ABSTRACT
Case Diagnosis: A 46-year-old male with severe COVID-19 pneumonia. Case Description or Program Description: The patient underwent bilateral orthotopic lung transplant (BOLT) after being on extracorporeal membrane oxygenation (ECMO) and mechanical ventilation for 202 days. He had multiple complications due to prolonged prone positioning, intubation, immobility and steroid use which include tongue fissure, critical illness neuromyopathy, bilateral brachial plexopathy, bilateral upper extremity contractures, avascular necrosis (AVN) of bilateral humeral heads and bilateral femoral heads, left sciatic mononeuropathy and a stage IV sacral wound. The patient had severe weakness throughout all limbs, but was cognitively intact. He was admitted to IPR 3.5 weeks after his BOLT. The patient was independent for ADLs and mobility prior to his illness and was dependent for activities of daily living (ADLs) and mobility at time of admission to inpatient rehabilitation (IPR). Setting(s): Inpatient rehabilitation hospital Assessment/Results: Following 12 weeks of IPR he ambulated independently and was discharged to the community with family assist in an outpatient Day Rehabilitation program for continued functional recovery. Unfortunately, he still required maximum assistance for ADLs due to loss of function of his arms. Discussion (relevance): This is a unique case of a patient with severe COVID-19 pneumonia who was intubated and on ECMO for a very long amount of time with survival ultimately leading to numerable sequela involving all extremities but notable injuries presenting as a person in a barrel type syndrome. Conclusion(s): Person in a barrel syndrome is a rare syndrome described by severe bilateral upper extremity weakness with strength preserved in the bilateral lower extremities as well as head, neck, and face. This patient developed this syndrome as a sequela to prolonged prone positioning and immobility related to severe COVID-19 disease. Consultation of PM&R services while in the ICU to aid in identification of patients at risk and help to optimize patient positioning without compromising life-saving procedures.
ABSTRACT
Objective: To describe the inpatient rehabilitation (IPR) course of patients who underwent bilateral lung transplant due to severe COVID-19 pulmonary disease. Design(s): Retrospective chart review Setting: Free-standing, academic, urban inpatient rehabilitation hospital Participants: Seventeen patients aged 28-67 years old (mean 53.9 +/- 10.7) who developed COVID-19 respiratory failure and underwent bilateral lung transplant. Intervention(s): Patients participated in a comprehensive IPR program including physical, occupational, and speech therapy tailored to the unique functional needs of each individual. Main Outcome Measure(s): Primary outcome measures of functional improvements, include mobility and self-care GG scores, as defined as quality measures by the Centers for Medicare and Medicaid Services. Other functional measures included 6 minute walk test, Berg balance scale, and Mann Assessment of Swallowing Ability (MASA). Wilcoxon Signed Rank Sum Test was used to evaluate statistical significance between admission and discharge scores. Result(s): Fourteen patients completed inpatient rehabilitation. Self-care (GG0130) mean score improved from 20.9 to 36.1. Mobility (GG0170) mean score improved from 30.7 to 70.7. Mean 6-minute walk distance improved from 174.1 to 455.1 feet. Mean Berg balance scores improved from 18.6/56 to 36.3/56. MASA scores improved from 171.3 to 182.3. All scores changes were statistically significant with p value < 0.01. 76% of patients discharged home. Conclusion(s): This retrospective review demonstrates that this new and unique patient population can successfully participate in a comprehensive inpatient rehabilitation program and achieve functional improvements despite medical complications. Advances in medical technology have increased the number of people with severe respiratory failure who are eligible for lung transplant and inpatient rehabilitation facilities have adapted to the changing COVID-19 medical landscape. It is important for rehabilitation providers to recognize opportunities to treat new patient populations and to be able to adjust treatment protocols accordingly.
ABSTRACT
INTRODUCTION: Maternal mortality rates have been increasing in the United States for decades. For several years, opioid overdoses have been a leading cause of maternal mortality in several states. New Hampshire (NH) is a particularly severe case, with 50% of all maternal deaths being caused by drug-related overdoses from 2016 to 2017. We report on the implementation of a point-of-care naloxone distribution program for an Ob/Gyn clinic in NH. METHODS: Naloxone distribution was tracked to measure program implementation. Proportion of patients screened for naloxone need was calculated monthly. Proportion of patients with which discussions about naloxone took place was calculated quarterly. Patient and provider perspectives on the program were captured periodically. Statistical process control charts monitored change over time and evaluated for special-cause variation. RESULTS: The clinic has distributed 12 doses of naloxone since program implementation in April 2020. Despite the challenges posed by the COVID-19 pandemic, screening for naloxone need has remained at pre-pandemic rates (moving average: 73%), except for a decrease in April-May 2020. Patient-provider discussions about naloxone have also remained at pre-pandemic rates (moving average: 51%). Qualitative feedback from patients and providers has indicated that the program has been well-received by both groups. DISCUSSION: The purpose of this description is to provide a framework for other Ob/Gyn clinics to use in implementing similar naloxone distribution programs. Although too early to determine whether this intervention will result in a significant decrease in maternal mortality due to opioid overdose in our patients, this measure will continue to be tracked annually. Implementation of a naloxone program in the obstetrical context provides an important way to improve outcomes for a vulnerable perinatal population.