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INTRODUCTION: While the COVID-19 syndrome is triggered by infection and expansion of the SARS-CoV2 RNA virus, secondary opportunistic infections can be a significant contributor to morbidity. In prior studies, our group employed RNA sequencing of whole blood RNA to identify RNA biomarkers of COVID-19 infection and severity. In the present studies, those biomarkers were expanded. METHOD(S): We performed a single-center prospective cohort study of SARS-COV2 infected ICU patients (n=20) during the peak of the Omicron wave (Jan-Feb 2022). Participants were consented for a venous blood draw into an RNA preservative. Samples were stored at -80degree C. Stored blood was used for RNA purification and droplet digital PCR quantitation of 6 novel RNA biomarkers for bacterial (DEFA1), biofilm (ALPL, IL8RB/CXCR2), and viral infections (IFI27, RSAD2). Viral titer in blood was analyzed in parallel by ddPCR for SARS-CoV2 sequences (BioRad, EUA). RESULT(S): Among clinical biomarkers, Pearson correlational analysis with SOFA scores identified lactate (r=0.24), BMI (r=0.34), creatinine (r=0.58), and LDH (r=0.68), as the best predictors. Viremic titer was not associated with SOFA scores (r=-0.07). Among the RNA biomarkers ALPL (r=0.48), a biofilm marker, showed the best correlation with SOFA score. The RNA biomarkers of viral infection IFI27 (r=0.72) and RSAD2 (r=0.42) were positively correlated with SARSCoV2 viral titer, suggesting that the host immune response is proportional to the viremia of COVID-19. CONCLUSION(S): Collectively, the results suggest that whole blood RNA transcripts involved in the host immune response can indicate the presence and severity of infection, including unexpected comorbidities. Furthermore, these biomarkers can distinguish between viremia, biofilms, and other types of infections that may undermine recovery from COVID-19.
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BACKGROUND: The COVID-19 (COVID) pandemic has caused incalculable damages throughout the U.S., with over 34-million infections and 600,000 deaths as of July 2021. Many medical personnel on the frontline, especially within emergency departments, experienced immense burnout. Although the extent of the burnout at the beginning of the pandemic has been reported in the literature, there is a paucity of data on how that has evolved over time. We aimed to survey providers a year into the pandemic on stress and burnout in the setting of new vaccine availability. METHODS: Two online surveys were distributed among healthcare providers at a tertiary academic center between 2020 and 2021. The initial survey was composed of questions evaluating the level of burnout and risk perception. The latter had the same questions for comparison, as well as questions regarding vaccination status and the Professional Quality of Life Scale (PROQOL). Chi-squared tests were used to compare the results. RESULTS: There were 63 responses in 2020 and 78 responses in 2021. 94% received the COVID vaccine in 2021. Measures of risk perception, specifically “Feels job is imposing great risk” and “Afraid of falling ill with COVID” saw statistically significant decreases (87% to 62%, p= 0.001;76% to 45%, p< 0.001, respectively). Meanwhile, while the point estimate for “feeling extra stress at work” and “thinking about resigning” also decreased, neither were statistically significant (85% to 76%, p=0.148;11% to 9%, p= 0.673, respectively). The PROQOL results from 2021 showed most responders experienced either moderate or high levels of Burnout and Post-traumatic stress, but also Compassion Satisfaction (85%, 62%, and 96%, respectively). CONCLUSIONS: During the 1-year study period there were significant improvements in terms of risk perception, though burnout and stress remained high. The reduction in risk perception may be related to vaccination, given the high rate of vaccination among this group and temporal correlation. However further research is necessary to support this relationship, as well as identify other potential factors to help reduce burnout in future pandemics.
