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SESSION TITLE: ECMO and ARDS in COVID-19 Infections SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/17/2022 12:15 pm - 1:15 pm PURPOSE: The use of neuromuscular blocking agents (NMBA) has been trialed in acute respiratory distress syndrome (ARDS) to decrease patient–ventilator desynchrony, decrease work of breathing and improve oxygenation. No consistent reduction in mortality or ventilator free days has been demonstrated. The use of NMBA’s can be associated with neuromuscular weakness and adverse cardiovascular events. The use of NMBA’s increased significantly in our ICU after the advent of COVID-19, partly related to the increase incidence of ARDS observed, but also because of the seemingly increased ventilator asynchrony seen in this patient population. Our group evaluated the use of NMBA infusions in our medical intensive care unit (MICU) and subsequently implemented a “Paralytic initiation decision bundle” to decrease the frequency (and duration) of NMBA infusions by optimizing conditions before initiating an NMBA. METHODS: We conducted a retrospective cohort evaluation of the pattern of NMBA usage in our MICU from December 2020 to May 2021 at the Memorial Hermann Hospital-Texas Medical Center. Patients were excluded if they were on ECMO or if the NMBA infusions were initiated at an outside hospital. We then started an NMBA initiation bundle to decrease the overuse of this intervention. RESULTS: Forty-four patients were initiated on an NMBA infusion during the preintervention period (average 7.3 patients/month). This cohort included 63% males, an average age of 59.7 years (SD +/- 13.3), with 81.8% diagnosed with COVID-19. 54.5% were started on a paralytic drip <24 hours after intubation, 11.4% between 24 and 48 hours and 34.1% were started on a paralytic drip >48 hours after intubation (mean 7.5 days;range of 3-15 days). 27 patients (61.4%) were noted to be on an NMBA infusion for greater than 48 hours. The average duration of continuous paralytic infusion in this group was 5.2 days (SD +/- 3.1;range of 3-16 days). After a paralytic bundle was implemented, the use of NMBAs dropped significantly (2 patients/month) with an average infusion duration of <48 hours. CONCLUSIONS: The use of NMBA’s for greater than 48 hours in patients with ARDS is not currently recommended. The extended use of paralytics is seen often in COVID-19 ARDS patients. The implementation of a paralytic bundle with alternatives for sedation, optimization of alternative ARDS treatment strategies and a mandatory stop (or reevaluation) of NMBA after 48 hours resulted in a reduction in paralytic use at our institution. Limitations of this study include the decrease in COVID-19 cases during the intervention (hence restricting the evaluation of the tool). We plan to continue to investigate the intervention and add to our current data. Further studies are also needed to investigate the optimal use of paralytics in COVID-19 ARDS. CLINICAL IMPLICATIONS: The use of an NMBA bundle in patient’s with ARDS can help reduce the overuse of this intervention. DISCLOSURES: No relevant relationships by Jennifer Cortes No relevant relationships by Kimberly DSouza No relevant relationships by Galyna Ivashchuk No relevant relationships by Ruckshanda Majid No relevant relationships by Zachary Pinchover No relevant relationships by Oriana Salamo
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Affordable housing remains a prevalent issue in the country. The definition suggests affordable housing as adequate housing in quality, location, and known as not so costly that prevents its occupants from meeting other essential living needs. In the effort of providing sufficient affordable housing, various affordable housing programs, namely Residensi Wilayah and PR1MA, are currently in the market with the aims to develop and deliver new affordable housing, which targeted the middle-and low-income group. Although the lacking of affordable housing persists, the severe glut in the property market has also records to reach an all-time high. The overhang crisis in the country became an infamous issue in the country with the slow market, which led to the increase in the overhang unit’s statistics year over a year which partially in affordable housing segmentation. It is highlighted that the overhang in affordable housing has shown significant rising despites of its strong demand. This paper attempts to examine the overhang issue in affordable housing in Malaysia and related factors. This research will add up some points of discussion as regards the impact of the Covid-19 Pandemic towards the issue of affordable housing and the strategies in reducing the overhang issue during the pandemic. A review of the past literature related to the topics was carried out and data derived from journals, reports, and websites were gathered and examined to establish the framework on this issue and to identify the overhang factors in affordable housing. The developers are urged to build houses that can cater to the demand of buyers in terms of the property type, location, and also price range. The overhang units did not attract the target market while the product mismatch is one of the contributing factors. Other related factors are affordability, high living costs, and stagnant income growth, cooling measures, financing, unsuitable location, accessibility, the lack of timely and accurate data of buyer’s preference including the shift in demand towards the better-quality project. A study on the overhang factors of affordable housing is needed to resolve the issue, or else, the overhang issue will be worsened and will create a lot of negative impacts in the future. At the end of the research, the list of the property overhang factors and its framework able to be identified and to be used as guidelines and references to the public.
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Recent studies using data accrued from global SARS-CoV-2 vaccination efforts have demonstrated that breakthrough infections are correlated with levels of neutralizing antibodies. The decrease in neutralizing antibody titers of vaccinated individuals over time, combined with the emergence of more infectious variants of concern has resulted in waning vaccine efficacy against infection and a rise in breakthrough infections. Here we use a combination of neutralizing antibody measurements determined by a high throughput surrogate viral neutralization test (sVNT) together with published data from vaccine clinical trials and comparative plaque reduction neutralization test (PRNT) between SARS-CoV-2 variants to develop a model for vaccine efficacy (VE) against symptomatic infection. Vaccine efficacy estimates using this model show good concordance with real world data from the US and Israel. Our work demonstrates that appropriately calibrated neutralizing antibody measurements determined by high throughput sVNT can be used to provide a semi-quantitative estimate of protection against infection. Given the highly variable antibody levels among the vaccinated population, this model may be of use in identification of individuals with an elevated risk of breakthrough infections.
