A RARE CASE OF HISTOPLASMA CAUSING OBLITERATION OF THE SUPERIOR VENA CAVA AND SUBSEQUENT DEVELOPMENT OF COLLATERAL CIRCULATION

SESSION TITLE: Critical Cardiovascular Disorders SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Physicians are educated on the traditional pathways of sanguineous return of the head and neck through the superior vena cava (SVC). There are known causes of disruption of this system such as SVC syndrome and malignancy causing compression, delayed transit or invasion of these vessels. While compensatory angiogenesis is not a new concept, it has been primarily documented in cases involving coronary artery circulation or congenital heart defects. Here, we present a rare case of the development of left-sided collateral flow in lieu of a right sided SVC with connection to the IVC as a complication of histoplasma infection. CASE PRESENTATION: Our patient was a 67-year female with a past medical history of histoplasmosis, asthma and diabetes who presented with a chief complaint of shortness of breath. Shortly following admission, she was diagnosed with COVID19. In the course of her diagnostic evaluation, she was noted to have significant abnormalities of her thoracic vasculature. More specifically, she had developed calcified granulomas that included a large old calcified granuloma of her right hilum that caused a complete obliteration of her SVC and right middle lobe airways. Her right middle lobe airways had evidence of chronic scarring with development of left sided collateral circulation. Her collateral flow went through her innominate vein into her azygos system and from there into her inferior vena cava and back to her heart. DISCUSSION: It is well established in the literature that histoplasma can lead to scarring and granulomatous changes within lung parenchyma. Our case is unique in the location where the patient developed a granuloma. The close proximity to the SVC over time led to the complete obliteration of the vessel and as a compensatory mechanism her body developed collateral circulation to the left side via her azygous vein and IVC. While we were unable to find similar cases in the literature specifically caused by histoplasma, other phenomena have led to the development of collateral circulation within the lungs. Specifically, Genta et. al. published a case report of an acute pulmonary vein occlusion leading to the development of collateral circulation through the patients' bronchial veins and into the azygous & hemiazygos system similar to our patient. One of the clinical implications for this patient during her hospitalization was the severity of her illness with COVID19. She did require treatment in the intensive care unit. This prompted a discussion among the treatment team regarding developing a plan of action for central line placement should this patient have required vasopressor support. CONCLUSIONS: This case stresses the importance of understanding primary anatomy in order to comprehend potential variants and predict future consequences for patients. It also highlights how sequela of chronic conditions can impact treatment plans. Reference #1: Yu CH, Chen MR. Clinical investigation of systemic-pulmonary collateral arteries. Pediatr Cardiol. 2008 Mar;29(2):334-8. doi: 10.1007/s00246-007-9086-y. Epub 2007 Sep 18. PMID: 17876652. Reference #2: Schaper W. Development of the collateral circulation: History of an idea. Exp Clin Cardiol. 2002 Fall;7(2-3):60-3. PMID: 19649224;PMCID: PMC2719163. Reference #3: Genta PR, Ho N, Beyruti R, Takagaki TY, Terra-Filho M. Pulmonary vein thrombosis after bilobectomy and development of collateral circulation. Thorax. 2003 Jun;58(6):550-1. doi: 10.1136/thorax.58.6.550. PMID: 12775876;PMCID: PMC1746717. DISCLOSURES: No relevant relationships by Alessandra Carrillo No relevant relationships by Chetachi Odelugo No relevant relationships by Shil Punatar No relevant relationships by Ravi Sundaram

Optimising filter lifespan in critically ill patients with SARS-CoV-2 receiving renal replacement therapy: An observational study in a district general hospital