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INTRODUCTION: Endotracheal tube (ETT) complications are common in intensive care unit (ICU) settings due to ETT malpositioning and migration. Point-of-care ultrasound (POCUS) has shown promise in predicting accurate ETT position but the safety profile compared to chest x-rays (CXR) remains unknown. We assessed whether a POCUS-guided repositioning protocol was non-inferior to CXRs for adverse clinical outcomes. METHODS: Intubated patients enrolled from 4 multidisciplinary ICUs over a 1-month period were randomized into two arms: CXR-guided or POCUS-guided daily monitoring of ETT position. In the POCUS-arm, novice sonographers assessed ETT positioning daily (normal range: superior balloon border between the 3rd-7th tracheal rings) and recommended repositioning maneuvers accordingly. The protocol allowed clinicians to use CXR landmarks if they did not agree with POCUS recommendations. The CXR-arm used radiographic landmarks (normal range: ETT tip 5±2cm from carina) without sonography. Exclusion criteria included COVID-19 status, C-spine precautions, prone positioning, anterior neck wounds, or planned extubation within 24 hours. Investigators used Fisher's exact test (α-error 5%) to compare rates of ETT bronchial or vocal cord migration, balloon rupture, unplanned extubation, repositioning maneuvers, and ventilator associated pneumonia (VAP). RESULTS: 22 patients met inclusion criteria with 11 patients in the POCUS-arm (35 ventilator-days) and 11 patients in the CXR-arm (36 ventilator-days). There was no significant difference in adverse events between the CXRand POCUS-arms (7.50% v 3.13%;p=0.41). There were 6 instances of patients crossing-over from the POCUS-arm to the CXR-arm but a secondary intention-to-treat analysis showed no impact on significance (7.50% v 3.13%;p=0.41). 3 VAP episodes occurred in the CXR-arm and 1 vocal cord herniation occurred in the POCUS-arm. Repositioning was more common in the CXR-arm than the POCUS-arm (23.5% v 0.00%;p=0.02). CONCLUSIONS: The use of POCUS compared to daily CXRs to monitor ETT positioning appears similar in terms of the adverse clinical outcomes. Further investigation is needed to assess if this non-inferiority remains with higher sample sizes.
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INTRODUCTION: There are many potential complications associated with endotracheal tube (ETTs) malpositioning in critical care settings, such as bronchial migration or vocal cord herniation. These events can prolong patient recovery and lengthen ICU stays. The goal of this study is to demonstrate that point of care ultrasound (POCUS) is noninferior to chest x-ray (CXR) in identifying proper ETT depth. METHODS: We conducted an observational cohort study of intubated patients across 4 multidisciplinary ICUs at an urban academic hospital who underwent daily POCUS assessment of ETT positioning by novice sonographers (medical students). ICU/ED physicians led 4 hour-long informal trainings to teach medical students POCUS technique. Subjects were excluded if they were COVID positive, in c-spine precautions, had recent neck surgery or planned to be extubated within 24 hours. Patient ETT position was measured using POCUS assessment (balloon cuff border ending between 3-7 tracheal rings) and compared to daily radiographic CXR landmarks (5 cm ± 2 cm above carina). Recommendations based on sonographic and radiographic landmarks were compared to assess sensitivity and specificity of POCUS to evaluate need for ETT repositioning. Statistical significance was assessed using the Clopper-Pearson binomial confidence interval. RESULTS: 20 patients were enrolled for a total of 62 ventilator-days. The cohort was majority female (55%), Black/African American (75%) and mean age 55 ± 18 years. In 58 instances (93.5%), both sonographic and radiographic landmarks agreed on maintenance of ETT position. In 1 instance (1.6%), sonographers recommended ETT repositioning while radiographic landmarks did not. In 3 instances (4.8%), ETTs appeared in place by sonographic but not radiographic landmarks. The data yields a specificity of 98.31% CI [90.91,99.96] for proper ETT placement with a negative likelihood ratio of 1.02 CI [.98, 1.05] and NPV of 95.08% CI [94.92,95.24]. CONCLUSION: The high specificity and NPV values suggest that if ETT position appears within normal limits on POCUS (tip of ETT between 3-7 tracheal rings), ETT position is likely adequately positioned even when performed by novices. Further studies should investigate the use of POCUS as a monitoring alternative and as a reliable tool post-intubation to confirm ETT depth.
