ABSTRACT
Introduction: New York City became the epicenter for the coronavirus disease 2019 (COVID-19) pandemic in the spring of 2020. Healthcare workers were faced with patients experiencing rapidly progressive respiratory failure, which led to the need for unconventional treatment approaches. Awake proning modified with alternating lateral decubitus positions was implemented to improve oxygenation in patients with type 2 acute respiratory distress syndrome (ARDS).1 In this case report, we discuss the positive outcome of one of many patients who improved with the modified proning approach implemented early on during their disease course. Case: A 59-year-old previously healthy male presented with fevers and shortness of breath for 10 days. He was febrile with saturation at 86% on room air with improvement to 94% on nasal cannula. Chest x-ray showed patchy bibasilar airspace opacities. His nasal swab for SARS-CoV-2 returned positive. Per protocol at the time, he was treated with Hydroxychloroquine and Azithromycin. He continued to deteriorate with increasing oxygen requirements. On hospital day 3, he desaturated to 77%. Patient was placed on 100% FiO2 via non-rebreather and placed in a prone position with improvement in his O2 saturation to 90%. He felt uncomfortable lying prone and was unable to assume the position for extended period of time. He was advised to alternate between prone positioning with lateral decubitus positions on either side as much as could tolerate. He continued to require oxygen supplementation via non-rebreather. On hospital day 20, he was weaned to room air and was discharged to a short-term facility. Discussion: COVID-19 is a pulmonary disease that causes type 2 ARDS1 at its most severe state. Proning mechanically ventilated patients has been established as a part of management in ARDS with severe hypoxemia. Its mechanism of improving oxygenation includes "affecting recruitment in dorsal lung regions, increasing end-expiratory lung volume, decreasing alveolar shunt, and improving tidal volume".4 During this pandemic, physicians extrapolated this concept and applied a modified maneuver on awake patients in attempts to improve oxygenation without invasive mechanical ventilation. The patient in this case demonstrated marked improvement with not only prone but also lateral decubitus positioning. This is one of many cases that showed the effectiveness of rotating the body in various positions early on during the disease process to prevent worsening of respiratory failure in mild to moderate type 2 ARDS in COVID-19. It also highlights the need for further research to expand it to other causes of ARDS.
ABSTRACT
SESSION TITLE: Critical Care Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: After the novel coronavirus disease (COVID-19), was declared a pandemic, New York quickly became the new epicenter of the disease, with Queens County reporting the most confirmed cases in the United States. This study was conducted during the peak of COVID-19 in Queens. Due to the severity of the disease and limited resources, patients were intubated at varying degrees of oxygenation. This study examines the preoxygenation state of COVID-19 ARDS patients prior to intubation and its implication on clinical outcomes. METHODS: At a single acute tertiary care hospital located in Queens, New York, all patients admitted between March 15 and April 15, 2020 were screened. Active COVID-19 status was confirmed with reverse transcriptase-polymerase chain reaction assay on nasopharyngeal samples. All COVID-19 patients who were intubated with documented pre-intubation oxygen saturation (PreO2) were included. All data were collected from the electronic health record, including laboratory data, ventilator settings, and hospital course. Peri-intubation cardiac arrest events up to 24 hours post-intubation and mortality during the study period were examined as outcomes. Data was analyzed with SPSS (version 25). Continuous variables were tested using independent T-tests. All tests of significance were two-tailed, and a p-value of 0.05 was considered significant. RESULTS: A total of 192 patients were included in the study. They had a mean age of 61.2 ± 12.2 years, and 130 (64.1%) were men. The mean preO2 of all patients was 71.3 ± 13.6, and the mean peri-intubation PF ratio was 120.84 ± 58.6. 32 out of 192 patients (16.7%) with peri-intubation cardiac arrest demonstrated significantly lower preO2 (p=0.03) compared to those without. These 32 patients also demonstrated more days with symptoms prior to intubation (p=0.004). 