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INTRODUCTION: Bivalirudin remains a viable strategy during extracorporeal membrane oxygenation (ECMO). The accuracy of activated partial thromboplastin time (aPTT) for bivalirudin intensity in ECMO may be imperfect resulting in suboptimal dosing, which may increase the risk of bleeding or thrombotic complications. The purpose of this study was to evaluate the correlation between PTT and thromboelastography (TEG) reaction (R) time in adult ECMO patients anticoagulated with bivalirudin. METHOD(S): This was a multicenter, retrospective study conducted over a 22-month period (January 2020 to October 2021. Adult ICU patients requiring ECMO and bivalirudin therapy with >=1 corresponding TEG and aPTT samples drawn <=4 hours of each other were included. The primary endpoint was to determine the correlation coefficient between the TEG R time and bivalirudin aPTT serum concentrations. Pearson's correlation coefficient was used to evaluate the correlation using a kappa measure of agreement between TEG results and bivalirudin aPTT serum concentrations. RESULT(S): A total of 104 patients consisting of 848 concurrent laboratory assessments of R time and aPTT were included. COVID-19 positive tests were confirmed in 48.1% (n=50) of included patients. A moderate correlation between TEG R time and aPTT was demonstrated in the study population (r=0.41;p< 0.001). A similar relationship between TEG R time and aPTT was observed in both COVID-19 positive (r=0.44;p< 0.0001) and negative (r=0.45;p< 0.0001). Overall, 59.2% of all concurrent TEG R time and aPTT values showed agreement on the study institution's therapeutic category (sub-, supra-, and therapeutic) of bivalirudin. 78.3% (n=277) of aPTT values were categorized as therapeutic among all discordant assessment (n=346) between TEG R time and aPTT. The discordant TEG R times with a therapeutic PTT were almost equally distributed between subtherapeutic and supratherapeutic categories. CONCLUSION(S): Moderate correlation was found between TEG R time and aPTT associated with bivalirudin during ECMO in critically ill adults. Further research is warranted to address the optimal test to guide clinical decision-making for anticoagulation dosing in ECMO patients with discordant results.
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SESSION TITLE: Challenging Cases of Hemophagocytic Lymphohistiocytosis SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Worsening respiratory disease is the most common complication of severe COVID-19. However, when patients develop multi-organ dysfunction, clinicians must have a high index of suspicion for rare syndromes such as hemophagocytic lymphohistiocytosis (HLH). CASE PRESENTATION: A 39-year-old male smoker presented with 1 week of shortness of breath and malaise. Initial physical examination revealed T 37.3 C, pulse 85 min-1, respiratory rate 18 breaths min-1, SPO2 96% and clear breath sounds without labored respirations. Chest X-ray showed bilateral patchy airspace opacities in the mid and lower lung fields. A SARS-COV2 PCR test was positive. The patient was prescribed antibiotics and discharged home. Subsequently, the patient's symptoms worsened and he presented 1 week later with SPO2 90% (O2 10 L/min via nasal cannula). He was admitted to the hospital with COVID-19 pneumonia and began remdesivir, barcitinib, systemic steroids, albuterol and IV antibiotics. On admission his complete blood count and complete metabolic panel were unremarkable. After 3 weeks of hospitalization, he developed multi-organ failure with acute liver injury, acute kidney injury, shock, pancytopenia and worsening hypoxemia leading to endotracheal intubation and mechanical ventilation. CT chest imaging showed bilateral ground glass opacities in the lungs with superimposed consolidation (figure 1). Blood cultures remained sterile, HIV, hepatitis B and C viral serologies were negative. Serum viral polymerase chain reaction detected Herpes Simplex Virus-1 (HSV-1) and Epstein Barr Virus (EBV) infections. Trans-jugular liver biopsy confirmed HSV-1 hepatitis and showed sub-massive hemorrhagic necrosis of the liver (figure 2). Bone marrow biopsy demonstrated phagocytic histiocytes engulfing red blood cells and platelets consistent with HLH (figure 3). The patient began HLH targeted therapy with anakinra and high dose steroids. Despite this, the patient continued to deteriorate, developed refractory shock and subsequently expired. DISCUSSION: HLH is a rare disease of the immune system in which a genetic or infectious trigger causes uncontrolled T cell activation. T cell activation triggers macrophage activation, cytokine storm and macrophage phagocytosis of erythrocytes, leukocytes, platelets and precursors in the bone marrow and other tissues. If the syndrome is unrecognized, it can quickly lead to multi-organ failure and death. EBV is the