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INTRODUCTION: The COVID-19 pandemic has provided many obstacles for healthcare providers. One challenge has been ensuring safety during high risk procedures such as Emergency Department (ED) intubations. The risks include: little preparation time, aerosolizing nature of the procedure, and unknown COVID status. Video review has shown effectiveness in quality improvement in critical care scenarios. We aimed to determine the feasibility of using video review of ED intubations in order to gather data about these events and enact change to improve provider safety. METHODS: We captured select videos of intubations that occurred in the COVID-19 pandemic in an audiovisual capable critical care bay. Each video was captured in real time and reviewed for intubation characteristics, intubator characteristics, exposure risk, and PPE compliance. RESULTS: The majority of the intubations were emergent (88.9%). Five patients (55.6%) were in cardiac arrest. The final COVID status was negative in 8 patients (88.9%). In most cases, a senior resident or attending was the intubating provider (77.8%). The mean number of intubation attempts was 1.1 (SD 0.33). The mean number of providers present at intubation was 3.9 (SD 1.97). The mean number of nurses and technicians present was 3 (SD 0.67) and 1.4 (SD 0.97), respectively. On average, the door to the room was opened 13.67 times (range: 1-40). Provider PPE compliance was 100%. All intubating providers wore a powered air purifying respirator. All others present wore an N95 mask, gloves, gown, and eye protection. CONCLUSIONS: Video review of emergency intubations was a feasible means of evaluating provider safety and quality assurance during a global pandemic. Video review is an effective manner of evaluating adherence to PPE guidelines. It can also identify areas for improvement, such as limiting the number of providers in the room and limiting exposure to others by minimizing door-opening. These data were used to improve our intubation process. We implemented the use of pre-prepared airway boxes for each critical care bay, and walkie-talkies to communicate to those outside of the room to minimize door opening. Video review remains a fruitful and open space for quality improvement innovation and furthering the safety of patients and providers.
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Introduction: Racial disparities continue to exist during the COVID-19 pandemic. A systematic review found that Black and Hispanic patients experience disproportionate COVID-19 hospitalizations and higher morbidity and mortality. Low level evidence in that review suggested that Asians' outcomes are similar to those of non-Hispanic whites. As most practicing gastroenterologists are White, and as endoscopies are aerosolizing procedures risking viral transmission, this study evaluates differences in fear levels among gastroenterologists from different racial backgrounds. Methods: This IRB-approved multi-center cross-sectional study used a snowball sampling approach to disseminate a 42-question survey, pilot-tested for reliability and validity, to gastroenterologists across different geographic locations in the US. Fear levels during endoscopic procedures on suspected/confirmed COVID-19 patients were assessed using a 1-10 Likert scale, with 10 being the greatest fear. Fear was assessed at three points for upper and lower endoscopies: first procedure, subsequent before the COVID-19 vaccine, and subsequent after the vaccine. Data was analyzed using Pearson's chi-squared, Mann-Whitney U, and Wilcoxon rank tests and significance was determined at p<0.05 Results: We analyzed 69 responses from gastroenterologists at 30 sites. Of the respondents, 39 selfidentified as white, 3 as Black, 6 as Latinx, 4 as Middle Eastern, and 17 as Asian. Due to the small sample size, non-White racial groups were combined to evaluate the impact of race on reported fear level reported by gastroenterologists who performed endoscopies during the COVID-19 pandemic. Fear levels at the six assessed points were not significantly different when comparing Asians to Whites, and when comparing Blacks and Latinx to Whites. However, Asians, Blacks, and Latinx had a higher fear level post vaccine when performing lower endoscopies compared to Whites (mean (m) 53.59, standard deviation (SD)=2.83 vs m=1.94, SD=1.083, respectively;P=0.045). Conclusion: While results can be due to chance due to the small sample size and survey response bias, our study suggests that after receiving the COVID-19 vaccine, minority endoscopists experienced greater fear than White endoscopists while performing lower endoscopies. It is possible that the disproportionate COVID-19 disease burden in Black and Hispanic communities negates the decrease in fear levels that was experienced by White endoscopists even after receiving the COVID-19 vaccine..
