ABSTRACT
Introduction: As further studies elucidate the extent of organ systems affected by COVID-19, extra-pulmonary involvement is emerging as an important contributor to its morbidity and lethality. Beta-islet cells in the pancreas have been shown to be affected by COVID-19 via ACE2 and TMPRSS2 receptors. Accordingly, diabetes mellitus (DM) has not only been described as an independent risk factor for severe COVID-19, but there is also an association between new-onset DM (NODM) and diabetic ketoacidosis (DKA) with COVID-19. This case report discusses a patient with NODM presenting with DKA precipitated by COVID-19. Case Summary: A 45-year-old male with no past medical history who emigrated from India in March 2020 presented to the emergency department with five days of dyspnea, chills, fatigue, polyuria, and polydipsia. He was COVID-19 PCR-positive while his labs were remarkable for WBC 14, sodium 126, bicarbonate 2, glucose 350, anion gap 33, pH 6.95, pCO2 26, lactate 4.4, D-dimer 479, LDH 350, Ferritin 2381, Procalcitonin 1.13, HIV negative, and significant ketonuria. Chest x-ray revealed bilateral lower lobe patchy infiltrates consistent with COVID-19. He was started on an insulin drip, therapeutic Enoxaparin, and fluid resuscitation. He did not require supplemental oxygen and was not treated with steroids or antivirals. He was transitioned to subcutaneous insulin after one day. He was discharged after an uncomplicated five-day hospital stay. Discussion: There has been an increasing number of reports describing DKA precipitated by COVID-19 in patients with NODM, though our patient presentation is unique because he had a mild COVID-19 course that precipitated severe DKA. This case indicates a more direct role of COVID-19 damaging beta-cells in the pancreas as our patient remained on insulin and no other diabetic medications at discharge and after follow-up, indicating a complete reliance on exogenous insulin and failure of the pancreas to produce insulin seen with type-1 DM. The patient's HbA1c of 13.3 indicates a chronic state of DM, though COVID-19 certainly contributed to establishing NODM and DKA likely by wiping the remaining function of the Beta-cells in the pancreas. This uncommon case presentation demonstrates that even mild COVID-19 can induce DKA, so it is imperative that further research be conducted on its mechanism and prevention in the future.
ABSTRACT
RATIONALE As of August 22, 2020 a total of 5,477 COVID-19 positive cases were identified at Elmhurst Hospital Center (EHC), New York, highlighting it as one of the earliest and hardest hit systems globally. Unraveling the COVID-19 pathophysiology remains slow alongside recommendations against autopsies.(1) Eventually COVID 19 placentas with micro-thrombi were identified,(2) as were autopsy confirmed thrombosis of small to mid sized pulmonary vessels with viral inclusion bodies in small bowel intima vasculature.3 The IDSA now supports steroids to counteract the inflammatory storm and reduce mortality.(4, 5) However, recommendations for the management of coagulopathies remain hesitant, citing the lack of descriptive patient characteristics and ineffective reporting of mortality outcomes.(6) METHODS We conducted a retrospective survival analysis on COVID-19 positive mechanically ventilated adults (n=335, 273 male, 62 female) between 3/8/2020 to 5/28/2020. The relative risk of mortality was compared with stratified analyses for hypertension and diabetes. Groups included standard of care (SOC) plus steroids, SOC plus therapeutic lovenox and SOC plus therapeutic lovenox and steroids. The SOC included +/-hydroxychloroquine, +/-azithromycin, +/-additional antibiotics, +/-DVT prophylaxis, sedatives, pressors, IVF and PPIs. RESULTS As of May 28, 2020, 62/335 (19%) mechanically ventilated patients remained alive. The average length of stay for survivors was 31 days. Those receiving SOC plus therapeutic lovenox and steroids demonstrated a survival benefit (33/73, 45%) with a statistically significant reduced relative risk of mortality RR=.5956, 95% CI (.4810-.7374;p<0.0001). Evidence of associations was enhanced in patients receiving SOC plus therapeutic lovenox and steroids with diabetes (n=127) and hypertension (n=140) demonstrating RR= 0.4119, 95% CI (0.2405-0.7057;p=0.0012) and RR=0.5492, 95% CI (0.3955-0.7627;p=0.0003), respectively. The SOC plus lovenox group demonstrated a significant difference in mortality, RR=.7932, 95% CI (.6483-.9704;p=.0244), while the SOC plus steroid group demonstrated no significant difference, RR .9855, 95% CI (.9038-1.0747;p=.7411). CONCLUSION Inflammatory storm and hypercoagulability from COVID 19 can lead to micro thrombosis and organ failure.(7) Our findings suggest that in mechanically ventilated patients with COVID-19 infection therapeutic anticoagulation plus steroids synergistically reduced the risk of mortality and should be treatment of choice. Endothelial damage from diabetes and hypertension may hasten dysfunction in COVID-19 infection, thus therapeutic anticoagulation in less severe cases may demonstrate benefit and warrants investigation.(8).
