Application Of Point-of-care Ultrasound In Covid-19 Patients With Multi-organ Injury

At the end of 2019,Coronavirus Disease 2019(COVID-19)was first reported in Wuhan and quickly spread to other parts of the country and the world,causing a global public health crisis.Based on the analysis of the pathogenesis,epidemiology and clinical characteristics of COVID-19,researchers generally believe that the disease is a complex disease that can affect multiple organs and systems throughout the body.In addition to respiratory infection and acute respiratory distress syndrome,There are also a significant proportion of patients with acute liver injury,heart injury,coagulation dysfunction,acute kidney injury,nervous system injury or testicular injury and other lesions.Point-of-care Ultrasound(PoCUS)is considered to be the most suitable imaging diagnostic tool in COVID-19 isolation wards due to the necessity to reduce the transfer of COVID-19 patients within the wards and the limitations of CT examinations application.This research project under the approval of the hospital ethics committee,applies PoCUS in COVID-19 patients to assess the pulmonary and extra-pulmonary organs(heart,kidney and testis)damage,summarize the ultrasonic imaging manifestation and characteristics,and evaluate the accuracy and practicability of the PoCUS.This study includes the following four parts.Part 1 Application of PoCUS in the assessment of lung injury in patients with severe COVID-19Objective: Apply the PoCUS to evaluate the pulmonary lesions of patients with severe COVID-19,The characteristics and semi-quantitative score method were summarized to analyze the accuracy of Lung ultrasonography(LUS).Methods: LUS and chest CT manifestations and semi-quantitative scores of 128 severe COVID-19 patients were retrospectively analyzed to summarize the characteristic manifestations of LUS.The accuracy of LUS was evaluated by reviewing the image data to obtain LUS and CT scores and analyzing the correlation between the two.The critical point of LUS score was obtained by ROC curve to distinguish severe patients from critically ill patients.The accuracy of LUS in the follow-up of COVID-19 lung disease was evaluated by comparing the correlation between LUS and CT scores in 72 patients.Results: 1)The most common abnormal manifestations on the sonogram of COVID-19 pulmonary disease were b-line crowding or aggregation,and multifocal patchy consolidation;2)There was a high correlation between LUS score and CT score(r = 0.891,P <0.01),the average LUS score was 8.1 in the critical group and15.7 in the critical group(P & LT;0.05);3)The ROC showed a sensitivity of 97.4%and specificity of 75.0% for the diagnosis of critical COVID-19 when LUS was higher than 10.5;4)The consistency between LUS and chest CT was 0.596 when the lung lesions were followed up,and the diagnostic consistency was higher for patients with progressive lesions(Kappa value 0.774).Conclusions: LUS patients with severe COVID-19 have characteristic pneumonia sonographic manifestations,and semi-quantitative scoring method can accurately assess lung disease,and be used for disease classification and follow-up.PoCUS is a reliable diagnostic tool for lung imaging in COVID-19 isolation areas,with incomparable advantages over CT.Part 2 Application of PoCUS in the assessment of heart injury in patients with COVID-19Objective: PoCUS was used to evaluate the cardiac structure and function of COVID-19 patients,and to explore the relationship between COVID-19 and myocarditis or myocardial injury in combination with changes of related cardiac markers.Methods: Clinical data and outcomes of hospitalized patients with COVID-19 were retrospectively analyzed,focusing on Ultrasonic Cardiogram(UCG),myocardial biomarkers and Electrocardiograph(ECG).To analyze the incidence and characteristics of abnormal UCG manifestations in COVID-19 patients;Using increased myocardial enzyme profile as the standard,we analyzed whether there were typical UCG/ECG changes in patients with potential myocardial injury.The abnormal manifestations of EGC,myocardial enzymogram and electrocardiogram in patients who died were analyzed to evaluate whether the related indicators could be used to judge the risk of adverse outcomes.Results: 1)A total of 112 COVID-19 patients were included in this study,and 45patients(40.2%)had at least one abnormal UCG presentation,The most common symptoms were pericardial effusion(19.6%),pulmonary hypertension(13.4%)and the decline of Left ventricular ejection fraction(LVEF)(5.6%).The incidence of abnormal UCG manifestations was higher in the severe group than in the milder group(34[50.7%] vs 11[24.4%],p<0.001);2)14 patients(12.5%)with more than three-fold increase in c Tn I level were considered as suspected myocardial injury,including 12 patients with abnormal UCG features and 4 patients with abnormal ECG features.3)At least one UCG abnormality was found in all 14 patients who died of COVID-19,with increased significantly abnormal levels of c Tn I and BNP in the week before death,and COX analysis showed a relatively high risk ratio.Conclusions: There is a possibility of myocardial injury/myocarditis in patients with COVID-19.UCG plays an important clinical role in detecting