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INTRODUCTION: The Endotoxin Activity Assay (EAA) is a lab analysis to detect primed neutrophils in inflammatory states such as sepsis. Its use as a potential biomarker in SARS-CoV-2 patients has not been previously studied. Other markers such as CRP, ESR, LDH, ferritin, d-dimer, WBC count, procalcitonin, and IL-6 have all been shown to be reliable predictors of inflammatory states. We sought to find out the correlation between EAA and other inflammatory markers in patients admitted to the ICU with SARS-CoV-2 infection. METHODS: This is a prospective cohort analysis of SARSCoV- 2 patients admitted to the ICU at a single academic hospital from March to June 2020. Values for all study variables were obtained from each COVID-positive patient on days 1, 2, and 7 of ICU stay, and also for the onset of mechanical ventilation, vasopressors, acute kidney injury, and increase in ferritin >50% from the level at admission. Logistic and linear regression analyses were used to compare EAA with IL-6, CRP, ferritin, ESR, LDH, d-dimer, WBC, and procalcitonin. RESULTS: A total of 214 EAA results were recorded from 99 patients, with characteristics of: median age 61.84, 45% female, 74% Black, 21% Hispanic, 4% White, and 1% Asian. A significant linear regression equation was found between EAA and CRP: F (1, 168)=19.20, p<.0001, with an R2 of 0.1031 and Pearson's r of 0.32109, indicating a moderate correlation. Significant Spearman Correlation Coefficients were found between EAA and CRP, LDH, and D-dimer: ρ (169)=0.2896, p=0.0001;ρ (180)=0.179, p=0.01;ρ (165)=0.169, p=0.03, suggesting a mild correlation. Other markers did not show a significant correlation with EAA: IL-6 ρ (35)=0.144, p=0.40;Ferritin ρ (173)=0.0533 p=0.48;ESR ρ (37)=0.067, p=0.69;WBC ρ (213)=0.057, p=0.40;Procalcitonin ρ (14)=0.014, p=0.96. CONCLUSIONS: EAA has a statistically significant positive correlation with CRP, LDH, and D-dimer, but not with IL-6, ferritin, ESR, WBC, and procalcitonin. Further studies exploring the relationship between EAA and other biomarkers can establish the validity and reliability of EAA in inflammatory states such as COVID sepsis. This can help identify the role of EAA as an adjunct biomarker to assess the efficacy of therapeutic strategies and to prognosticate and predict mortality in patients with SARS-CoV-19.
