ABSTRACT
Malignant hyperthermia is a rare but potentially fatal condition. We present 2 cases of young patients with coronavirus disease 2019 (COVID-19) requiring intubation for hypoxic respiratory failure who both developed significant hyperthermia post intubation and were suspected to have malignant hyperthermia. However, the 2 patients had different responses to conservative management and dantrolene. These cases highlight the increased challenge imposed by intubation complications when managing patients with COVID-19. Copyright © 2021 Shandong University, published by Wolters Kluwer, Inc.
ABSTRACT
INTRODUCTION: Osimertinib is a molecular targeted antineoplastic tyrosine kinase inhibitor that is primarily used in the treatment of non-small cell lung cancer (NSCLC). It has been associated with the development of interstitial lung disease/pneumonitis that requires discontinuation of the drug and occurs usually within the first 2-3 months of therapy. Approximately 3% of patients treated with osimertinib will experience lung toxicity. Acute fibrinous and organizing pneumonia (AFOP) is a rare form of interstitial pneumonitis that has been associated with drug toxicity but to our knowledge has not yet been described in association with osimertinib. Here we present one such case. DESCRIPTION: A 77 year old woman with a history of EGFR+ stage IIB adenocarcinoma presented with two weeks of shortness of breath, fevers, and dry cough. She had been started on osimertinib two months prior to presentation. On admission she was noted to be hypoxic with new oxygen requirement of 4L nasal cannula. CT chest showed bilateral ground glass opacities. She was started on empiric vancomycin and zosyn without improvement in symptoms. She underwent bronchoscopy on hospital day 3 with lung biopsy pathology showing AFOP. Infectious workup including bronchoalveolar lavage, blood, and sputum cultures, as well as respiratory viral panel and COVID-19 test was negative. Transthoracic echocardiogram showed normal cardiac function with an ejection fraction of 64%. Given these findings she was started on methylprednisolone 1 mg/kg for TKI-induced pneumonitis on day 5. Her oxygen requirements increased during hospitalization and on day 7 she acutely desaturated and was intubated. Repeat chest CT was negative for pulmonary embolism but showed interval worsening of infiltrates and consolidation at lung bases. Her methylprednisolone was increased to 2 mg/kg on day 10. Her pulmonary function improved and she was extubated to nasal cannula on day 12. DISCUSSION: Molecular targeted antineoplastic agents have been associated with lung toxicity, which can be severe and even fatal. To our knowledge this is the first known case of osimertinib-induced AFOP, which improved with discontinuation of the drug and initiation of high-dose methylprednisolone.
ABSTRACT
SESSION TITLE: Critical Care Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: The novel coronavirus (SARS-CoV-2) has become a global pandemic, with many suffering from resultant severe acute respiratory distress syndrome (ARDS). Initiation of veno-venous extracorporeal membrane oxygenation (ECMO) support, which can restore gas exchange, has been used in patients with refractory ARDS, and is now being trialed in select patients with SARS-CoV-2 infection. However, use of ECMO in ARDS remains controversial, and both its usage and data are limited in SARS-CoV-2 infection. We describe consecutive patients who received ECMO support for refractory COVID-19-related ARDS in our facility. METHODS: We performed a retrospective cohort analysis of the first fourteen COVID-19 patients admitted to Yale New Haven Hospital who required ECMO support between April 6 and May 23, 2020. RESULTS: All 14 subjects were male;median age 50 (range 32-61) years;median BMI 37 (IQR 32-41) kg/m2;the most common ethnicity Hispanic (79%);and most prevalent comorbidities included diabetes and hypertension (36% each). The majority of patients received a trial of prone positioning and neuromuscular blockade (100%), pulmonary vasodilators (71%), and Tocilizumab (93%) prior to initiation of ECMO (Table 1). Patients had higher levels of positive end-expiratory (median 16 cmH2O) and plateau (median 36 cmH2O) pressures, with P/F ratio consistent with severe ARDS category (median 75) at the time of cannulation (Table 2). Bleeding requiring transfusion (86%) and sepsis excluding pneumonia (29%) were the most common complications while on ECMO. Six patients (43%) were successfully de-cannulated, of which two patients were discharged from the hospital. Four patients have died (29%) and another four (29%) continue to receive ECMO support (Table 3). CONCLUSIONS: COVID-19 patients with severe ARDS refractory to invasive mechanical ventilator support, prone positioning, and neuromuscular blockade have significant mortality with limited therapeutic options. Although use of ECMO in such patients has been debated, our experience suggests otherwise. Successful decannulation (43%), mortality (40%), and complications are in keeping with those of all-cause pulmonary failure requiring ECMO support in global registries. CLINICAL IMPLICATIONS: Veno-venous extracorporeal membrane oxygenation should be considered a feasible therapeutic option in restoring gas exchange in COVID-19-related ARDS once standard methods of mechanical ventilation, proning, and paralysis have proven insufficient. DISCLOSURES: No relevant relationships by Pramod Bonde, source=Web Response No relevant relationships by Astha Chichra, source=Web Response Owner/Founder relationship with Vent Multiplexor Please note: $1-$1000 Added 06/01/2020 by Elaine Fajardo, source=Web Response, value=Equity Owner/Founder relationship with prevents Please note: $1-$1000 Added 06/01/2020 by Elaine Fajardo, source=Web Response, value=Intellectual property rights No relevant relationships by Jan Fouad, source=Web Response No relevant relationships by Arnar Geirsson, source=Web Response No relevant relationships by Phillip Joseph, source=Web Response No relevant relationships by Akhil Khosla, source=Web Response No relevant relationships by Andres Oswaldo Razo-Vazquez, source=Web Response No relevant relationships by Jonathan Siner, source=Web Response No relevant relationships by Inderjit Singh, source=Web Response No relevant relationships by Christopher Szabo, source=Web Response No relevant relationships by Hossam Tantawy, source=Web Response