121 patients who expired during the clinical course demonstrated lower PreO2 (p=0.60) and PF Ratios (p=0.48) compared to the 71 patients who did not, but these comparisons were not statistically significant. Patients who expired demonstrated fewer symptomatic days prior to intubation than those who did not, but this was not statistically significant (p=0.06). CONCLUSIONS: At the time of intubation, the patients had significant hypoxemia and severe ARDS by PF ratio. Lower oxygenation prior to intubation is associated with an increase in peri-intubation complications. CLINICAL IMPLICATIONS: Due to unclear pathophysiology of ARDS in COVID-19, the optimal timing of intubation continues to be debated. Physicians should consider intubation earlier in the disease course prior to significant hypoxemia, which may have a negative impact on peri-intubation complications. Clinical outcome was further impacted by the restriction on preoxygenation of the patients prior to intubation, given its risk of viral aerosolization. Means of preoxygenating with minimal risk of disease spread should continue to be explored. DISCLOSURES: Advisory Committee Member relationship with Ambu Please note: $1-$1000 by Olumayowa Abe, source=Admin input, value=Honoraria No relevant relationships by Ahmed Al-Ghrairi, source=Web Response No relevant relationships by Christian Castaneda, source=Web Response No relevant relationships by Ettaib El Marabti, source=Web Response No relevant relationships by Hadya Elshakh, source=Web Response No relevant relationships by Teressa Ju, source=Web Response No relevant relationships by Michael Karass, source=Admin input No relevant relationships by Miri Kim, source=Web Response No relevant relationships by Jack Mann, source=Web Response No relevant relationships by Christina Jee Ah Rhee, source=Web Response No relevant relationships by Fizza Sajid, source=Web Response No relevant relationships by Angelina Voronina, source=Web Response
ABSTRACT
SESSION TITLE: Critical Care Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: After the novel coronavirus disease (COVID-19), was declared a pandemic, New York quickly became the new epicenter of the disease. This study was conducted during the peak of COVID-19 in Queens. Many COVID-19 patients with severe acute respiratory distress syndrome (ARDS) required endotracheal intubation and heavy sedation for prolonged periods of time. Unplanned extubation (UE) events have a notable impact on clinical course and outcome. [1] Self-extubation (SE) is the most common reason for UE, and inadequate sedation is one of its most significant risk factors. [1,2] This study examines factors associated with SE events in patients with ARDS in COVID-19. METHODS: At a single acute tertiary care hospital located in Queens, New York, all patients with SARS-CoV-2 infection admitted between March 15, 2020 and April 15, 2020, were screened. Active COVID-19 status was confirmed with reverse transcriptase-polymerase chain reaction assay performed on nasopharyngeal samples. All patients who underwent endotracheal intubation were included in the study. All data were collected from the electronic health record for 28-day outcomes. All UE events, including SE and other causes for UE, number and dosages of sedatives at the time of SE, adverse events, such as cardiac arrest and anoxic brain injury following UE, were examined. RESULTS: A total of 205 patients were included in the study. Of these, 24 patients (11.7%) had one or more UE. Nine were due to SE (4.4%). None of these patients had plans for extubation. Only one was not on sedation due to a delay on the general medicine floor. The rest were sedated on 2 or more sedatives, including continuous infusions of opioids, propofol, dexmedetomidine, and ketamine at high doses. (Table 1) Five patients out of 9 with SE got reintubated right after SE event (55.6%). Two patients with SE events did not require reintubation (22.2%). There were 2 cardiac arrests following 9 SE events (22.2%), and only 1 patient survived. The 28-day mortality for patients with SE and patients without any UE were 66.7 % and 62%, respectively. CONCLUSIONS: Multiple SE events occurred in ARDS in COVID-19 patients, who were on multiple sedatives without any plans for extubation trial. In comparison with SE in other ARDS patients, these patients required higher doses of sedatives to achieve adequate sedation. SE events also had a significant rate of complication. Although this study is limited by its small sample size, it provides a narrative of what the experience has been with the COVID-19 patients. This highlights the need for further studies with higher statistical power in order to better understand the disease characteristics. CLINICAL IMPLICATIONS: Critical care physicians should consider tracheostomy in ARDS patients with COVID-19, to prevent complications of heavy