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INTRODUCTION: Endotoxin Activity Assay (EAA), which measures the chemiluminescent response of the neutrophils to endotoxin using an anti-endotoxin antibody, has been used to predict mortality in patients with gram-negative sepsis. Recent evidence has shown that this indirect method of endotoxin measurement does not account for other causes that may excite or depress neutrophil activity. We sought to evaluate the levels of EAA in patients with severe COVID-19 infections without bacteremia but rather a systemic inflammatory state and acute respiratory distress syndrome. METHODS: This is a single-center, prospective cohort analysis of SARS-CoV-2-positive patients admitted to the ICU at a single academic hospital, from March to June 2020. EAA levels were obtained from each COVID-positive patient at ICU admission. Demographics, as well as the development of bacteremia on blood culture, were abstracted from medical records. Initial EAA values were categorized into low EAA (<0.4), intermediate EAA (0.41-0.60), high EAA (0.61-0.80), and severely high EAA (>0.80). RESULTS: A total of 78 patients were included in the study, with baseline characteristics as follows: mean age 62.9 years, 46% female, with a racial distribution of 72% Black, 15% White, and 4% Asian. Of the 78 COVID-positive patients, only eight were confirmed positive for bacteremia, while the remaining patients had two negative blood cultures. Of the eight bacteremic patients, the EAA level was low in zero patients, intermediate in three, high in four, and severely high in one patient, resulting in 100% of patients with intermediate or higher EAA level. Of the 70 patients without bacteremia, the EAA level was low in 13, intermediate in 10, high in 34, and severely high in 13, resulting in 81.4% of patients with an intermediate or higher EAA level. CONCLUSIONS: Elevated levels of EAA representing significant endotoxemia are frequently observed in nonbacteremic patients with severe SARS-CoV-2 viral infection. The source of the endotoxemia is unidentified. Possible explanations include gut bacterial translocation from the endothelial cell dysfunction that is known to occur with COVID 19 infection, or that EAA is an indicator of a primed neutrophil state. Further investigation of the elevated EAA levels seen in COVID -19 infections is warranted.
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INTRODUCTION/HYPOTHESIS: Endotoxin Activity Assay (EAA), which measures the chemiluminescent response of the neutrophils to endotoxin using an anti-endotoxin antibody, has been used to predict mortality in patients with gramnegative sepsis. Recent evidence has shown that this indirect method of endotoxin measurement does not account for other causes that may excite or depress neutrophil activity. We sought to evaluate the levels of EAA in patients with severe COVID-19 infections without bacteremia but rather a systemic inflammatory state and acute respiratory distress syndrome. METHODS: This is a single-center, prospective cohort analysis of SARS-CoV-2-positive patients admitted to the ICU at a single academic hospital, from March to June 2020. EAA levels were obtained from each COVID-positive patient at ICU admission. Demographics, as well as the development of bacteremia on blood culture, were abstracted from medical records. Initial EAA values were categorized into low EAA (<0.4), intermediate EAA (0.41-0.60), high EAA (0.61-0.80), and severely high EAA (>0.80). RESULTS: A total of 78 patients were included in the study, with baseline characteristics as follows: mean age 62.9 years, 46% female, with a racial distribution of 72% Black, 15% White, and 4% Asian. Of the 78 COVID-positive patients, only eight were confirmed positive for bacteremia, while the remaining patients had two negative blood cultures. Of the eight bacteremic patients, the EAA level was low in zero patients, intermediate in three, high in four, and severely high in one patient, resulting in 100% of patients with intermediate or higher EAA level. Of the 70 patients without bacteremia, the EAA level was low in 13, intermediate in 10, high in 34, and severely high in 13, resulting in 81.4% of patients with an intermediate or higher EAA level. CONCLUSIONS: Elevated levels of EAA representing significant endotoxemia are frequently observed in nonbacteremic patients with severe SARS-CoV-2 viral infection. The source of the endotoxemia is unidentified. Possible explanations include gut bacterial translocation from the endothelial cell dysfunction that is known to occur with COVID 19 infection, or that EAA is an indicator of a primed neutrophil state. Further investigation of the elevated EAA levels seen in COVID -19 infections is warranted.
