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.