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1.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927932

ABSTRACT

Rationale: Asthma affects 20 million adults in the United States resulting in up to 500,000 hospitalizations each year. Patients admitted to the intensive care unit (ICU) for asthma exacerbations requiring invasive ventilation have a mortality of ∼7%. Extracorporeal membrane oxygenation (ECMO) is a salvage technique used in patients with respiratory failure to increase delivery of oxygen, remove CO2 and allow time for recovery. Case series and uncontrolled registry studies have examined benefits of ECMO for asthma exacerbations with respiratory failure, but no studies have examined outcomes associated with use of ECMO for asthma exacerbations compared to standard care. Objective: To assess outcomes associated with use of ECMO during asthma exacerbations requiring invasive ventilation compared to standard care. Methods: Patients were extracted from the Premier Database from 2010-2020 if they had a primary diagnosis of asthma, or a primary diagnosis of respiratory failure with a secondary diagnosis of asthma, and were treated with invasive ventilation. Patients were excluded for age < 18y, no ICU admission, chronic lung disease other than asthma, COVID-19, or if they were not treated with corticosteroids. Hospital mortality was the primary study outcome. Key secondary outcomes included ICU length of stay (LOS), hospital LOS, length of invasive ventilation and hospital costs. Differences in outcomes were assessed using propensity score matching at a 1:2 ratio of ECMO versus no ECMO, and by covariate adjustment of the entire study group. Results: A total of 20,494 patients with asthma exacerbations requiring invasive ventilation were included in the study, of which 130 were treated with ECMO and 20,364 were not. After propensity matching, ECMO (N=103) versus no ECMO (N=206) was associated with reduced mortality (11.4% vs. 23.3%, p = 0.017) and increased hospital costs, but no difference in ICU LOS, hospital LOS or length of mechanical ventilation (Table). The covariate-adjusted model replicated these findings (Table). When individual patients were assigned a probability of being treated with ECMO equal to the hospital rate where they were admitted, each 10% increase in the hospital rate of ECMO was associated with no change in the odds of mortality (OR, 1.12: 95% CI, 0.82-1.52), p=0.48). ECMO was also associated with increased renal replacement therapy (P = 0.02), shock (P=0.02) and 30-day all-cause readmission (P = 0.01). Conclusion: ECMO was associated with reduced mortality at the cost of increased morbidity in asthmatics requiring invasive ventilation, indicating that ECMO has the potential to save thousands of lives.

2.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927788

ABSTRACT

Rationale: It is recognized that ventilator dyssynchrony (VD) may propagate ventilator induced lung injury (VILI). Yet some VD cannot be detected without advanced monitoring like measuring esophageal pressure (Pes) and it is unknown which types of VD propagate VILI. We describe the automated detection of VD using machine learning (ML) in patients with esophageal manometry to quantify the frequency and association between VD, tidal volume (VT) and transpulmonary driving pressure (ΔPdyn.tp). Methods: We enrolled 42 patients with ARDS or ARDS risk factors, including COVID-19. XGBoost, a ML algorithm, was trained to identify 7 types of breaths using a one-vs-all strategy, from a training set of 3500 random breaths. We compared the models' sensitivity and specificity with and without features derived from Pes. Finally, the association between each VD type and VT or ΔPdyn.tp was calculated using separate linear mixed-effect models. Temporally related breaths were nested by patient and modeled as random effects, accounting for repeat measures and changing pulmonary mechanics in each patient. Breaths without an adequate Pes signal were excluded from analysis Results: Patients were 37.5% female, 52±15 years old, had an initial P:F ratio of 140±64, and 24.2% of the 480, 976 breaths were dyssynchronous. Normal passive (Nlp), normal spontaneous (Nls), late reverse triggered (RTl), reverse triggered double triggered (DTr), mild flow limited (FLm), severe flow limited (FLs), and early ventilator terminated (EVT) account for 47.0%, 28.7%, 4.8%, 3.7%, 8.9%, 4.2%, and 2.5% of all breaths, respectively. ML training, VT and ΔPdyn.tp results are show in the table (∗p<0.001). Conclusion: ML algorithms can be trained using Pes to identify types of VD that traditionally need Pes measurements, although without Pes sensitivity may decrease. VD is frequent and DTr is associated with an increase in VT, while FLm and FLs are associated with an increased in ΔPdyn.tp. These data suggest that double triggered breaths and flow limited breaths have the potential to propagate VILI, while other types of VD may not be as deleterious. (Table Presented).