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INTRODUCTION: High-flow nasal cannula oxygen therapy (HFNC) has gained attention as an alternative respiratory support for critically ill COVID-19 patients, however, the evidence behind HFNC has been unbalanced as it covers various comorbidities in hypoxic and hypercapnic respiratory failure. We sought to identify what group of patients needed HFNC and to assess whether its use impacted length of stay and survival. METHODS: A retrospective cohort study was performed at a single center urban academic center. Data collected included age, gender, BMI, medical comorbidities, length of hospital stay and mortality for all patients hospitalized with COVID-19. We compared the characteristics of the patients who received HFNC at any point during their hospitalization to all patients hospitalized with COVID-19. RESULTS: The total number of COVID-19 patients was 363. HFNC was used in 115 admitted patients, of which, 74 were in the ICU with a mean length of stay of 7 days. Overall this group had an average hospital length of stay of 15 days in total as opposed to 10.2 days in non-HFNC utilizers. The most common comorbidities seen in the cohort were hypertension (76.4%), diabetes mellitus (37.4%), asthma (14.6%), COPD (11.24%), and obstructive sleep apnea (4.5%). In patients who received HFNC, 41.2% survived compared to 71.8% of all COVID-19 patients. CONCLUSIONS: Factors determining the outcome of patients using HFNC are not well understood. Our patients who received HFNC were more likely to have underlying cardiopulmonary disease than non-HFNC utilizers. Furthermore, they had a longer length of stay and a higher mortality rate in comparison to all COVID-19 patients. While we specifically identified patients who received HFNC, some of these patients received other forms of supplemental oxygen therapy during their hospital stay which may confound the characteristics of this group. It is also possible that patients receiving HFNC were sicker in general, which may explain their disparity in mortality and hospital stay duration. Further research needs to be done in order to clarify if HFNC in COVID-19 patients, particularly those with cardiopulmonary comorbidities, is beneficial in delaying escalation of oxygen therapy and potentially prolonging survival.
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INTRODUCTION: As the COVID-19 pandemic continues, respiratory management strategies emerged as a primary concern. The mortality rate for patients with COVID19 who require intubation, and the predictors of mortality for this specific population are poorly characterized with only a few case series and retrospective studies. Published mortality rates of patients requiring intubation have ranged from as low as 35% to as high as 80%. Given the overall high mortality rate associate with intubation, growing literature calls for further efforts to characterize this critical population. METHODS: Analysis of a single urban academic center prospective database of intubated patients with COVID-19, including transferred patients. Descriptive statistics were used to characterize the intubated patients. Logistic regression was performed to account for age, gender, BMI, race, history of diabetes, COPD, and asthma. RESULTS: From March 2020 to July 2020, 369 COVID-19 patients were included in the registry 93 of whom were intubated. Of those intubated, mean age was 57.3 years, with an average BMI of 32.5. 63.7% of the intubated patients were males, with 62.6% Black, 24.2% Hispanic, and 13.2% Caucasian. We report an overall mortality of 80%, with a crude odds ratio of 28.5 (95% CI: 14.5 - 55.8) for death associated with intubation. Logistic modeling revealed that age and gender are significantly associated with mortality, with mortality odds increasing approximately 9% for each year of age, and 2.8 times higher for males. BMI, race, and history of diabetes, COPD, and asthma did not meet statistical significance for association with mortality, nor were there any significant interaction effects. Holding age and gender constant, the odds ratio for death associated with intubation increases to 105.3 (95% CI: 38.5-287.8). CONCLUSIONS: We report a high mortality rate of intubated patients, which may be multifactorial from being a referral center accepts critically ill patients, including evaluation for ECMO. Furthermore, our institution was an early adopter of noninvasive ventilation methods in an attempt to avoid intubation whenever possible. Ultimately, further studies are needed to better characterize those COVID-19 patients that require intubation and what variables are more closely associated with morbidity and mortality.
