ABSTRACT
SESSION TITLE: Outcomes Across COVID-19 SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: ED clinicians play a critical role in the early detection and management of septic shock. Intravenous fluid (IVF) resuscitation is a central component of the recommended treatment for septic shock (SEP-1), but experts have expressed concerns that excessive fluid administration to patients with COVID-19 could lead to poor clinical outcomes due to the development of ARDS like lung physiology. COVID-19 status is often unknown in the first several hours after ED arrival and withholding adequate IVF resuscitation to patients with septic shock is known to be harmful. Our objective was to evaluate whether adult ED patients meeting criteria for septic shock (≥2 SIRS + initial lactate ≥4 or Mean Arterial Pressure (MAP) <65) who receive 30ml/kg of IV fluids in the ED have poor clinical outcomes, if they are later found to have COVID-19, compared to adult ED patients with non-COVID-19 septic shock. METHODS: In this retrospective cohort study we analyzed EHR of adult patients who visited any of 3 EDs within a single academic health system in Rhode Island. We included patients who had a discharge diagnosis of septic shock and presented to the ED between February 15 -September 30, 2020. The exposure was the receipt of 30ml/kg of IVF and outcomes were intensive care unit (ICU) admission, ventilator receipt, and inpatient mortality. We used multivariate logistic regression and adjusted for fluid volume, age, receipt of antibiotics, and Charlson Comorbidity Index. RESULTS: Of 278 patients with septic shock, 39 (14%) were COVID positive. 15 (38%) COVID positive patients received 30ml/kg IVF per SEP-1 bundle compared to 163 (68%) of COVID negative patients. The overall inpatient mortality rate of COVID positive septic shock patients (n=25, 64%) was three times higher as compared to COVID negative septic shock patients (n=51, 21%). Receipt of 30ml/kg IVF in the ED did not increase the odds of ICU admission [AOR 0.46 (0.07-3.26), p = 0.43], receipt of ventilator [AOR 0.40 (0.07-2.28), p=0.30], or inpatient mortality [AOR 0.15 (0.020-1.10), p=0.06] in patients who were COVID positive. However, in COVID negative patients, receipt of 30ml/kg IVF in the ED significantly reduced the odds of ICU admission [AOR 0.50 (0.27-0.93), p=0.029], receipt of ventilator [AOR 0.41 (0.22-0.74), p=0.003] and inpatient mortality [AOR 0.44 (0.22-0.87), p=0.018]. CONCLUSIONS: Optimal and timely fluid resuscitation per the SEP-1 bundle reduces the odds of unfavorable clinical outcomes in patients with septic shock who test negative for COVID-19, while causing no increased odds of harm to patients with COVID-19 and septic shock. Replication of our work in a post-vaccination cohort and during waves with different variants is advisable as the clinical outcomes may vary. CLINICAL IMPLICATIONS: Early fluid resuscitation in patients diagnosed with septic shock in the ED appears to be a safe strategy even in patients that are later diagnosed with COVID-19. DISCLOSURES: No relevant relationships by Natalie Davoodi No relevant relationships by Elizabeth Goldberg No relevant relationships by Richa Nahar
ABSTRACT
INTRODUCTION: Early enteral nutrition is beneficial in critically ill patients. Enteral nutrition may reduce muscle wasting, decrease length of ICU stay, stress ulcer development, maintain gut health, and reduce risk of bacterial pneumonia. In this study, we looked to see whether mechanically ventilated SARS-CoV-2 patients were receiving adequate tube feeds, identify barriers to feeding, and follow clinical outcomes in these patients with prolonged ICU stays due to hypoxemia. METHODS: Study Design: This study involved retrospective chart review of 33 mechanically ventilated patients at a medium sized university based hospital from February 2020 to April 2020 who had ARDS secondary to SARSCoV- 2. Main Outcomes and Measures: i) ICU length of stay ii) Time to initiation of tube feeding iii) Days Goal Caloric Intake achieved iv) Barriers to early tube feeding v) Mortality outcomes vi) Disposition RESULTS: On average, these patients were intubated for 12.1 ± 7.6 days and ICU length of stay was 15.6 ± 9.6 days. Initiation of tube feeding was 3.7 ± 2.5 days after mechanical ventilation. The main barriers to starting early enteral nutrition were vasopressor usage (93.9%), paralytics (69.6%), and proning (48.5%). For 64.34 ± 25.3% of the days intubated did the patients receive tube feeds, and only 39.7 ± 25.7% of the days intubated did patients receive one hundred percent of their goal caloric intake. Survival rate for patients aged ≥65 years was higher in patients tube fed >50% of the intubated days, compared to those who were tube fed for ≤50% of intubated days. Patients suffered severe protein calorie malnutrition and their BMI dropped by 8.2% at time of discharge. Also, patients with BMI ≥30 and age ≥65 years, had a 75% mortality rate, which was 1.7 times the overall average mortality rate of 45.5%. Of the 54.5% patients who survived the hospitalization, 12.12% were discharged home. 31.5% of the survived patients developed critical illness myopathy requiring aggressive rehabilitation therapy. CONCLUSIONS: Delayed initiation of enteral nutrition in intubated SARS-CoV-2 patients was mainly due to vasopressor and paralytic usage. Further studies are also needed to evaluate the nutritional requirements of intubated SARS-CoV-2 patients with long ICU stays as compared to non SARS-CoV-2 patients.