ABSTRACT
INTRODUCTION: Multisystem Inflammatory Syndrome in Adults (MIS-A) is an underrecognized post-infectious manifestation of COVID-19.We report a case of a 21-year-old male with MIS-A who presented with adrenal hemorrhages, acute kidney injury (AKI) and cerebral strokes leading to multiorgan system failure and death. DESCRIPTION: A 21-year-old, morbidly obese male presented at an outside hospital with COVID-19 and abdominal pain. His abdominal CT demonstrated bilateral adrenal hemorrhages, he was discharged home on hydrocortisone. A month later was readmitted with fever, diarrhea, thrombocytopenia and AKI. Laboratory work revealed creatinine 5.49mg/dL, ferritin 701ng/ml, BNP 3020 pg/ml and D-Dimer 17,650 ng/ml. He received hydrocortisone, intravenous immunoglobulin and enoxaparin. Fever subsided and renal function normalized. On day 7 he developed acute altered mental status and recurrent AKI. Head CTA showed multiple short stenotic segments in the anterior circulation, diminutive appearance of several intracranial arteries and basal ganglia hypodensities. Brain MRA demonstrated extensive bilateral acute/subacute strokes, no evidence of sinus thrombosis and markedly decreased caliber of internal carotid, left middle and anterior cerebral arteries without evidence of thrombus. He received aggressive neurocritical care management including decompressive craniectomy and pulse steroids for suspected vasculitis. Due to the severity of his neurological injury and poor neurologic prognosis family elected to withdraw support. His autopsy demonstrated hepatomegaly, acute tubular necrosis, bilateral adrenal hemorrhages and hypercellular bone marrow with myeloid predominance. Neuropathology showed severe segmental stenosis of the carotid arteries and bilateral vertebral arteries. DISCUSSION: Stroke is a potentially life-threatening complication of COVID-19 including large vessel occlusion and less frequently vasculitis-like phenotype with vessel wall enhancement. Despite initial improvement, our patient developed an acute extensive ischemic stroke leading to a devastating neurologic injury. The neuropathology findings suggest SARS-CoV-2 associated vasculitis. Stroke in the context of COVID-19 may have different pathogenetic mechanisms, clinical characteristics and complications that warrant further investigation.
ABSTRACT
INTRODUCTION: Burnout results from physical and mental exhaustion and affects the intentionality to leave the profession. Unfortunately, burnout scenarios have been quite common among Critical Care Advance Practice Providers (APPs). The calls to action to sustain the critical care workforce were in full force before COVID-19 attacked the world and rapidly turned into a pandemic. Already overburdened and depleted critical care workforce was further exacerbated by overwhelming work demands. Our research was aimed at understanding the influence of COVID-19 on the critical care APPs. METHOD(S): We utilized a cross-sectional REDCap survey to understand the self-perceived extent to which the burnout among critical APPs had changed. A single link to survey was emailed to 2775 SCCM physician assistant and nursing section members. There were 578 responses (response rate 20.8%). After excluding 60 non-APPs responses, our sample size was 518. Survey questions asked about the symptoms of emotional exhaustion, depersonalization, perception of reduced personal accomplishments and intention to leave. RESULT(S): We found an increase in burnout and related dimensions. Emotional exhaustion increased from 28.8%- 69.9%, depersonalization increased from 17.2%-37.6%%, and perception of reduced personal accomplishments increased from 18.1%-38% among our study population. We also asked about the intentions to leave critical care and a total of 513 participants engaged with this question. Twenty-two percent (n=114) of our sample expressed an intention to leave critical care. We also asked about the intention to leave the profession altogether and only 21.8% (n=113) participants responded. A total of 43.3% (n=49) respondents reported the intention to leave the profession altogether within the following 2-5 years. Of those who responded, 22.1% (n=25) intended to leave within 1 year and 25.7% (n=29) intended to leave between 5-10 years while 8.9% (n=10) stated that they intended to stay beyond 10 years. CONCLUSION(S): COVID-19 pandemic exacerbated the burnout and its dimensions among critical care APPs. It is crucial to attend to the trends in burnout and intention to leave and mitigation strategies must be employed to sustain the critical care workforce which is key to planning the future of critical care in the US and globally.