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INTRODUCTION: A patient on VV ECMO for COVID ARDS survived a prolonged ECMO course and refractory acidosis with double oxygenator support. METHODS: A 32-year-old previously healthy Latino male presented with cough, fever, myalgias and dyspnea and was positive for COVID-19. He was admitted on high flow oxygen but required mechanical ventilation on Hospital Day (HD)6. He developed oliguric renal failure and progressed to severe ARDS requiring paralytic, proning and PEEP of 16. He was cannulated for VV ECMO on HD9 for refractory acidosis and hypoxia. Murray score was >3, P:F ratio was 60. Despite ECMO and continuous dialysis, the patient remained acidotic and was reliant on supplemental ventilator support, ongoing paralytic and heavy sedation. He developed a pneumothorax due to barotrauma and had multiple chest tubes for poor re-expansion. Due to maximum sweep support, an additional oxygenator was added on HD19. The patient had a prolonged recovery with complications of transfusion dependent epistaxis requiring ENT packing and hematochezia requiring rectal and IMA embolization. After significant transfusion he developed acute right ventricular dysfunction which was supported with inotropy and inhaled nitric oxide and later developed sepsis from bacteremia as well. He was finally stable for tracheostomy on HD61 and was decannulated from ECMO on HD66. He has since had cardiac and renal recovery and is weaning from vent support. RESULTS: ECMO has been used as rescue therapy in COVID ARDS but multi-center studies report mortality rates of 50% to as high as 94%- much higher when compared to MERS or H1NI viral ARDS support. Life threatening complications of bleeding, thrombosis, infection and refractory cardiopulmonary failure are common but COVID ARDS presents new physiologic challenges that are not yet well understood. As of July 27 2020, of a cohort of 148 ECMO supported COVID patients in the SpecialtyCare national perfusion database, the average support duration is 16 days (SD 14 days). Our patient required 57 days on ECMO and is the only patient to have survived double oxygenator support in our database. His case supports future use of additional oxygenators in refractory acidosis, which may be more common in COVID physiology. He also reminds us that prolonged COVID ARDS recovery is possible.
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INTRODUCTION: Acute respiratory disease syndrome (ARDS) is due to compromised lung oxygen exchange in the setting of severe alveolar inflammation. This can be assessed and diagnosed using the ratio of alveolar oxygen saturation (PaO2) to the fraction of inspired oxygen (FiO2), P-F ratio. In hospitalized COVID-19 patients, the role of trending inflammatory markers to categorize levels of ARDS severity in the clinical setting has yet to be established. In this study, we describe the correlational relationship of five biomarkers to the PaO2/FiO2 ratio (P-F ratio), a key diagnostic criterion, and a measure of severity in ARDS. METHODS: This is a prospective cohort analysis of SARs-CoV-2 patients admitted to the ICU at a single urban academic center from March to June 2020. Levels of Endotoxin activity assay (EAA), CRP, ferritin, LDH, and d-dimer were obtained from intubated patients throughout their ICU stay. PaO2 and FiO2 values matching the same days as the biomarkers and demographic information were abstracted from the medical record. The inflammatory markers were matched to the P-F ratios of the same day, and Spearman Correlation Coefficients were performed to detect the relationship between them. RESULTS: A total of 45 intubated COVID patients were included, with baseline characteristics of: median age 55 years and 33% female, 62% Black, 27% Hispanic, 9% Asian, and 2% White. Spearman Correlation Coefficient (ρ) showed statistically significant relationships between P/F ratios and EAA, IL-6, CRP, and ESR, with respective values of: ρ (89)=-0.2366, p=0.02;ρ (13)=-0.7143, p=0.006;ρ (77)=-0.3670, p=0.001;ρ (17)=-0.5569, p=0.02. ρ was also calculated between P/F ratios and Ferritin, D-dimer, WBC, and LDH with respective values of: ρ (77)=0.0819, p=0.47;ρ (78)=-0.2105, p=0.06;ρ (88)=-0.1046, p=0.33;ρ (73)=0.0420, p=0.72, showing no statistically significant relationship between these variables. CONCLUSIONS: EAA, IL-6, CRP, and ESR levels had a statistically significant negative correlation with the P-F ratio. Elevations in these biomarkers correlated with worsening P-F ratios, suggesting that they could serve as useful biomarkers to predict ARDS severity. Additional studies are needed to further understand the trend of these biomarkers and validate their clinical use in prognostication in ARDS.