Introduction: Acute kidney injury (AKI) and need for renal replacement therapy (RRT) is a known complication of SARS-Coronovirus-2 (SARS-CoV-2) in critically ill patients. 1 Early evidence suggested SARS-CoV-2 patients have increased incidence of filter cartridge failure on RRT.2,3 Frequent filter changes can lead to reduced therapy delivery, increased cost and anaemia. To mitigate this, our intensive care unit developed a new protocol for patients with SARS-CoV-2 requiring RRT to balance the benefits of preserving filter lifespan and risks of anticoagulation associated bleeding. Objectives: To investigate whether an increased citrate dose and an adjusted RRT prescription would increase the filter lifespan for patients with SARS-CoV-2. Methods: We performed a retrospective observational study looking at all patients admitted to our Level 3 critical care unit since the pandemic in March 2020 to date. Data was collected from Ward Watcher, a Scottish Intensive Care Society Audit Group (SICSAG) database and the CAREVUE electronic patient records. We introduced a modified RRT prescription for continuous venovenous haemodiafiltration (CVVHDF) with a citrate dose of 4mmol/l, increasing the dialysate flow rate to 1500ml/hr to mitigate the risk of increased citrate load. Results: During the period for data collection, the unit had 106 patients with SARS-CoV-2 of whom 15 required RRT. The median duration spent on RRT was 188 hours (range 24-677). Eight patients were managed exclusively on the adjusted protocol. The average lifespan of a filter in SARSCoV-2 patients on the standard protocol was 37 hours compared to 45 (range 6-70) hours using the adjusted protocol. The median number of filters per patient per RRT day on the adjusted protocol was 0.3 (range 0.2 -1). It also allowed more therapy to be delivered with patients spending on average 79% of the day on RRT. There were no adverse bleeding outcomes and no documented evidence of citrate toxicity or acid-base disturbances Conclusion: This small study showed an increase in filter life for patients on an increased citrate dose protocol of CVVHDF without any adverse outcomes. This results in cost savings and more appropriate resource usage during a pandemic without increased bleeding risk. Another suggested measure to reduce frequent filter malfunctions was that centres returned to using heparin anticoagulation, but this is known to have increased bleeding risk.4.

Rationalising glycaemic control in critically ill patients during the Sars-CoV-2 pandemic

Introduction: Poor glycaemic control is associated with worse outcomes in critically ill patients.1,2 A blood glucose target of 6-10 mmol/L was suggested by the NICE-SUGAR trial. In the context of hyperglycaemia, this target is achieved utilising variable rate insulin infusions (VRIIs). Furthermore, there is increasing evidence that critically ill patients with SARS -CoV -2 infection suffer more complications if they are diabetic or have altered glycaemic control.3 Through a series of Plan-Do-Study-Act (PDSA) cycles, we attempted to improve the glycaemic management of critically ill patients in our Intensive Care Unit (ICU) over the last twelve months. Objectives: Through a retrospective multi-cycle audit and QI project we sought to: 1. Identify our diabetic patient demographics 2. Understand our current practices around use of VRIIs and rationalising of glycaemic management upon discharge from ICU 3. Improve documentation of glycaemic management plan upon discharge. 4. Actively collaborate with the Endocrinology team to produce local guidance. Methods: The RAH is a 7 bedded Level 3 ICU which admitted 324 patients between August 2020 and August 2021. All ICU survivors with a length of stay >24 hours were included. Data was collected retrospectively at the end of each cycle via ICCA Carevue between September 2020 and August 2021 in three cycles. Cycle 1 September 2020-December 2020, Cycle 2 January 2021-May 2021 and Cycle 3 June 2021-Ongoing. Intervention 1 (post cycle 1): Presentation of baseline data to department Intervention 2 (post cycle 2): Addition of Glycaemic Management plan to ICU discharge form on ICCA Carevue Intervention 3 (mid cycle 3) Creation of Guidance on Glycaemic Management at discharge from RAH ICU departmental guide created Results: Cycle 1 results: 56 eligible patients 14 of which were diabetic. 12 of these diabetic patients were discharged on a VRII. Three patients (25%) had a documented glycaemic management plan upon discharge. Cycle 2 results: 60 eligible patients, 17 were diabetic. 11 of these diabetic patients were discharged on VRII. Six patients (54.5%) had a documented glycaemic management plan upon discharge. Cycle 3 results: eligible patients, 11 were diabetic. 9 of these diabetic patients were discharged on a VRII. Eight patients (88.8%) had a documented glycaemic management plan upon discharge. Conclusion: Using PDSA cycles and Quality Improvement methodology, we have demonstrably improved the percentage of diabetic ICU patients with documented glycaemic management plans upon discharge. We have also encouraged formulation of a clear glycaemic plan and involvement of the endocrinology team upon discharge ensuring opportunities are not missed to reduce downstream VRII use where possible. The above guidance document has been a collaborative process between ICM and Endocrinology ensuring that support is available for doctors in ICU. Randomised control studies such as SWEET-AS have highlighted the long-term impact of diabetes in ICU survivors. 4 Our QI work confirms that it is important to understand the needs of the local population and ensure robust guidance is in place when optimising patient's glycaemic control safely.