ABSTRACT
Introduction: When COVID-19 was declared a pandemic by the WHO in early 2020, the United States was only beginning to focus on the potential impact of the disease. Elmhurst Hospital Center in New York City became the “epicenter of the epicenter” at the height of the first wave. In order to meet the demand of a large surge of acutely ill patients requiring mechanical ventilation for hypoxemic respiratory failure, widespread collaboration resulted in the use of different types of ventilators, including those designed primarily for patient transport. While typical ICU ventilators give extensive graphical and numeric information with respect to patient and vent parameters, travel ventilators do not. Therefore, utilization of these ventilators outside of their intended spectrum of use has the potential to compromise patient care. Barotrauma is a relatively common complication of ventilated patients with critical COVID-19 infections, which raises the concern that the use of travel ventilators could compound the risk. Materials and Methods: A retrospective analysis of patients with COVID-19 pneumonia admitted and intubated for respiratory failure from March 2 to May 9, 2020 was undertaken. Clinical and demographic information, incidence of barotrauma with respect to ventilator type, and mortality were evaluated using non-parametric analysis as appropriate. Time-to-event analysis was performed for both barotrauma and mortality with respect to ventilator type. Results: Of 335 patients identified, 313 had sufficient data available. Median age was 61 years and males made up 81.5% of the population. Overall mortality was 81%. Age was associated with greater mortality (p=0.047), but there was no mortality difference with respect to sex, BMI, or with respect to known comorbid risk factors. Travel ventilators were associated with longer length of stay (p=0.0002), a longer time intubated (p=0.0009), but also a longer time to intubation (p=0.014). No significant difference in incidence of barotrauma (p=0.18), pneumothorax (p=0.35), or mortality (p=0.52) by ventilator type was observed. Barotrauma was associated with a longer length of stay (p=0.0001) and days intubated (p=0.0001), but not with time from admission to intubation or increased risk mortality. Conclusion: Adaptation is required by healthcare providers during a pandemic, especially the utilization of available critical resources including ventilators. While adaptation to new equipment with different original intended uses and capabilities presents its own set of intrinsic challenges, the extended use of Transport Ventilators was not associated with an increase in barotrauma or mortality. (Table Presented).
ABSTRACT
RATIONALE The first confirmed case of COVID-19 in New York was on March 1, 2020.(1) A nationwide emergency declared on March 13 made New York immediately eligible for FEMA public assistance.(2) At the peak of this pandemic, over 50,094 FEMA employees, Public Health Service Commissioned Corps officers from HHS and the National Guard were deployed across the US(2) to care for suspected or confirmed COVID-19 cases, including 10,437 NYC H+H cases, many of which required ICU level care. Elmhurst Hospital Center (EHC) experienced an unprecedented surge, resulting in resource strain. At EHC 2,409 patients (1501, COVID-19 positive) were newly admitted between March 1st to May 29, 2020, drastically surpassing hospital capacity. Herein, we compare patient outcomes before and after assistance. METHODS A retrospective review of cardiopulmonary resuscitation code team data was carried out for admitted adults requiring code response team between March 11 to May 25. A total of 145 cases were analyzed with respect to different grades of FEMA assistance to determine impacts of ancillary staff to patient ratios on survival. RESULTS Prior to FEMA support (3/11-3/25), code survival was 47% (8/17) and survival to discharge was 0% (0/17). The first wave of FEMA support (3/26-4/8) brought 221 Critical Care providers. Code survival was 39% (24/62) and survival to discharge was 5% (3/62). The second wave (4/9-4/23) included both 86 providers and volunteers, after which code survival was 56% (28/50) and survival to discharge was 2% (1/50). A third wave of 79 additional providers (4/24-5/10) resulted in decreased number of codes, code survival to 38% (3/8) and improved survival to discharge 38% (3/8). During the subsequent weeks while FEMA support staff remained at EHC (5/11-5/25), code survival was 50% (4/8), and the improved survival to discharge of 38% (3/8) was maintained. Overall, while the probability of code survival remained relatively constant (38-56%), survival to discharge showed significant and sustained improvement with additional provider support. CONCLUSION Given the exponential rise in COVID-19 admissions, hospitals are likely to become overwhelmed and medical practice is forced to adapt.(3) Swift action from FEMA and optimal ancillary staff deployment was critical to improving survival to discharge in critically ill patients requiring cardiopulmonary resuscitation.(4) Flexibility in step-up planning with timely high acuity capacity and appropriately trained provider staffing is vital to ensuring proper care during a pandemic surge.
ABSTRACT
RATIONALE COVID-19 infection has affected 5 million lives, resulting in over 300,000 deaths worldwide. Those with respiratory failure requiring mechanical ventilation (MV) make up less than 10% of individuals, but account for the majority of fatalities.(1) Exploring characteristics of those extubated, strategies for treatment and resource allocation can be potentially implemented. METHODS A retrospective review of the initial 33 adult patients positive for COVID19 admitted to EHC, with respiratory failure and extubated from 3/8/2020 to 5/8/2020 was performed. Clinical characteristics were evaluated descriptively. RESULTS Successfully extubated patients averaged 56 years of age, males made up 91% of the population. Average BMI was 28.2 and hemoglobin A1C was 6.26. The mean maximum creatinine was 4.39 and max procalcitonin was 26. Mean admission and maximum D-dimer levels were 5,349 and 12,450 respectively, while mean admission CRP was 204. The mean days on nasal cannula, non-rebreather and CPAP prior to intubation were 5, 4, and 3, respectively, with overall mean time to intubation of 11.9 days and average length of stay of 20.6 days. The mean minimum PaO2 was 57.7 (most often on 100% FiO2) and max mean PEEP was 12.7. Total sedation days and total pressors days were calculated giving each pressor or sedative used the equivalence of 1 to provide an estimate of sedative and pressor requirements. The mean number of pressor days was 9.8;with a mean number of sedative days as 28. Survival after extubation at time of analyses was (21/33) 63%. CONCLUSION These results signal that these initial extubated patients were quite hypoxic and ventilated with a low PEEP strategy deviating from those suggested by surviving sepsis guidelines. They were in a hyperinflammatory state with moderate renal failure and propensity for infection, however, perhaps the BMI, low A1C scores, relatively fast decline in D dimers and ventilation with low PEEP strategy allowed them to be mechanically liberated. Classifying patient demographics and disease severity early can help identify patients likely to achieve successful extubation. The duration of preintubation oxygen support, duration of intubation, ideal vent settings, and realistic sedative requirements should be explored to optimize successful MV and extubation strategies.