most common infectious trigger of HLH;however, infection with HSV-1 and SARS-COV-2 viruses have been identified as rare and independent causes. CONCLUSIONS: This case illustrates the high index of suspicion providers should have for HLH in patients with severe COVID-19 who develop multi-organ injuries. Once HLH is suspected, prompt initiation of HLH-94 protocol with etoposide and dexamethasone may be lifesaving. For those patients with liver failure, other agents (e.g. anakinra) may be provided. Reference #1: Ramos-Casals M, Brito-Zerón P, López-Guillermo A, et al.: Adult haemophagocytic syndrome. Lancet 2014;383:1503–1516 Reference #2: Risma K, Jordan MB: Hemophagocytic lymphohistiocytosis: updates and evolving concepts. Curr Opin Pediatr 2012;24:9–15 Reference #3: Trottestam H, Horne A, Aricò M, et al.: Chemoimmunotherapy for hemophagocytic lymphohistiocytosis: long-term results of the HLH-94 treatment protocol. Blood 2011;118:4577–4584 DISCLOSURES: No relevant relationships by Erin Biringen No relevant relationships by Christine Brennan No relevant relationships by Joann Hutto No relevant relationships by Daniel Puebla Neira
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SESSION TITLE: COVID-19 Infections: Issues During and After Hospitalization SESSION TYPE: Original Investigations PRESENTED ON: 10/17/2022 01:30 pm - 02:30 pm PURPOSE: To characterize the health care utilization (HCU) of patients after discharge from a hospitalization due to Coronavirus Disease 2019 (COVID-19). METHODS: Retrospective analysis from a national cohort using the Optum Clinformatics Data Mart. Included all adults hospitalized with a primary diagnosis of COVID-19 between April 2020 and March 2021, with prior 12 months of continuous enrollment. HCU of patients discharged to a home setting was evaluated in three periods (0-90 days;91-180 days;181-275 days post-discharge). HCU was defined as emergency department (ED) visits, inpatient (IP) admissions, rehabilitation/skilled nursing facility (SNF) admissions, outpatient (OP) and telemedicine visits and was expressed as the number of visits per 10,000 person-days to adjust for time from discharge. We also examined the distribution of office visits by provider specialty RESULTS: We identified 91,374 unique patients who were discharged alive after a hospitalization due to COVID-19. A greater percentage of patients was discharged to a home setting (n=63,674 or 65.6%: home 41.54%;home with home health services 14.65%: home with outpatient services 4.42%) than to a non-home setting (26.23%: i.e., SNF, hospice, rehabilitation facility, etc.). The patients discharged to a home setting were mostly white (58.8%), females (53.4%), whose mean age was 72.4 (SD± 12). The percentage of office visits to Primary care provider (57.8%;48.3%, 47.7%), Cardiology (7.7%;8.0%;7.4%) Pulmonary medicine (4.7%;3.9%;3.1%) varied in the 3 time periods evaluated. Additionally, the outpatient visits to endocrinology (1.3%, 1.6%, 1.7%), Neurology (1.1%, 1.5%, 1.5%), Physical Medicine & Rehabilitation (0.7%, 1.0%, 1.2%), Psychiatry (0.7%, 0.9%, 1.1%) and other mental health professionals (0.4%, 0.5%, 0.5%) increased over time. CONCLUSIONS: In our nationally representative study, health care utilization remains high among patients discharged to a home setting after a hospitalization due to COVID-19. Additionally, the use of mental health services increased overtime among survivors. CLINICAL IMPLICATIONS: Understanding post-discharge health care utilization of patients after an index hospitalization due to COVID-19 will help health systems prepare and allocate resources for the most likely to be used services. DISCLOSURES: No relevant relationships by Alexander Duarte No relevant relationships by Yong-Fang Kuo No relevant relationships by Shawn Nishi, value=Consulting fee Removed 04/03/2022 by Shawn Nishi No relevant relationships by Efstathia Polychronopoulou No relevant relationships by Daniel Puebla Neira No relevant relationships by Gulshan Sharma No relevant relationships by Mohammed Zaidan
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Rationale. Chronic obstructive Pulmonary Disease (COPD) has been associated with severe coronavirus disease 2019 (COVID-19) in Chinese and European cohorts. To date, no studies have evaluated the outcomes of COVID-19 in a selected cohort of patients with COPD in the United States (USA). We hypothesize that patients with COPD infected with Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV2) will have higher likelihood of 14-day hospitalization, mechanical ventilation use, and mortality compared to non-COPD SARS-CoV2 positive patients. Methods. We performed a retrospective analysis of electronic health records (EHR) from facilities across the 4 geographical regions of the USA (Optum Covid-19 Biweekly Data). We defined COVID-19 positive as having International Classification of Disease-10 (ICD-10) code of U07.1, or positive laboratory test results. COPD patients are defined by having at least 2-outpatient visits or 1- inpatient visit with any COPD diagnosis codes within a year prior to COVID-19 positive date. Results. We studied a cohort of 150,775 patients with COVID-19 between March and August 2020 in the United States. COPD was identified in 6,056 (4%) patients. The baseline characteristics of the cohort are presented in table 1. The percentage of patients with COPD and COVID-19 admitted to the hospital in 14-days for any cause was greater than that for non-COPD COVID-19 patients (28.7% vs 10.42%, p< 0.0001). The mean length of stay was longer for COPD with COVID-19 individuals than that for non-COPD COVID-19 patients (12.3 days vs 9.0 days, p<0.001). Amongst all hospitalized, the percentage of patients who required ICU was greater for COPD patients with COVID-19 than that for non-COPD patients (26.4% vs 16.11%, p<0.001). In addition, mechanical ventilation use was higher in COPD vs non-COPD COVID-19 patients (26.4% vs 16.11%, p<0.001) Moreover, the percentage of patients who died in 30 days was greater for COPD than that for non-COPD COVID-19 patients (13.6% vs 7.25%, p<0.0001). Discussion. Patients with COPD and COVID-19 have worse outcomes compared to non-COPD COVID-19 patients.
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Rationale. The association between smoking status and severe Coronavirus Disease-2019 (COVID-19) remains controversial. To assess the risk of 14-day hospitalization, as a marker of severe COVID-19, in patients who are ever-smokers and tested positive for the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) compared to those who are never smokers and tested positive for the virus in a single academic health system in the United States. Methods. We conducted a retrospective cohort study of patients who tested positive for SARS-CoV-2 in the University of Texas Medical Branch Health System between March 1st and October 30th 2020 to identify the risk of 14-day hospitalization in ever-smokers compared to non-smokers. Results. In our study period, we identified 5,738 patients who met the inclusion criteria and had documentation of smoking habits. Out of this group, 636 (11%) were consider to be ever-smokers. One hundred and ninety one patients were current smokers and 445 were former smokers. Of the 5,738 patients, 35.1% were male, average age was 43.8 (SD± 17.6), 37.4% were Caucasian, 51.5% were obese (BMI≥30), 3.19 % had vaping history, and 76.5% had at least one comorbidity. We identified 624 (10.8%) patients who were admitted in 14 days and 49(0.8%) who died in 14 days during hospitalization. The percentage of ever smokers admitted in 14 days was greater than that of never smokers (17.9% vs 10%, p<0.0001). In addition, the percentage of smokers who died in 14 days was greater than that of never smokers (2.8% vs 0.6%, p<0.0001). However, after adjusting for other covariates the odds for 14-day hospitalization among ever smokers with COVID-19 was not significant (OR 0.96, 95% CI 0.7-1.2). Conclusions. In our single center study, smoking status was not associated with severe COVID-19 infection.
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RATIONALE: The association between smoking status and severe Coronavirus Disease 2019 (COVID-19) remains controversial. OBJECTIVE: To assess the risk of hospitalization (as a marker of severe COVID-19) in patients by smoking status: former, current and never smokers, who tested positive for the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV2) at an academic medical center in the United States. METHODS: We conducted a retrospective cohort study in patients with SARS-COV2 between March-1-2020 and January-31-2021 to identify the risk of hospitalization due to COVID-19 by smoking status. RESULTS: We identified 10216 SARS-COV2-positive patients with complete documentation of smoking habits. Within 14 days of a SARS-COV2 positive test, 1150 (11.2%) patients were admitted and 188 (1.8%) died. Significantly more former smokers were hospitalized from COVID-19 than current or never smokers (21.2% former smokers;7.3% current smokers;10.4% never smokers, p<0.0001). In univariable analysis, former smokers had higher odds of hospitalization from COVID-19 than never smokers (OR 2.31;95% CI 1.94-2.74). This association remained significant when analysis was adjusted for age, race and gender (OR 1.28;95% CI 1.06-1.55), but became non-significant when analysis included Body Mass Index, previous hospitalization and number of comorbidities (OR 1.05;95% CI 0.86-1.29). In contrast, current smokers were less likely than never smokers to be hospitalized due to COVID-19. CONCLUSIONS: Significantly more former smokers were hospitalized and died from COVID-19 than current or never smokers. This effect is mediated via age and comorbidities in former smokers.