Critical care ultrasonography during COVID‐19 pandemic: The ORACLE protocol

TLDR

COVID‑19 causes severe lung involvement and hemodynamic changes, and critical‑care ultrasonography provides real‑time diagnostic and therapeutic information, yet no protocols for image acquisition and measurement had been evaluated before this study. The study aimed to evaluate the ORACLE protocol for structured cardiac and pulmonary ultrasonographic assessment in critically ill COVID‑19 patients. The authors performed cardiac and pulmonary ultrasonography on 82 consecutive critically ill COVID‑19 patients using the ORACLE protocol, a structured imaging workflow designed to reduce staff exposure. The protocol revealed frequent right‑ventricular strain (elevated pulmonary artery systolic pressure in 69.5%, E/e′ > 14 in 29.3%, RV dilatation in 28%, dysfunction in 26.8%), a high fluid‑responsiveness rate (82.9%), and that elevated pulmonary artery systolic pressure correlated with increased in‑hospital mortality, while the ORACLE protocol proved feasible, rapid, and safe.

Abstract

Coronavirus disease 2019 (COVID-19) is characterized by severe lung involvement and hemodynamic alterations. Critical care ultrasonography is vital because it provides real time information for diagnosis and treatment. Suggested protocols for image acquisition and measurements have not yet been evaluated.This cross-sectional study was conducted at two centers from 1 April 2020 to 30 May 2020 in adult patients with confirmed COVID-19 infection admitted to the critical care unit. Cardiac and pulmonary evaluations were performed using the ORACLE protocol, specifically designed for this study, to ensure a structured process of image acquisition and limit staff exposure to the infection.Eighty-two consecutively admitted patients were evaluated. Most of the patients were males, with a median age of 56 years, and the most frequent comorbidities were hypertension and type 2 diabetes, and 25% of the patients had severe acute respiratory distress syndrome. The most frequent ultrasonographic findings were elevated pulmonary artery systolic pressure (69.5%), E/e' ratio > 14 (29.3%), and right ventricular dilatation (28%) and dysfunction (26.8%). A high rate of fluid responsiveness (82.9%) was observed. The median score (19 points) on pulmonary ultrasound did not reveal any variation between the groups. Elevated pulmonary artery systolic pressure was associated with higher in-hospital mortality.The ORACLE protocol was a feasible, rapid, and safe bedside tool for hemodynamic and respiratory evaluation of patients with COVID-19. Further studies should be performed on the alteration in pulmonary hemodynamics and right ventricular function and its relationship with outcomes.