Outcomes of Barotrauma in Critically Ill COVID-19 Patients With Severe Pneumonia.

BACKGROUND: Pneumomediastinum and pneumothorax are complications which may be associated with barotrauma in mechanically ventilated patients. The current literature demonstrates unclear outcomes regarding barotrauma in critically ill patients with severe COVID-19. The purpose of this study was to examine the incidence of barotrauma in patients with severe COVID-19 pneumonia and its influence on survival. STUDY DESIGN AND METHODS: A retrospective cohort study was performed from March 18, 2020 to May 5, 2020, with follow-up through June 18, 2020, encompassing critically ill intubated patients admitted for COVID-19 pneumonia at an academic tertiary care hospital in Brooklyn, New York. Critically ill patients with pneumomediastinum, pneumothorax, or both (n = 75) were compared to those without evidence of barotrauma (n = 206). Clinical characteristics and short-term patient outcomes were analyzed. RESULTS: Barotrauma occurred in 75/281 (26.7%) of included patients. On multivariable analysis, factors associated with increased 30-day mortality were elevated age (HR 1.015 [95% CI 1.004-1.027], P = 0.006), barotrauma (1.417 [1.040-1.931], P = 0.027), and renal dysfunction (1.602 [1.055-2.432], P = 0.027). Protective factors were administration of remdesivir (0.479 [0.321-0.714], P < 0.001) and receipt of steroids (0.488 [0.370-0.643], P < 0.001). CONCLUSION: Barotrauma occurred at high rates in intubated critically ill patients with COVID-19 pneumonia and was found to be an independent risk factor for 30-day mortality.

Rapid Adoption of an Interdisciplinary Care Team Model for Surgical Residents Managing Coronavirus Disease-19.

Introduction: Patients infected with SARS-Cov-2, the causative virus behind the coronavirus disease-19 (COVID-19) pandemic, have been increasing rapidly in New York City. New York City has the highest incidence in the United States and fully 45% of all deaths from COVID-19. Our medical center is located within a high-density region of cases in south Brooklyn and, in fact, three of our neighborhood zip codes are in the top seven in New York in incidence. As a result, our center has experienced a dramatic increase in hospitalizations, particularly respiratory distress secondary to COVID-19, which rapidly exceeded the capacity of our internal medicine service. This necessitated the formation of new COVID-19 units throughout the hospital, replacing all former service lines. These units employed management teams composed of residents from many medical and surgical disciplines, including general surgery residents. Methods: Our general surgery residency program established a surgical COVID-19 (SCOVID) management team. Initially, 4 surgical residents (2 senior and 2 junior), 1 attending surgeon, and 1 attending internal medicine physician were allocated to the initial SCOVID team. On day 3 of implementation, to achieve more rapid competence in the complex management of these patients, a senior medicine resident with direct experience in the care of COVID-19 patients was added in an advisory capacity. Results: The addition of an experienced senior medical resident and attending allowed for the quick adoption of uniform management protocols by surgical residents and attendings. Discussion: We describe a protocol for the establishment of COVID-19 management teams staffed with general surgical residents, as well as a strategy for the achievement of rapid increases in competency. The addition of a senior internal medicine resident and attending to our SCOVID team allowed for rapid achievement of competency in the care of COVID-19 patients in our large institution at the epicenter of the COVID-19 pandemic.

Assessing the immediate impact of COVID-19 on surgical oncology practice: Experience from an NCI-designated Comprehensive Cancer Center in the Northeastern United States.

