ABSTRACT
Background: Severe COVID-19 pneumonitis in elderly frail patients is associated with poor outcomes, and therefore invasive mechanical ventilation is often deemed an inappropriate course of action. Some evidence suggests high-flow nasal oxygen (HFNO) may prevent the need for invasive ventilation in other groups of patients, but whether it is an appropriate ceiling of care for older frail patients is unknown. Method(s): We retrospectively identified patients with severe COVID-19 pneumonitis requiring FiO2 >60% who were deemed inappropriate for invasive ventilation or non-invasive continuous positive airway pressure ventilation (CPAP). Our local protocol based on national guidance suggested these patients should be considered for HFNO. We observed whether the patients received HFNO or standard oxygen therapy (SOT) and compared mortality and survival time in these groups. Result(s): We identified 81 patients meeting the inclusion criteria. From this group, 24 received HFNO and 57 received SOT. The HFNO group was similar in age, BMI and co-morbidities to the SOT group but less frail, as determined by the Clinical Frailty Scale (CFS). All 24 patients that received HFNO died in comparison to 46 patients (80.7%) in the SOT group. Mortality in the HFNO group was significantly higher than in the SOT group. Conclusion(s): Elderly frail patients with severe COVID-19 pneumonitis deemed inappropriate for invasive ventilation and did not benefit from HFNO. Further, HFNO may have been associated with harm in this group. Copyright © 2022 Merchant et al.
ABSTRACT
Background: Lead extraction procedures historically involve overnight hospital observation to detect delayed manifestation of procedural complications. The need for routine hospitalization patients after uncomplicated lead extractions remains to be determined. A desire to limit hospitalization during the COVID 19 pandemic provided an opportunity to assess the appropriateness of same-day discharge (SDD) after lead extraction. Objective: To determine the appropriateness of SDD and identify characteristics that identify potential candidates for SDD in a selected cohort after lead extraction. Methods: We reviewed procedural outcomes in consecutive patients undergoing lead extraction between Jan 2020 and October 2021. Events identified as complications during the first 30 days after the procedure include death, the need for rescue cardiac/chest surgery, hemopericardium with or without tamponade, venous tear, septic embolism, hematoma or pneumothorax requiring intervention, and access-associated AV fistula. Results: One-hundred eighty-four patients, 53% women of mean age 65.6± 14 years, underwent lead extraction at our institution during the specified interval. We discharged seventy-three patients (40%) on the same day;we chose to observe another 111 (60%) in the hospital at least one night. Table 1 shows the baseline and procedural characteristics in both groups. The SDD cohort preferentially included older (68 ± 12 vs. 63.2 ± 16.7, p=0.02) patients, women (59% vs. 44%, p=0.02), those with fewer (1.4 vs. 1.9, p<0.001) leads requiring extraction, a shorter lead dwell time (3.5 ± 4.2 years vs.7.4 ± 12 years, p=0.01), and an indication for extraction other than infection (4% vs. 54%, p<0.0001). The SDD patients suffered fewer complications (0 vs. 6%, p<0.001). Complications observed in the non-SDD group include one femoral AV fistula requiring surgical intervention, three pocket hematoma, and three septic emboli causing hemodynamic instability. Four patients died from underlying sepsis during their hospitalization. Conclusion: SDD appears appropriate in selected patients following lead extraction. Women with relatively fewer leads, shorter lead dwell times, and indications other than infection appear reasonable candidates for SDD. Age alone does not identify better candidates for SDD. [Formula presented]