morphological and functional changes of the heart in a timely manner,and abnormal increase of some indicators may be associated with poor prognosis of patients.Part 3 Application of PoCUS in the assessment of acute kinney injury in severe COVID-19 patientsObjective: Acute kidney injury(AKI)is one of the most common complications in patients with severe COVID-19,which greatly affects fluid management.In this study,PoCUS was used to evaluate the hemodynamic characteristics of these patients and analyze the predictive value of related indicators for the poor outcomes of patients.Methods: All clinical data of patients with severe COVID-19 and related hemodynamic indexes of kidney,heart and lung measured by PoCUS were retrospectively analyzed,and the outcome status(survival/death)of all patients after28 days were recorded.Patients were divided into AKI group and non-AKI group according to the serum creatinine elevation standard of Kidney Disease: Improving Global Outcomes(KDIGO).To analyze the incidence of abnormal renal sonography in COVID-19 patients and compare whether there is a difference between the two groups;The differences of hemodynamic indexes between the two groups were compared.The differences of major hemodynamic indexes among patients with different outcomes were analyzed and a Logistic regression equation model was established to predict the risk of adverse outcomes.Results: 1)A total of 45 patients with severe COVID-19 were included in this study.According to diagnostic criteria,21 patients(46.7%)were complicated with AKI,and the AKI group had a higher mortality rate;2)The Renal resistance Index(RRI)in the AKI group was higher than that in the non-AKI group.ROC analysis showed that RRI=0.725 could be used as the threshold of AKI diagnosis,and the sensitivity and specificity were 61.9% and 91.7%,respectively.The incidence of abnormal two-dimensional ultrasonography features of kidney was very low in all patients,and there was no significant difference between AKI groups.3)AKI group presented high incidence of decreased left ventricular ejection fraction(LVEF),high systolic pulmonary artery pressure(SPAP)and other abnormal hemodynamic indicators than that of non-AKI group.4)The incidence rate of RRI>0.70,LVEF<50% and SPAP>40mm Hg in the 28-day death group was significantly higher than that of the survival group,and the Logistic regression equation included RRI>0.70 and SPAP>40mm Hg could correctly predict the outcome status of 88.9%patients.The relative risks of RRI>0.70 and SPAP>40mm Hg were 9.429 and 9.909,respectively.Conclusions: Patients with severe COVID-19 complicated with AKI have a higher mortality rate.Although the two-dimensional ultrasonographic changes of kidney were not obvious in PoCUS examination,hemodynamic changes such as increased RRI,decreased LVEF,increased volume load and high pulmonary ultrasound score could be found,which were used to guide fluid management and treatment.In addition,the Logistic regression equation established by RRI and SPAP can effectively evaluate the probability of adverse outcomes in patients.Part 4 Application of PoCUS in acute testicular infection in COVID-19 patientsObjective: PoCUS was used to evaluate testicular and epididymis in male patients with COVID-19,to explore whether there were acute scrotal infection sonographic manifestations.Methods: Male hospitalized patients diagnosed with COVID-19 were examined by scrotal ultrasound beside the bed,focusing on the ultrasonographic changes related to acute scrotal infection,such as tunica albuginea thickening,enlargement and heterogeneous echogenicity of the testis,epididymis,or both,an abscess,scrotal wall edema,and hydrocele.The incidence of orchitis,epididymitis and testicular epididymitis was analyzed according to the diagnostic criteria,and the characteristics of the incidence in different age groups and mild/severe groups were analyzed.Results: 1)A total of 142 confirmed COVID-19 patients were included in this study,with 41.5% severe cases.There were 39 patients(27.5%)showed at least one ultrasonography feature related to acute scrotal inflammation during scrotal ultrasound examination.The incidence rate was higher with tunica albuginea thickening(36 cases [25.4%]),increased blood flow signal of testis/epididymis(32cases [22.5%])and enlargement and/or heterogeneous echogenicity of the testis,epididymis,or both(19 cases [13.4%]).2)A total of 32 patients(22.5%)met the criteria and were considered to have acute orchitis(10 cases),epididymitis(7 cases)or epididymo-orchitis(15 cases);3)The risk of acute scrotal infection increased with age.The incidence of acute scrotal infection was 53.3% in men over 80 years old.The incidence of acute scrotal infection in severe group was significantly higher than that in mild group(21 cases [35.6%] vs 11 cases [13.3%];P = 0.002).Conclusions: In this study,PoCUS was used to evaluate testicular and epididymis of hospitalized male COVID-19 patients and acute scrotal infection was confirmed,which also confirmed the speculation that SARS-COV-2 may damage the male reproductive system.In the treatment of COVID-19,clinicians should payd more attention to the multi-faceted application of PoCUS to reduce the missed diagnosis of extrapulmonary injury.