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INTRODUCTION: The COVID-19 pandemic has proliferated since the start of this year and has strained ICU resources globally. Far from an isolated respiratory illness, COVID-19 has multisystem effects, including pronounced neurological effects. Very little is known about critically ill patients and their sedation/analgesia requirements. We sought to quantify the sedation requirements for critically ill patients with COVID-19. METHODS: A prospective registry from 03/2020 to 06/2020 with COVID-19 at an urban tertiary care hospital was analyzed for intubated COVID-19 patients. Sedation data was abstracted for days 1,3,5,7,10,13,16,19,22,25, and 28 from the EMR, and infusion information was recorded as weighted average doses over a 24-hour period. Narcotics were reported as oral morphine equivalents (OMEs) and benzodiazepine doses were reported as midazolam equivalents (ME). A comparison was made to the placebo group of patients from the MIND-USA study as the median of the means. RESULTS: A total of 62 patients were analyzed with 55% African American, 33% Hispanic, 65% male, mean age of 58.5 years old, BMI of 33, and APACHE II score on ICU admission of 18.6. The median duration of mechanical ventilation was 9.5 days and an in-hospital mortality of 80.6%. Compared to the control arm of the MIND-USA study, the COVID-19 cohort had 2.89x higher propofol dose (TDD 4032 mg vs. 1391 mg), 5.5x higher precedex dose (TDD 3400mcg vs. 617mcg), 8.8x higher benzodiazepine dose (35 mg ME vs. 4 mg ME) and 1.79x higher OME dose (363 mg vs. 203 mg). The average infusions per patients was 2.42 and the most used infusions used were propofol (30% of patients per day) and precedex (25.8%). Approximately 17.6% of patients per day were receiving a paralytic infusion;however, a considerably greater share of patients (46.6% per day) were demonstrating quadriplegic paralysis. CONCLUSIONS: Critically ill patients with COVID-19 infection have significantly higher sedation/narcotic requirements than patients without COVID-19. This may be related to the underlying neurological effects of the virus and a potentially synergistic effect with sedation causing a high rate of quadriplegic paralysis. Further prospective trials are required to evaluate this hypothesis.
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INTRODUCTION: African American and Hispanic patients have been disproportionately affected by infection with SARS-CoV-2 and subsequent coronavirus disease (COVID-19). Initial data suggests that these populations are more likely to suffer severe illness requiring hospitalization compared to Whites. We sought to further investigate the effects of race and ethnicity on critical care outcomes in hospitalized COVID-19 patients within the ethnically diverse area of the District of Columbia. METHODS: We performed a single-center, review of a prospective registry of 233 patients hospitalized with COVID-19 at an urban, academic hospital in Washington, D.C. Demographic and clinical data was gathered from chart review. We compared mean admission SOFA and APACHE scores, along with rates of ICU admission, intubation and mortality between White, Black, Hispanic, and Other ethnicities. RESULTS: Of the admitted patients 3.8% (n=9) were White, 70% (n=166) were Black, and 17% (n=41) Hispanic, with 7.7% (n=18) unknown or other race. The mean admission SOFA score for White, Black and Hispanic patients were 3.14, 2.65 and 1.88, respectively. The mean APACHE scores for Whites, Blacks, and Hispanics were 15.25, 17.85, and 14.75, respectively. 56% (n=5) of Whites, 29% (n=48) of Blacks, and 41% (n=17) of Hispanics were admitted to the ICU. Intubations occurred in 44% (n=4) of Whites, 17% (n=28) of Blacks, and 37% (n=15) of Hispanics. Mortality rates were 22% (n=2), 30% (n=49), and 29% (n=12) in Whites, Blacks, and Hispanics, respectively. CONCLUSIONS: According to estimates by the US census bureau, the population of the District of Columbia is 46% White, 46% Black, and 11.3% Hispanic. Our data demonstrates a disproportionate hospitalization rate in minorities affected by COVID-19. Despite lower ICU admission and intubation rates, Blacks had a high mortality rate. There was a disproportionately high utilization of the ICU care, intubation and mortality amongst Hispanics. Further investigation is necessary to examine causes of these significant health disparities and to prevent further health inequalities amongst minorities.