sedation required for endotracheal intubation and complications of SE. DISCLOSURES: Advisory Committee Member relationship with Ambu Please note: $1-$1000 by Olumayowa Abe, source=Admin input, value=Honoraria No relevant relationships by Ahmed Al-Ghrairi, source=Web Response No relevant relationships by Ettaib El Marabti, source=Web Response No relevant relationships by Hadya Elshakh, source=Web Response No relevant relationships by Teressa Ju, source=Web Response No relevant relationships by Michael Karass, source=Admin input No relevant relationships by Miri Kim, source=Web Response No relevant relationships by Jack Mann, source=Web Response No relevant relationships by Christina Jee Ah Rhee, source=Web Response No relevant relationships by Fizza Sajid, source=Web Response No relevant relationships by Angelina Voronina, source=Web Response
ABSTRACT
SESSION TITLE: Critical Care Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: As of May 2020, Queens County, New York reported the most confirmed cases of the novel coronavirus disease (COVID-19) in the United States. This study was conducted during the peak of COVID-19 in Queens. Many COVID-19 patients with acute respiratory distress syndrome (ARDS) required mechanical ventilation via endotracheal intubation for extended periods of time. This study examines the length of ventilation via endotracheal tube (ETT) and the outcome of extubation attempts (EXA). METHODS: At a single acute tertiary care hospital located in Queens, New York, all patients with COVID-19 admitted between March 15 to April 15, 2020, who were intubated with ETT were included. All data were collected from the electronic health record until April 25, 2020. Hospital course, extubation events, reintubation events, and number of tracheostomies were gathered. Number of ventilated days via ETT and mortality were studied as outcomes. Patients were divided into those who expired with ETT, were successfully extubated at first EXA, failed EXA, and underwent tracheostomy. Cardiac arrest and anoxic brain injury were studied as adverse events. RESULTS: 205 patients were included. Their mortality was 63.4% with 130 in-hospital deaths, of which 110 patients (54.7%) expired while on ventilator via ETT. 13 out of 205 patients (5.4%) were successfully extubated on first attempt, of which 2 were unplanned self-extubation events. The average ventilated days via ETT for this group was 9.36 days (SD 4.7 days). 7 out of 205 patients (3.4%) failed EXA. The average time to EXA in this group was 9.29 days (SD 5.8 days). There were 0 reported cardiac arrests or anoxic brain injuries following EXA. The average time from EXA to reintubation was 1.14 days (SD 1.9 days). 2 of the 7 patients who failed EXA expired on ventilator support via ETT. 36 out of 205 patients underwent tracheostomy. The mortality rate for this group was 19.4% (SD). The average ventilated days via ETT was 16.2 days (SD 5.3 days). CONCLUSIONS: COVID-19 patients that were intubated for severe ARDS had a notable mortality rate, and those who survived required a prolonged course of ventilation. Both groups of successful extubation and failed extubation had similar time on endotracheal ventilation prior to the attempt, making it an unlikely factor determining successful extubation. Patients who were able to undergo tracheostomy had lower mortality, but it is unclear if there was a direct correlation, as patients were generally less ill to be able to undergo such a procedure. CLINICAL IMPLICATIONS: Patients with severe ARDS in COVID-19 required a prolonged course of mechanical ventilation and exhibited a high likelihood of failure to extubate. In order to avoid the complications of prolonged ventilation via ETT, early tracheostomy should be considered. In the future, a larger cohort of patients should be examined to provide statistical reinforcement of our findings. DISCLOSURES: Advisory Committee Member relationship with Ambu Please note: $1-$1000 by Olumayowa Abe, source=Admin input, value=Honoraria No relevant relationships by Ahmed Al-Ghrairi, source=Web Response No relevant relationships by Christian Castaneda, source=Web Response No relevant relationships by Ettaib El Marabti, source=Web Response No relevant relationships by Hadya Elshakh, source=Web Response No relevant relationships by Teressa Ju, source=Web Response No relevant relationships by Michael Karass, source=Admin input No relevant relationships by Miri Kim, source=Web Response No relevant relationships by Jack Mann, source=Web Response No relevant relationships by Christina Jee Ah Rhee, source=Web Response No relevant relationships by Fizza Sajid, source=Web Response No relevant relationships by Angelina Voronina, source=Web Response