headache, impaired consciousness, acute cerebrovascular disease, ataxia, seizure, ageusia, hyposmia, anosmia, vision impairment, nerve pain and skeletal muscular injury manifestations.3 Stroke, cerebral venous thrombosis, encephalitis, Guillain-Barre syndrome, hemorrhagic necrotizing encephalitis, meningitis and epileptic seizures have also been reported.4
Our neurocritical care service was established in 2017, fully resourced with an on-site intensivist with continuous access to neuro-interventional radiologist, neurosurgeon, neurologist and a stroke service. We have 24/7 access to CTs (including CT perfusion with RAPID software), MRIs and portable video EEG. We have established structured training program for our neurocritical residents, fellows and critical care nurses. Additionally, we have started introducing Emergency Neurological Life Support (ENLS) and Neurocritical Care Society (NCS) guidelines. The above expertise, resources and training have enabled us to manage all neurocritical care complication of COVID-19 expeditiously.
Similar to the other human coronaviruses (MERS-CoV and SARS-CoV), definitive antiviral therapy against 2019-nCoV has not yet been identified.5 Hence, besides early supportive care, the management of severe life-threatening cases relies heavily on implementing the standards of intensive care management (eg, adequate analgosedation, early protective ventilation, etc.) along with utilization of evidence-based therapies to treat the underlying pathology.
In our center, the protocol of managing critically ill COVID-19 patients is continuously being reviewed and updated to reflect the available evidence. Alongside supportive and standard intensive care support, drugs targeting different viral structures and functions have been prescribed (including lopinavir/ritonavir, ribavirin, interferons and others). The early use of immunomodulators (including steroids or tocilizumab) have been advocated yet the decision has been left to the discretion of the treating physician based on the individual case scenario. Finally, convalescent plasma therapy was recently introduced and is utilized in some severe cases as an alternative.
Throughout their ICU stay, similar to previous publications6, we have noticed several pulmonary complications among COVID-19 patients, including pulmonary embolism, ARDS, pneumonia, pulmonary hypertension, spontaneous pneumothorax and pneumomediastinum. The majority of patients who develop pneumothorax seem to be healthy at baseline with no comorbid conditions. Many of them developed spontaneous pneumothorax, following the use of invasive or non-invasive positive pressure ventilation (PPV).
Mainly due to respiratory complications of COVID-19, our referrals for extracorporeal membrane oxygenations (ECMO) have jumped by almost six-fold. Despite revising our usual criteria for a more conservative approach, we increased our ECMO capacity to more than 200%. Expedited training was organized for three different ECMO devices and physician and nursing rotas were amended to meet the patient demand. During these longer than usual ECMO runs, we saw several pregnant patients, a high number of pneumothoraces, pulmonary embolisms and patients requiring support by VA ECMO.
COVID-19 is well known for a high incidence of thrombotic events, including pulmonary embolism and myocardial injury. A D-dimer level greater than 1 μg/mL has been identified as a risk factor for poor outcomes in COVID-19 patients.7,8 Despite all patients in our ICUs being treated with at least an intermediate dose of anticoagulation if the D-dimer level exceeded 1.2 μg/mL, and high risk patients with acute worsening in oxygenation, dead space or rapid rise in D-dimer (>5 folds in 48 hours) are started on a therapeutic anticoagulation regimen, the authors have seen several patients with pulmonary embolism among COVID-19 patients in ICUs in Qatar.
Similar to healthcare systems across the world, staffing requirements to meet the surge of patients has been challenging in Qatar. To meet the extraordinary challenges created by the COVID-19 pandemic, our dedicated healthcare team came together in the spirit of commitment and solidarity, with a shared sense of purpose that has strengthened the entire healthcare team. Coping strategies including lifestyle modifications, and psychological adjustments were introduced to deal with the added stress of wearing restrictive personal protective equipment (PPE) for long periods.
We have worked in new environments and integrated harmoniously with new teams sharing a common goal of protecting and treating our patients. Our multidisciplinary team have continued to innovate, research and update our therapeutic strategies to play a crucial role in fighting the pandemic that has left no place on earth untouched.
- WORLDOMETERS 2020. COVID-19 CORONAVIRUS PANDEMIC- Coronavirus Update (Live) (https://www.worldometers.info/coronavirus/) [Accessed 15th July 2020].
- Legatum Institute. The Legatum Prosperity Index 2018, 12th (https://li.com/wp-content/uploads/2018/11/2018_Prosperity_Index.pdf)
- Mao L, Wang M, Chen S, et al. Neurological manifestations of hospitalized patients with COVID-19 in Wuhan, China: a retrospective case series study. MedRxiv. 2020 (https://www.medrxiv.org/content/10.1101/2020.02.22.20026500v1) (preprint)
- Carod-Artal FJ. Neurological complications of coronavirus and COVID-19. Revista de Neurologia 2020;70(9):311-322.
- Li L, Li R, Wu Z, et al. Therapeutic strategies for critically ill patients with COVID-19. Ann Intensive Care 2020;10(1):45.
- Wang W, Gao R, Zheng Y, Jiang L. COVID-19 with spontaneous pneumothorax, pneumomediastinum and subcutaneous emphysema. J Travel Med 2020 April 25 (online ahead of print).
- Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J. Thromb. Haemost 2020; 18: 844–847.
- Klok FA, Kruip MJHA, van der Meer NJM, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res 2020; 191:145-147.