ABSTRACT
Background: Gastrointestinal (GI) bleeding is one of the impactful complications in patients hospitalized from Covid-19 infection. The previous study showed the risk factors of overall (upper and lower) GI bleeding in patients with Covid-19 infection but no study focused on patients with upper GI bleeding (UGIB). This study aimed to identify the risk factors and outcomes of patients who were hospitalized from Covid-19 infection and developed UGIB. Methods: This is a retrospective in university-hospital which enrolled patients who were admitted due to Covid-19 infection and developed UGIB between April and October 2021. The primary outcome was the associated factors of high risk UGIB defined by having hematemesis or fresh blood from NG tube or hematochezia plus hemodynamic instability. The secondary outcomes were etiologies of high risk UGIB and mortality in those patients. Results: Of 7,214 patients hospitalized though the period, 49 patients (0.7%) had evidence of UGIB. The majority were male (63.3%) with mean ages of 70+12 years. Twenty-seven from 49 patients (55.1%) had mechanical ventilator, 40 patients (81.6%) received systemic corticosteroids, and 13 patients (26.5%) received anticoagulants for venous thromboembolic prophylaxis. Seven from 49 patients (14%) had high risk UGIB;5 hematemesis (71.4%), 1 fresh blood from NG tube (14.3%), and 1 hematochezia (14.3%). There was no significant difference in term of number of patient taking antiplatelets, anticoagulants, or steroids and severity of COVID-19 infection (e.g. Mechanical ventilator needed) between two groups. The emergency endoscopy was performed in 6/7 (85.7%) patients and showed 5 peptic ulcer with non-bleeding visible vessel and 1 gastric lymphoma with blood oozing (Table 1). All 6 patients underwent endoscopic hemostasis including adrenaline injection, bipolar coaptation, clipping, Hemospray®, and over-the-scope clip. There was a robust result when conducting uni- (p=0.005) and multi-variate analysis (OR 6.38;95%CI 1.04-38.92;p= 0.045) that an absence of proton-pump inhibitor (PPI) use was the significant risk factor of high risk UGIB in targeted patients (Table 2). The overall mortality rate in patients with UGIB was 20/49 (40.8%) and 1 from 20 patients (5.0%) expired from UGIB due to moribund condition and unsuitable for endoscopy. None of patients with high risk UGIB and underwent therapeutic endoscopy expired during admission. Conclusion: Our study demonstrated that the absence of PPI use was a sole significant risk factor for high risk UGIB which required therapeutic endoscopy in patients with COVID-19 infection. We suggest that PPI prophylaxis should be prescribed in those patients once they need hospitalization regardless of the severity of COVID-19 infection and anticoagulant usage to minimize the severity of UGIB.(Table Presented)
ABSTRACT
DDW 2022 Author Disclosures: Jukkaphop Chaikajornwat: NO financial relationship with a commercial interest ;Rapat Pittayanon: NO financial relationship with a commercial interest ;Prooksa Anancheunsook: NO financial relationship with a commercial interest ;Rungsun Rerknimitr: NO financial relationship with a commercial interest Introduction: Esophagogastroduodenoscopy (EGD) has been considered as an aerosol-generating procedures (AGP) with high risk of transmission of respiratory aerosols similar to an endotracheal intubation during COVID-19 pandemic. However, the risk of AGP at different distances to the patient’s mouth and the benefit of the protective measure such as the head box have never been fully studied. We performed a randomized control trial to evaluate the efficacy of acrylic head box for preventing the aerosol spreading to personnel standing at different distances to the patient’s mouth during EGD. Method: This trial is a randomized, open-label, single center, in adult patients scheduled for EGD between September and November 2021. Patients were randomly assigned with 1:1 allocation to either head box group or without head box group (control group). The 0.3- and 0.5-micron aerosol particles were measured with particle counters (PCE-PCO 1;PCE Deutschland GmbH, Meschede, Germany) at nurse anesthetist’s and endoscopist’s position for 2 minutes before EGD, and every 30 seconds automatically entire the procedure. The primary composite outcomes were the mean difference of aerosol particle level between during and before EGD at the nurse anesthetist’s face position (40 cm from the patient’s mouth) and at the endoscopist’s face position. (Figure) Result: The analysis included 50 patients undergoing EGD in each arm. The baseline characteristics were not difference between the 2 groups. The mean distance between the endoscopist’s face and the patient’s mouth was 66.1 ± 4.9 cm. (Figure) The mean differences of both 0.3- and 0.5-micron particle levels between during the procedure and baseline before the procedure measuring at the nurse anesthetist's position decreased in the head box group whereas those particle level increased in the control group (-491.9 versus 1095.8 particle/L (P=0.008) and -366.7 versus 249.8 particle/L (P=0.004), respectively). There was no significant difference of the mean differences of either 0.3- or 0.5-micron particle levels between during the procedure and baseline before the procedure measuring at the endoscopist’s position whether with or without headbox. (Table) Conclusion: EGD with the head box can reduce significant aerosolization to the endoscopy personnel including nurse anesthetist who standing near the patient’s mouth. However, those who stand further away such as the endoscopist who stands about 2 feet away from the patient’s mouth is already safe from aerosolization and does not get benefit from the head box because AGP from EGD affects only to the short-distant area. [Formula presented] [Formula presented]
ABSTRACT
For management of endoscopy units during the worldwide coronavirus disease 2019 (COVID-19) outbreak caused by the new coronavirus SARS-CoV-2 in Thailand, a working group of the Thai Association for Gastrointestinal Endoscopy (TAGE) in collaboration with the Endoscopy Nurse Society (Thailand) (ENST) has developed the following recommendations for Thai doctors and medical personnel working in gastrointestinal endoscopy (GIE) units. Upper and lower GIE is considered as an aerosol generating procedure (AGP). Information regarding chance of infection in patients must be obtained before performing endoscopy to help determine the level of risk. Endoscopies should only be performed in emergency/urgency cases. Hospitals that have no confirmed cases with low incidences of infection in their coverage area may consider performing selective endoscopies. For the confirmed infected patient, the recommendations are as follows;the endoscopist who performed the procedure must be an experienced one, wear the enhanced personal protective equipment (PPE) with correct practice how to wear and take off PPE, and strict hand hygiene. The endoscopic procedure should be performed in a negative pressure room;however, If not available, a bedside procedure in the cohort ward should be performed. Endotracheal tube intubation and removal should be done by an anesthesiologist. Most enzymatic detergent solutions can eliminate SARS-CoV-2. The use of an additional pre-cleaning process in order to prevent AGP from occurring during endoscope reprocessing is recommended. Patient(s) under investigation (PUI) should wait for the test result before considering endoscopic procedure. For the low risk patient for COVID-19 infection who needs an endoscopic procedure, standard PPE is recommended. Due to the limitation of medical resources, only medical personnel who are necessary for the procedure and at risk of COVID-19 infection should be allowed to use the recommended PPE.