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SESSION TITLE: Critical Care Management of COVID-19 SESSION TYPE: Original Investigations PRESENTED ON: 10/17/2022 01:30 pm - 02:30 pm PURPOSE: To compare the incidence of hospital acquired infections (HAI) in patients treated with systemic corticosteroids (dexamethasone or equivalent alternative corticosteroid) with high (> 10 mg/day) vs low (6 mg/day) dose for COVID-19 related acute hypoxemic failure METHODS: Observational cohort study of COVID-19 patients from July 25 and Oct 1, 2021 at a tertiary care hospital. 227 hospitalized patients were positive for COVID-19. 168 patients were included in the analysis. Corticosteroid type and dose was analyzed. Comparison of high vs low dose cohorts was done. Primary outcome measure was incidence of HAI in each group. Bloodstream Infections (BSI), Hospital Acquired Pneumonia (HAP) and Urinary Tract Infections (UTI) were included. Secondary measures were number of patients requiring intubation, length of ICU stay and inpatient mortality. Descriptive statistics were used to compare variables between cohorts including body mass index (BMI), severity of illness (SOFA and modified SOFA scores) and glucose control RESULTS: Of 168 patients: 68 (40%) received high dose (> 10 mg dexamethasone) & 100 patients (60%) received low dose (6 mg dexamethasone) corticosteroids. High vs Low dose: Demographics: Age (57 vs. 64 years;p 0.21), sex (51% vs. 57% female;p 0.77) & chronic comorbidities including BMI (29.2 vs 33.1;p 0.45). Severity of illness scores at day of corticosteroid use were similar (SOFA 4.7 vs 4.1;p 0.71 & mSOFA 2.6 vs 2.3;p 0.07) despite difference in rates of patients that required intubation (56% vs 18%;p<0.001). 45% of intubated died in high dose compared to 18% in low dose group. Overall mortality was 29.4% vs 11%;p 0.011. Glucose control (insulin > 50 u/day) was worse in high dose group (35% vs 14%;p<0.01). Baricitinib or tocilizumab used in 60% vs 44% of intubated;p0.62). HAI data: BSI- High dose 18/68 (26.5 %) vs low dose group 13/10 (13%);p 0.07. UTI-High dose 4/68 (6%) vs low dose group 5/100 (5%);p 1.00. HAP-High dose 27/68 (39.7%) vs low dose group 11/100 (11%);p <0.001. High dose group HAP > 1 organism: 15/27 (MSSA 44%, Aspergillus 18%, MRSA 18%, Streptococcus 26%, Pseudomonas 18%, rest were Enterobacter, H Influenzae, Acinetobacter, Serratia, E coli, Klebsiella, Providencia and Citrobacter species at 3% each). Low dose group HAP > 1 organism: 2/11 (Streptococcus 36%, MSSA 27%, H Influenzae 18%, rest were pseudomonas, E coli, stenotrophomonas and acinetobacter species) CONCLUSIONS: In hospitalized COVID-19 patients with acute respiratory failure, high dose dexamethasone use was associated with significantly higher HAP rates compared to low dose dexamethasone. Moreover the high dose group had higher BSI, worse glucose control, higher intubations and deaths in the intubated cohort despite similar severity of illness in either group CLINICAL IMPLICATIONS: High dose dexamethasone may increase susceptibility to HAIs and negatively impact outcomes in COVID-19 associated hypoxemic failure DISCLOSURES: No relevant relationships by Beenish Bhutta No relevant relationships by Rosalyn Chi No relevant relationships by Jason Graf No relevant relationships by mohsin iqbal No relevant relationships by Rajat Kapoor No relevant relationships by Rachel Kruer No relevant relationships by Connor Parker No relevant relationships by Omar Rahman No relevant relationships by James Skinner
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Purpose/Aims Healthcare workers internationally continue to look for innovative ways to improve patient outcomes and optimize resource utilization during the coronavirus disease 2019 (COVID-19) pandemic. Proning awake, nonintubated patients has been suggested as a potential intervention in critical care. The aim of this study is to provide a multidisciplinary approach to safely perform awake self-prone positioning in the acute care setting. Design This is a prospective, descriptive study. Method Patients with COVID-19 were screened and enrolled within 48 hours of a positive test. After approval from the primary team, patients were provided education materials by a multidisciplinary team on the self-prone intervention. Visual cues were placed in the room. Patients were requested to maintain a diary of hours of prone positioning. Patients' baseline characteristics, admission vitals, daily oxygen requirements, and level of care were collected. Results Of 203 patients screened, 31 were enrolled. No pressure-related injury or catheter (intravenous or urinary) displacement was identified. Eighty-one percent of patients spent less than 8 hours a day in prone positioning. Among patients enrolled, none required invasive ventilation or died. Conclusions Awake self-proning can be performed safely in patients given a diagnosis of COVID-19 in the acute care setting with a multidisciplinary team.