3.
ASAIO Journal ; 68(SUPPL 1):4, 2022.
Article in English | EMBASE | ID: covidwho-1913102

ABSTRACT

ECMO has become a widely recognized support modality for patients with severe cardiac or respiratory failure, and has been increasingly utilized in the ongoing severe acute respiratory syndrome due to coronavirus-2 (SARS-CoV-2) pandemic. Long-term support on ECMO for acute respiratory distress syndrome (ARDS) is also becoming more commonplace with eventual lung recovery, obviating the need for lung transplantation. However, long-term ECMO support has not been well studied for SARS-CoV-2 ARDS patients. We report the case of a 39-year-old female with severe SARS-CoV-2-induced ARDS successfully supported on venovenous ECMO (V-V ECMO) for 5,208 hours (217 days) in a high ECMO-volume, quaternary care children's hospital in 2021. At the time of this writing, this is the longest reported patient successfully supported on ECMO for SARS-CoV-2 ARDS. Our patient was initially cannulated at our children's hospital with dual-site V-V ECMO, via the right internal jugular vein (RIJ) and right common femoral vein. Bedside tracheostomy was performed on ECMO day 40, for early mobility, oral feeding, interaction, and pulmonary rehabilitation planning. Unfortunately, during her course she suffered multiple complications including bacterial co-infections, bleeding requiring anticoagulant changes from unfractionated heparin (UFH) to bivalirudin, multiple ECMO circuit changes due to blood product consumption and coagulopathy, and pneumothoraces requiring thoracostomy tube placements. Approximately 1.5 months into her ECMO course, she suffered acute hypoxemia and echocardiography revealed indirect evidence of pulmonary hypertension with right heart failure. Initial right heart catheterization while on V-V ECMO revealed elevated right ventricular end-diastolic pressure (RVEDP=15-20 mmHg) and severe systemic desaturation with main pulmonary artery (MPA) pressure of 30 mmHg. Pulmonary hypertension and right heart support was initiated in the form of inhaled nitric oxide (iNO), inotropes, phosphodiesterase inhibitors, nitrates, angiotensin-converting enzyme inhibitors, and diuresis. Ultimately, due to necessity of right-heart decompression and support, on ECMO day 86 she was transitioned to single-site V-V ECMO utilizing a 31 Fr dual-lumen venovenous cannula (ProtekDuo (LivaNova, UK)) placed via her RIJ through her right atrium (RA) into the MPA in the cardiac catheterization laboratory. Subsequent heart catheterization more than 2 months later revealed severe right ventricular (RV) diastolic dysfunction (RVEDP=35 mmHg) and moderate left ventricular (LV) diastolic dysfunction (pulmonary capillary wedge pressure (PCWP=24 mmHg)). During her course, multiple trials off ECMO were attempted with varying lengths of time off ECMO support, but ultimately required ongoing ECMO support. She developed evidence of end-organ dysfunction from her cor pulmonale, including oliguric renal failure requiring renal replacement therapy (RRT), hepatic injury with elevated transaminases and hyperammonemia leading to depressed mental state, feeding intolerance, and coagulopathy. Additionally, due to long-term nasogastric enteral tube placement for caloric supplementation and enteral medication administration, she developed concerns for invasive sinusitis with erosion into ethmoid and maxillary sinuses. As she was an adult patient being cared for in a free-standing academic children's hospital, multiple adult medicine consultants were involved in her care. Specifically, adult nephrology, cardiology, cardiothoracic surgery (for ProtekDuo cannula placement), and gastroenterology/ hepatology were integral into her care, along with our pediatric critical care medicine and ECMO teams. Notably, this was the first patient supported on ECMO to receive tracheostomy, RA-MPA dual-lumen VV cannula, and full autonomous mobility outside of the ICU at our well-established ECMO program, which has served as the index patient leading to future advances in the care of our ECMO patients. Over time and with multiple therapies to alleviate her cor pulmonale, the patient's echocardiograms evealed improved, half-systemic right-sided cardiac pressures. She was ultimately decannulated from ECMO at our center before being transferred back to the referring adult facility, and discharged to home 8 months after her initial presentation with acute respiratory failure.

