Hemodynamic changes associated with neuraxial anesthesia in pregnant women with covid 19 disease: a retrospective case-control study.

BACKGROUND: Neuraxial blocks is the recommended mode of analgesia and anesthesia in parturients with Coronavirus 19 (COVID-19). There is limited data on the hemodynamic responses to neuraxial blocks in COVID-19 patients. We aim to compare the hemodynamic responses to neuraxial blocks in COVID-19 positive and propensity-matched COVID-19 negative parturients. METHODS: We conducted retrospective, cross-sectional case-control study of hemodynamic changes associated with neuraxial blocks in COVID-19 positive parturients in a Tertiary care academic medical center. Fifty-one COVID-19 positive women confirmed by nasopharyngeal reverse transcription-polymerase chain reaction (RT-PCR), were compared with propensity-matched COVID negative controls (n = 51). Hemodynamic changes after neuraxial block were recorded by electronic medical recording system and analyzed using paired and unpaired T- test and Wilcoxon-Mann-Whitney Rank Sum tests. The primary outcome was ≥ 20% change in MAP and HR after neuraxial block placement. RESULTS: In the epidural group, 7% COVID-19 positive parturients had > 20% decrease in mean arterial pressure (MAP) from baseline compared to 15% COVID-19 negative parturients (P = 0.66). In the spinal group, 83% of COVID-19 positive parturients had a decrease in MAP more than 20% from baseline compared to 71% in control (P = 0.49). MAP drop of more than 40% occurred in 29% COVID positive parturients in the spinal group versus 17% in COVID-19 negative parturients (P = 0.5465). In COVID-19 positive spinal group, 54% required vasopressors whereas 38% in COVID-19 negative spinal group required vasopressors (P = 0.387). We found a significant correlation between body mass index (BMI) > 30 and hypotension in COVID ( +) parturient with odds ratio (8.63; 95% CI-1.93 - 37.21) (P = 0.007). CONCLUSION: Incidence and severity of hypotension after neuraxial blocks were similar between COVID-19 positive and COVID-19 negative parturients. BMI > 30 was a significant risk factor for hypotension as described in preexisting literature, this correlation was seen in COVID-19 positive parturients. The likely reason for parturients with BMI > 30 in COVID negative patients not showing similar correlation, is that the sample size was small.

Clostridioides difficile Burden of Disease: A Prospective Population-Based Surveillance Study of Hospitalized Adults in Louisville, Kentucky

Background. Clostridioides difficile (C. difficile) is an important cause of morbidity and mortality. C. difficile infection (CDI) may be frequently under-diagnosed because laboratory confirmation requires collection of a stool specimen from a patient with diarrhea and appropriate laboratory testing. Methods. A prospective population-based CDI surveillance study was launched in 8 adult hospitals in Louisville, Kentucky on September 16, 2019. Surveillance officers in each hospital identified all cases of new-onset diarrhea (≥3 loose stools in the past but not preceding 24 hours) in Louisville residents ≥50 years of age. After informed consent, stool samples were collected and tested at the University of Louisville reference laboratory for 1) glutamate dehydrogenase (GDH) and 2) Clostridioides difficile toxins A and B using C. DIFF QUIK CHEK COMPLETE®, Techlab. We defined CDI as GDH positive and toxin positive. The study was paused on April 3, 2020, due to COVID-19 restrictions. Results. There were 85,719 eligible patient-days during the study period. A total of 1541 patients had new-onset diarrhea corresponding to 1.8 cases of new-onset diarrhea per 100 eligible patient-days. We enrolled 84% (1291/1541) of patients with new-onset diarrhea and tested stool samples for C. difficile from 82% (1055/1291) for a testing density of 123 per 10,000 patient-days. Of the 1055 tested stool specimens, 73 (7%) were GDH positive and toxin positive (Figure 1) yielding a hospital-based CDI incidence of 8.5 CDI cases per 10,000 patient-days. Conclusion. New-onset diarrhea was common among hospitalized adults ≥50 years of age. CDI was frequently identified through stool specimens collected from eligible inpatients with new-onset diarrhea. Further analysis of these data and additional laboratory testing will contribute to a better understanding of the frequency of CDI underdiagnosis and the burden of CDI in the United States.

Outcomes of COVID-19 patients admitted to the intensive care unit with neurologic manifestations

INTRODUCTION: Coronavirus disease 2019 (COVID-19) is a multisystem disease. It can affect the central and peripheral nervous systems. Neurological manifestations at the time of disease presentation may have severe outcomes of COVID-19. The objective of our study is to evaluate the outcomes of hospitalized COVID-19 patients admitted in the intensive care unit who presented with neurological symptoms. METHODS: This is a multi-center, retrospective, and observational study of hospitalized COVID-19 patients in the city of Louisville, Kentucky, and southern Indiana region from March 10, 2020 to June 20, 2020. Patients were included in this analysis if they were: tested positive for COVID-19 by reverse transcriptase-polymerase chain reaction and admitted to the intensive care unit (ICU) in one of the nine hospitals in Louisville, Kentucky. Patients were considered to have a neurological symptom if one of the following clinical features was present during admission: 1) headache 2) dizziness 3) confusion 4) anosmia 5) ageusia and 6) altered mental status. Baseline characteristics and outcomes were compared using t-tests of means for continuous data, and t-test of proportions for categorical data. P-values < 0.05 was considered statistically significant. RESULTS: Out of 700 hospitalized COVID-19 patients in the study, 231 were admitted to ICU. Among 231 ICU patients, 92 (39.82%) patients had neurological symptoms at the presentation. Among the patients admitted to ICU, those who presented with neurological symptoms have higher mortality than those who had no neurological symptoms at presentation (50% vs 30%, p=0.003). In addition, ICU patients who presented with neurological symptoms had a higher rate of cardiac arrest (16% vs 2%, p<0.001) and cerebrovascular accident (7% vs 1%, p=0.034) during hospitalization in comparison to ICU patient without neurological symptoms at presentation. CONCLUSIONS: Our study demonstrated that among the patients admitted in ICU, patients who presented with neurological symptoms have higher mortality than those without neurological symptoms. In addition, ICU patients have a higher rate of cardiac arrest and cerebrovascular accidents if they presented with neurological symptoms.