Subject(s)
COVID-19 , Breakthrough PainABSTRACT
Introduction: Coronavirus disease 2019 (COVID-19) was first reported in the Houston city area in the first week of March 2020. Soon hospitals in the city were overrun with COVID-19 patients. By October, COVID-19 had resulted in 216,025 deaths in the US1. Older patients and Hispanic, American Indian/Alaskan Natives, Black, and Asian patients have experienced the highest excessive deaths1. The aim of our research was to study the factors associated with mortality among COVID-19 patients. Methods: The study was conducted on patients at a large university-affiliated multi-hospital system. The study used data from electronic medical records with an inpatient admission from March-October 2020 and a confirmed diagnosis of COVID-19. The data included demographic information, prescreening information, length of stay, discharge disposition, diagnoses and comorbidity, respiratory support, medications, and laboratory test results. The dependent variable in all analyses was defined as a discharge disposition of in-hospital death or hospice. Unadjusted logistic regression analyses were carried out on all variables, and a multivariable logistic regression model was built using variables that lowered the Akaike information criterion. Laboratory values missing at random were imputed by multiple imputations using chained equations. Results: There were 8,341 inpatients admissions, of whom 1,139 died or received hospice. The median age was 72 years among dead/hospice patients and 55 years among patients discharged alive (p<0.01). Death/hospice was higher among men (15% of all men vs. 12% of all women) and people who were Asian (20%), White (15%), and African American (12%). 10% of Hispanics and 13% of Non-Hispanic died or received hospice. The multivariable logistic regression model showed that receiving mechanical ventilation (OR 19.171), Non-invasive ventilation, using non-rebreather masks, high flow nasal cannula, ICU admission had higher odds of death/hospice. Increase in age, Charlson comorbidity index of 2 &3, and receiving convalescent plasma also had higher odds of death/hospice. Not receiving supplemental oxygen and increase in the anticoagulants administration days reduced the likelihood of death/hospice. Among laboratory values, an increase in the initial lactic acid, blood urea nitrogen, total bilirubin, and alkaline phosphatase were associated with higher death/hospice odds. Conclusion: COVID-19 mortality has decreased over time due to a better understanding of managing the patients. This study highlights the most important predictors of mortality, which must be followed up by future studies. (Table Presented).
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SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Reports during the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic have raised concerns for a hypercoagulable state.1 An increased incidence of venous thromboembolism and pulmonary microthrombi have been found on autopsy. We present a case of a spontaneous aortic thrombosis in a patient with SARS-CoV-2. CASE PRESENTATION: A 70-year-old with dyspnea and fevers presented with hypoxia, bilateral pulmonary infiltrates, and tested positive for Coronavirus-19. He was managed with high flow oxygen and was initiated on therapeutic heparin drip for atrial flutter. Laboratory results revealed elevated inflammatory markers (ferritin 932ng/ml, erythrocyte sedimentation rate of 43mm/hour, C-reactive protein of 227mg/L, IL-6 141pg/ml, fibrinogen 606mg/dL, D-Dimer of 1.08ug/mL). The patient was intubated on day three for worsening hypoxia. Bilateral mottled lower extremities were immediately noted, with non-palpable pulses and an arterial doppler confirming absent flow in both femoral arteries. The patient underwent emergent surgical exploration with the discovery of extensive abdominal aortic clot ex-tending into the bilateral femoral and renal arteries on intraoperative aortogram. Despite emergent thrombectomies, the muscle tissue demonstrated extensive non-viability, and bilateral above the knee amputations were performed. The patient’s condition continued to deteriorate, with the development of rhabdomyolysis, severe shock, and acute renal failure. The family made a decision to pursue comfort care secondary to futility. DISCUSSION: Individuals with COVID-19 have a number of coagulation abnormalities. Direct invasion of endothelial cells by the SARS-CoV-2 virus, potentially leading to cell injury, in addition to other indirect mediators of endothelial injury (interleukin [IL]-6), other acute phase reactants and complement-mediated endothelial injury have been postulated to contribute to the hypercoagulable state and clot pathogenesis.2 COVID-19 has been widely accepted to lead to the development of venous and pulmonary micro-emboli. There are however less frequent reports of arterial thrombosis (strokes, acute coronary syndrome, acute limb ischemia).3 This case is the first report of an acute central arterial thrombosis likely secondary to the SARS-CoV-2 virus, in a patient who was already being treated with heparin. This may demonstrate resistance to anticoagulation, the etiology of which needs further investigation. CONCLUSIONS: Life-threatening arterial thromboses are likely within the spectrum of the SARS-CoV-2 virus syn-drome. Serious consideration should be made to anticoagulate these patients to prevent clots with careful monitoring of the coagulation profile to ensure adequate protection. Reference #1: Klok FA et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res.2020;S0049-3848(20)30120-1. Reference #2: Magro C, Mulvey JJ, Berlin D, Nuovo G, Salvatore S, Harp J, Baxter-Stoltzfus A, Lau-rence J. Complement associated microvascular injury and thrombosis in the pathogenesis of severe COVID-19 infection: a report of five cases. Transl Res. 2020 Reference #3: Paolo Perini, Bilal Nabulsi, Massoni CB, Matteo Azzarone, Antonio Fryries. Acute limb ischemia in two young, non-atherosclerotic patinet with COVID-19. The Lancet. 2020 Vol. 395 (10236) P1546. Doi: https://doi/org/10.1016/S0140-6736(20)31051-5. DISCLOSURES: No relevant relationships by Logan Hostetter, source=Web Response No relevant relationships by Bibi Aneesah Jaumally, source=Web Response No relevant relationships by Ruckshanda Majid, source=Web Response No relevant relationships by Joanna Scoon, source=Web Response