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INTRODUCTION: Novel coronavirus disease 2019 (COVID-19) associated severe hypoxemic respiratory failure is mediated by severe inflammation that may be mitigated by administration of corticosteroids. Our aim was to evaluate pattern and effects of corticosteroid use in these patients during an initial surge of the pandemic. METHODS: An observational study of COVID-19 patients between March 1 and April 27, 2020 was conducted at a tertiary care academic hospital in Indianapolis, IN. Comparison of patients who received corticosteroids plus standard care to standard care only was done. Corticosteroid type, dose and timing of administration were analyzed. Outcome measures included number of patients requiring intubation, duration of mechanical ventilation, length of ICU stay and inpatient mortality. Descriptive statistics outlined the type, timing and duration of administration of corticosteroids during severe COVID-19. Clinical course and laboratory metrics were compared between patient cohorts. RESULTS: 626 patients tested positive for severe respiratory syndrome coronavirus-2 RNA by PCR during the specified time period. 136 COVID-19 patients admitted to the ICU were included in the analysis, and 72 (53%) received corticosteroids. Groups had similar demographics: age (60.5 vs. 65;p=0.083), sex (47% male vs. 39% female;p=0.338) and comorbidities. Corticosteroid group had increased severity of illness: PaO2/FiO2 ratios (113 vs. 130;p=0 .014) and SOFA scores (8 vs. 5.5;p<0.001). There was no difference in overall mortality (21% vs. 30%;p=0.234) or proportion of patients intubated (78 vs. 64%;p=0.078). There was no mortality difference among intubated patients (27% vs. 15%;p=0.151) however, there were no deaths among patients who were not intubated and received corticosteroids (0% vs 57%;p <0.001). Administering corticosteroids early (within 48 hours vs. 2-7 days, vs >7 days) was associated with decrease in proportion of patients intubated (66% vs. 87% vs. 100%;p=0.045), ICU days (6 vs. 16 vs. 18;p<0.001), and ventilator days (3 vs. 12 vs. 14;p<0.001). Methylprednisolone was used in 45% of patients. CONCLUSIONS: Early administration of corticosteroids in hypoxemic respiratory failure of COVID-19 improves survival in non-intubated patients, decreases ICU stay and may prevent intubation.
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Background: The SARS-CoV-2 pandemic has caused over 400,000 deaths worldwide thus far, and poses therapeutic challenges for millions of patients. There is currently no treatment for SARS-CoV-2 infection approved by the United States Food and Drug Administration. Multiple agents have been used off-label to treat SARS-CoV-2 infection based on small observational cohorts and in vitro data. Here we present the experience of a large academic medical center in treating SARSCoV- 2 infection. Methods: We performed a retrospective cohort study of patients admitted for greater than 24 hours with a nasopharyngeal, oropharyngeal, and/or bronchoalveolar lavage sample positive for SARS-CoV-2 by polymerase chain reaction (PCR). Demographic data, comorbidities, clinical data, and treatment data were collected from the electronic medical record. Off-label therapies were used at the discretion of the treating providers guided by regularly updated treatment guidelines assembled by infectious diseases physicians and antimicrobial stewardship pharmacists. The primary outcome assessed was in-hospital mortality. Secondary outcomes included admission to the intensive care unit (ICU), endotracheal intubation, initiation of vasopressors, and drug-related adverse events. Results: Data collection was completed for 448 patients admitted between March 18, 2020 and May 8, 2020. All-cause in-hospital mortality was 13.4% (60/448) during this time. Mortality rates increased with age, up to 45% for patients over 80 years old. Male sex, hypertension, chronic pulmonary disease, end-stage renal disease, chronic liver disease were also risk factors for increased mortality. QTc interval prolongation occurred significantly more frequently in patients who received hydroxychloroquine (HCQ) with or without azithromycin(AZM) than those who did not (HCQ 6%, HCQ+AZM 7.8% vs all other patients, 0%, p< .0001). Review of treatment trends showed close adherence to the treatment recommendations at that time (Figure 1). Conclusion: SARS-CoV-2 infection is associated with significant inpatient mortality, and use of off-label treatments was associated with significant drug-related adverse events. Treatment regimens changed rapidly, and providers adhered closely to institutional guidelines as they evolved. (Table Presented).
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Due to the inherent thrombotic risk associated with the ECMO circuit, therapeutic anticoagulation is recommended. While unfractionated heparin is commonly used due to wide availability, the use of bivalirudin, a direct thrombin inhibitor, is gaining popularity. The benefits of bivalirudin over heparin include: Relatively organ-independent metabolism, inhibition of fibrin-bound and freely circulating thrombin, rapid clearance, and less resistance. Early reports in the COVID-19 pandemic suggest a hypercoagulable state. Particular attention should be paid to adequate anticoagulation in the high-risk patients with SARs-CoV-2 on ECMO support. To date, there are few reports discussing the use of bivalirudin in COVID ECMO patients. Bivalirudin is the anticoagulation of choice for the maintenance of patients on ECMO at our institution. We conducted a retrospective analysis of the first 20 patients with COVID that required ECMO support. Data was collected on outcomes related to hemostasis. Standard protocol for ECMO patients includes screening duplex ultrasound at regular intervals following decannulation to evaluate for thromboembolism. Three patients did not receive screening due to terminal weans. Of the remaining 17 patients, 7 had confirmed acute venous thromboembolism. Four patients had hemorrhage requiring intervention;two cases of epistaxis, one intra-abdominal bleeding, and one cannulation site bleeding. One patient developed nonfatal intracranial hemorrhage that did not require intervention. Only two patients developed renal failure requiring temporary renal replacement therapy. This is in comparison to the 24% rate noted in the ELSO COVID-19 database. Our findings suggest bivalirudin is an alternative to heparin for appropriate COVID ECMO patients.