BACKGROUND: The effects of the coronavirus disease 2019 (COVID-19) pandemic on surgical oncology practice are not yet quantified. The aim of this study was to measure the immediate impact of COVID-19 on surgical oncology practice volume. METHODS: A retrospective study of patients treated at an NCI-Comprehensive Cancer Center was performed. "Pre-COVID" era was defined as January-February 2020 and "COVID" as March-April 2020. Primary outcomes were clinic visits and operative volume by surgical oncology subspecialty. RESULTS: Abouyt 907 new patient visits, 3897 follow-up visits, and 644 operations occurred during the study period. All subspecialties experienced significant decreases in new patient visits during COVID, though soft tissue oncology (Mel/Sarc), gynecologic oncology (Gyn/Onc), and endocrine were disproportionately affected. Telehealth visits increased to 11.4% of all visits by April. Mel/Sarc, Gyn/Onc, and Breast experienced significant operative volume decreases during COVID (25.8%, p = 0.012, 43.6% p < 0.001, and 41.9%, p < 0.001, respectively), while endocrine had no change and gastrointestinal oncology had a slight increase (p = 0.823) in the number of cases performed. CONCLUSIONS: The effects of the COVID-19 pandemic are wide-ranging within surgical oncology subspecialties. The addition of telehealth is a viable avenue for cancer patient care and should be considered in surgical oncology practice.

Clinical Characteristics and Outcome of Pneumomediastinum in Patients with COVID-19 Pneumonia.

Introduction: Pneumomediastinum (PM) is characterized by the presence of air within the mediastinum. The association between PM and coronavirus 2019 (COVID-19) has not been well established in the current literature. We sought to summarize the limited body of literature regarding PM in patients with COVID-19 and characterize the presentation and clinical outcomes of PM in patients with severe acute respiratory syndrome (SARS)-COV-2 pneumonia at our institution to better define the incidence, prognosis, and available treatment for this condition. Materials and Methods: All patients with a proven diagnosis of COVID-19 and PM between March 18, 2020 and May 5, 2020 were identified through hospital records. Retrospective analysis of radiology records and chart review were conducted. Clinical characteristics and outcomes were collected and descriptive statistics was analyzed. Results: Thirty-six patients met inclusion criteria. Out of the 346 intubated COVID-19 patients, 34 (10%) had PM. The incidence of PM increased for the first 4 weeks of the pandemic, and then began to decrease by week 5. At the endpoint of the study, 12 (33.33%) patients were alive and 24 patients (66.67%) had died. Conclusion: PM, although a rare phenomenon, was more prevalent in COVID-19 patients compared with historical patients with adult respiratory distress syndrome. The etiology of this condition may be attributed to higher susceptibility of patients infected with SARS-CoV-2 to a combination of barotrauma and airway injury.

Gastrointestinal perforation in a critically ill patient with COVID-19 pneumonia.

Gastrointestinal complications in critically ill patients during the COVID-19 pandemic pose a diagnostic and treatment dilemma. We present a case of a 74-year-old male who was brought to our emergency department with worsening shortness of breath, fever, and dry cough and was found to have COVID-19 pneumonia. Early in his hospital course, he was admitted to the intensive care unit, and was found to have significant abdominal distension with large amounts of simple fluid on bedside ultrasound. Bedside paracentesis returned succus and enteric feeds, and a methylene blue test confirmed a likely gastrointestinal perforation. The patients' family refused surgical intervention and the patient underwent bedside drainage. This case represents several critical dilemmas clinicians faced during the recent surge of the COVID-19 pandemic.

Safe extubation during the COVID-19 pandemic.

Extubation of patients with Coronavirus Disease 2019 (COVID-19) is a high risk procedure for both patients and staff. Shortages in personal protective equipment (PPE) and the high volume of contact staff have with COVID-19 patients has generated an interest in ways to reduce exposure that might be feasible especially during pandemic times and in resource limited healthcare settings. The development of portable barrier hood devices (or intubation/extubation boxes) is an area of interest for many clinicians due to the theoretical reduction in aerosolization of SARS-CoV-2, the causative virus for COVID-19. We present a review of the current literature along with recommendations concerning safe extubation during the COVID-19 pandemic. In addition, a focused summary on the use of portable barrier hood devices, during the recent surge of COVID-19 is highlighted.