4.
Journal of Allergy and Clinical Immunology ; 149(2):AB97-AB97, 2022.
Article in English | Web of Science | ID: covidwho-1798303
6.
American Journal of Respiratory and Critical Care Medicine ; 203(9):2, 2021.
Article in English | Web of Science | ID: covidwho-1407392
8.
American Journal of Respiratory and Critical Care Medicine ; 203(9), 2021.
Article in English | EMBASE | ID: covidwho-1277371

ABSTRACT

RATIONALE: The COVID-19 pandemic has rapidly become the most significant worldwide public health crisis in the modern era. Like other states around the country, the state of Colorado instituted a statewide lockdown to combat increasing case and hospitalization rates for COVID-19 throughout the state. The impact of this mandate on the ICU admission rates and outcomes of other medical problems has never been investigated. Our study aimed to determine the effects of stay-at-home orders on outcomes for other diagnoses by analyzing ICU admission rates and outcomes of patients presenting to the ICU for non-COVID related issues before, during, and after the statewide mandate. METHODS: We performed a retrospective analysis of all ICU admissions in three phases: before (2 months prior), during, and 1.5 months after the statewide lockdown (March 26 to April 27, 2020). We included all patients admitted to the University of Colorado Health System hospitals ICUs within this defined time period. A time-to-event analysis was performed with the date of index ICU stay set as time zero. Baseline characteristics were obtained. Primary outcome measures were 28-day mortality and all-time mortality. Kaplan-Meier curves were used to estimate survival probabilities, while Cox regression and multivariable logistic regression were utilized to model phase-specific mortality controlling for comorbidities, demographics, and admission diagnoses. Counts of typical ICU admission diagnoses were also analyzed to determine any changes across lockdown periods. RESULTS: 9201 total ICU admissions occurred, of which 8154 (88.6%) were non-COVID-19 related. Approximately 57.4% were male with a mean age of 60.4 years. 28-day mortality rates for non-COVID-19 ICU admissions were 475 (11.0%), 127 (13.8%), and 306 (10.5%) before, during, and after the lockdown, respectively. The increased mortality during lockdown persisted after adjustment for comorbidities and demographics (HR=1.23, 95% CI, 1.007 to 1.512, p = 0.043). Acute respiratory failure was the most common diagnosis in each time period, and increased during lockdown (p<0.001). Admissions for sepsis increased during lockdown and decreased after (p = 0.001);myocardial infarction (MI) admission decreased during lockdown but increased after (p = 0.014);and alcohol withdrawal (AW) admission increased both during and after lockdown (p < 0.001). CONCLUSIONS: For non-COVID-19 related ICU admissions, the mortality rate increased during the state-wide shutdown but decreased after shutdown, although this difference became insignificant after controlling for patient admission diagnoses. Admission diagnoses also differed with more admissions for sepsis and AW during lockdown and more admissions for MI and AW after lockdown.

9.
American Journal of Respiratory and Critical Care Medicine ; 203(9), 2021.
Article in English | EMBASE | ID: covidwho-1277106