PRIVACY CONCERNS AND PROTECTION BEHAVIOR DURING THE COVID-19 PANDEMIC

This paper aims to analyze the protection behavior of employees while working remotely during the Covid-19 pandemic using online video chat software. This pandemic changed the way organizations work, managers meet with employees, and employees communicate. An e-mail-based survey among computer users who use video chat software for remote working is employed in this study. Using 306 responses, structural equation modeling explores the relationship between privacy concerns, protection behavior, and antecedents. The technological changes induced due to Covid-19 influence privacy concerns and protection behavior. Privacy efficacy increases privacy concerns and protection behavior. Perceived vulnerability increases privacy concerns. Perceived effectiveness of organization software affects privacy concerns but does not affect protection behavior. There is a positive relationship between privacy concerns and protection behavior;however, this positive relation is negatively moderated by a propensity to trust. A finding of threat severity measure using Covid-19 factors concludes that both privacy concerns and protection behavior increased for online video chat software users. The theoretical model explicates 75% of variances in privacy concerns and 57% of variances in protection behavior. Every one-unit increase in Covid-19 induced changes regarding the work environment increases the privacy concern by 35%, and every one-unit increase in perceived effectiveness of organization software increases privacy concern by 22%. Every one-unit increase in the privacy concern increases the protection behavior by 48%, and every one-unit increase in privacy efficacy increases protection behavior by 59%. © 2022 The author(s).

Low-molecular-weight heparin dosing and anti-xa level monitoring in critically ill COVID-19 adults

INTRODUCTION: Coronavirus disease-19 (COVID-19) is associated with a prothrombotic state and increased incidence of thromboembolic disease. Despite limited evidence, many ICUs have implemented increased prophylactic anticoagulation dosing protocols. However, anticoagulant medications increase the risk of bleeding and warrant additional monitoring. As a result, based on the Thromboembolism and Anticoagulant Therapy During the COVID-19 Pandemic: Interim Clinical Guidance from the Anticoagulation Forum, the study site increased doses of venous thromboembolism prophylaxis (VTEP) to a standard dose of enoxaparin 40 mg subcutaneous (subcut) Q12H for critically ill patients with COVID-19. For patients less than 60 kg, the dose was decreased to enoxaparin 30 mg subcut Q12H. Additionally, anti-Xa level monitoring was utilized to enhance monitoring for patients receiving enoxaparin. METHODS: This retrospective, observational study aimed to describe the anti-Xa level findings and enoxaparin dose adjustment needs. Patients with an estimated creatine clearance of less than 30 mL/min were excluded. Data collection included weight, serum creatinine, enoxaparin dose, anti-Xa levels, peak D-dimer, incidence of pulmonary emboli (PE), deep vein thrombosis (DVT), major bleeding, and minor bleeding, and ICU length of stay (LOS), hospital LOS, and mortality. Data below are presented as median (IQR). RESULTS: Seventeen adults were in the included and 76.5% (n=13) were started on enoxaparin 40 mg subcut Q12H. Twenty-three anti-Xa levels drawn at steady state. Of those, 82.6% (n=19) were within goal range, 8.7% (n=2) were below goal range, and 8.7% (n=2) were above goal range. Peak D-dimer was 2594 ng/mL (1575.5, 13086.3), two patients (10%) had a DVT, and no PEs were detected. Neither of the patients were receiving enoxaparin for VTEP at the time of the DVT. One patient (5%) had minor bleeding and no major bleeding was observed. The ICU LOS was 7 days (5, 15). Prior to the implementation of increased enoxaparin dosing, 4 anti-Xa levels were drawn for 4 patients on enoxaparin 40 mg subcut Q24H and 3 (75%) were below goal range. CONCLUSIONS: In conclusion, when utilizing increased doses of enoxaparin for VTEP, the majority of anti-Xa levels were within goal range and only 1 patient experienced minor bleeding.