Definitions and Treatment
Fever was defined as an axillary temperature of 37.3°C or higher. Positive endotracheal aspirate or lower respiratory tract sputum culture with signs and symptoms of bacteremia or pneumonia was considered secondary bacterial infection. Treatment of patients diagnosed as having ventilator-associated or hospital-acquired pneumonia was planned based on available guidelines. Diagnosis and grading of acute respiratory distress syndrome (ARDS) was done according to Berlin 2015 diagnostic criteria. If the patients’ daily cardiac-specific troponin level was above normal, echocardiography was performed to evaluate for the development of new cardiac pathologies. Coagulopathy was defined as a prothrombin time more than 3 seconds higher than normal and partial thromboplastin time 5 seconds higher than normal. Treatment strategies were implemented according to the Turkish Ministry of Health COVID-19 Adult Diagnosis and Treatment guidelines based on the patients’ disease severity. Patients were monitored for MAS in the presence of signs such as persistent fever, persistently high or increasing CRP and ferritin levels, elevated D-dimer levels, lymphopenia/thrombocytopenia, deterioration in liver function tests, hypofibrinogenemia, and increasing triglyceride levels despite treatment. Patients with successive increases in daily measurements of these parameters which could not be explained by secondary bacterial infections were administered 400 mg of tocilizumab for MAS if they had no contraindications. In patients who showed appropriate clinical and laboratory response after 24 hours, treatment was not continued. However, if an appropriate clinical and laboratory response was not observed, treatment was repeated at the same dosage.