ABSTRACT

Introduction: Before the COVID-19 pandemic, 20-30% of family members had symptoms of Post-Traumatic Stress Disorder (PTSD) or anxiety, while 15-30% had symptoms of depression. Interventions supporting family members have reduced burden of these symptoms. COVID-19 has resulted in prolonged ICU stays, high morbidity/mortality, and hospital policies severely limiting family presence at the bedside. We hypothesized the combination of prolonged critical illness and the necessary reduction of family presence would lead to high rates of PTSD, anxiety, and depression;likely higher than observed in previous studies. Methods: This was a multicenter study including 12 US hospitals, 8 academic and 4 community-based hospitals. A consecutive sample of family members of all patients with COVID-19 receiving ICU admission during the spring US peak in 2020 were called 3-4 months after the patients' ICU admission, except for New York City hospitals where a random sample was generated given the large number of hospitalizations. Consented participants completed the Impact-of- Events Scale-6 (IES-6;scored 0-30, higher scores indicate more symptoms of PTSD), Hospital-Anxiety- Depression Score (HADS, scored 0-20 for anxiety and 0-20 for depression, higher scores indicate more symptoms), and a subset of questions from Family-Satisfaction in the ICU-27 (FS-ICU27;scored on a Likert scale 1 to 5, with higher scores indicating more positive responses) selected as most likely impacted by restrictive family presence.Results: There were 945 eligible family members during the study period. Of those, 594 were contacted and 269 (45.3%) consented and completed surveys. The mean IES-6 score was 12.6 (95% CI 11.8- 13.4) with 65.4% having a score of 10 or greater, consistent with high levels of symptoms of PTSD. The mean score on the HADS-anxiety was 9.4 (95% CI 8.8-10.1) with 59.5% having a score of 8 or greater, consistent with high levels of symptoms of anxiety. Finally, the mean score for the HADS-depression was 8.0 (95% CI 7.3-8.7) with 47.6% having scores of 8 or greater, consistent with high level of symptoms of depression. The mean response for the FSICU27 questions of “I felt I had control” was 3.5 (95% CI 3.3-3.6), “I felt supported” was 3.8 (95% CI 3.6-4.0), and “I felt included” was 4.3 (95% CI 4.2-4.4).Conclusion: The consequences of a family member admitted to the ICU with COVID-19 infection are significant. We identify rates of PTSD, anxiety, and depression higher than recorded in non-COVID population. Further analysis is warranted to understand modifiable risk factors for developing these symptoms.

10.
Open Forum Infectious Diseases ; 7(SUPPL 1):S318-S319, 2020.
Article in English | EMBASE | ID: covidwho-1185866

ABSTRACT

Background: Mount Sinai Beth Israel (MSBI) is a 220 bed acute care hospital located in the Manhattan borough of Manhattan in New York City. Prior to COVID-19, the hospital had one 16-bed Medical/Surgical ICU. When the COVID epidemic struck New York City, the MSBI ED was flooded with critically ill patients requiring ICU care. Seven other ICUs were opened, all of which were filled with COVID patients. The majority of these patients required central lines for the multiple antibiotics, steroids, and vasopressors they needed to survive. Agency RNs were brought in to care for ICU patients. In April, the MSBI Infection Prevention (IP) department received several CLABSI notifications through its data mining system. The IPs were alarmed at the number of CLABSIs occurring in ICU COVID patients with central lines. ICU CLABSI Rates in an Acute Care Hospital During the COVID-19 Epidemic in New York City Methods: A baseline assessment, using the central line maintenance bundle, was conducted on all COVID patients with central lines. This assessment revealed issues with central line maintenance, including: undated, bloody, and non-intact dressings, poorly placed CHG impregnated disks;blood in end-caps, and missing alcohol impregnated caps on ports. The decision was made to bring in infusion RNs from an outpatient system site to perform daily rounds on central lines. These RNs performed daily intensive maintenance bundle rounds for a month during the COVID epidemic. During their rounds, ICU nurses and managers were notified of central line dressing and cap issues and educated on how to correct them. These RNs also e-mailed daily reports of their findings to Nursing Leadership for their review. Central Line Audit Team: RNs Who Monitored Central Lines in COVID ICUs in An Acute Care Hospital in NYC Results: Central line rounds performed after the intervention showed a great improvement in compliance with the central line maintenance bundle, from 13% during the first rounds performed in April, to 88% in May, less than a month after these rounds started. Since this intervention, the ICU CLABSI rate has decreased from a rate of 3.3 per 1,000 central line days in April and May to a current rate of 0. Conclusion: The timely identification and root cause analysis of a problem must be followed by timely, intensive, and repeated interventions that are designed to attack the causes of problems at their source. After the crisis period is over, the interventions must be maintained to ensure that gains made can be sustained.

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