Transient Spike in Open Colon Resections During Covid-19 Pandemic

Introduction: Shortly after the onset of the COVID-19 pandemic, SARS-CoV-2 virus was discovered in non-respiratory bodily fluids. This raised the potential of aerosolizing virus with insufflation. The aim of this study was to compare trends in surgical approach and indication at the start of the pandemic. Method(s): A retrospective cohort study was performed using the National Surgical Quality Improvement (NSQIP) Participant Use File and Targeted Colectomy databases to identify patients undergoing colon resections in 2020. Cohorts were divided by quarter of operation (Q1-Q4). The minimally invasive cohort included all cases using an insufflation-based approach. Primary outcomes included planned open operation. Multivariate analysis was used to assess confounders and effect modification on open operation. Result(s): Univariate analysis found the percentage of open colonic resections was greater in Q2 of 2020 with a subsequent return to pre-pandemic levels (38% Q2 vs 32%, 34%, and 33% for Q1, Q3, Q4 respectively;p< 0.001). There was a concordant increase in emergent surgeries (20% in Q2 vs 15% Q1), but multivariate analysis revealed having operation in Q2 independently increased the odds of having open operation (OR 1.11, p=0.004). Serious complication rate was highest in Q2 (17% vs 14%, 16%, 16% for Q1, Q3, Q4;p <0.001). Conclusion(s): There was an increase in the percentage of open colon resections in Q2 of 2020. Multivariate analysis found having operation in Q2 independently increased the odds of an open operation. The increase in planned open operation was potentially related to concern for SARS-CoV-2 becoming aerosolized in minimally invasive cases.

Role of Point-of-Care Ultrasound in the Management of Mechanical Ventilation

Ultrasound (US) became an essential tool in the hands of the intensivist and is now recommended both for procedural guidance and diagnostic purposes. Point-of-care ultrasound (POCUS) is an immediately available and repeatable, non-irradiating bedside tool integrating the clinical examination. Recent years were characterized by a growing interest in the fields of lung ultrasound (LUS) and diaphragm ultrasound (DUS). The combination of these two ultrasound techniques with critical care echocardiography (CCE) may integrate the classical approach to mechanically ventilated patients, both for monitoring and diagnostic purposes, finally contributing to the titration of mechanical ventilation and to the management of respiratory disease. Lung, diaphragm, and cardiac US provide significant information to improve the management of the critical patient under mechanical ventilation, from the initial assessment, through the ventilation setting (like PEEP) and its complication diagnosis (like pneumothorax, atelectasis), until the weaning process. LUS is of particular help in COVID-19 patients. It is potentially able to distinguish between the two phenotypes (type H and type L) of COVID-19, based on the different signs and patterns and also the assessment of prone positioning effects and lung recruitment maneuvers in these patients. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

Lung Ultrasound in Critical Care and Emergency Medicine: Clinical Review.

Lung ultrasound has become a part of the daily examination of physicians working in intensive, sub-intensive, and general medical wards. The easy access to hand-held ultrasound machines in wards where they were not available in the past facilitated the widespread use of ultrasound, both for clinical examination and as a guide to procedures; among point-of-care ultrasound techniques, the lung ultrasound saw the greatest spread in the last decade. The COVID-19 pandemic has given a boost to the use of ultrasound since it allows to obtain a wide range of clinical information with a bedside, not harmful, repeatable examination that is reliable. This led to the remarkable growth of publications on lung ultrasounds. The first part of this narrative review aims to discuss basic aspects of lung ultrasounds, from the machine setting, probe choice, and standard examination to signs and semiotics for qualitative and quantitative lung ultrasound interpretation. The second part focuses on how to use lung ultrasound to answer specific clinical questions in critical care units and in emergency departments.

Respiratory support for adult patients with COVID-19

The COVID-19 pandemic is creating unique strains on the healthcare system. While only a small percentage of patients require mechanical ventilation and ICU care, the enormous size of the populations affected means that these critical resources may become limited. A number of non-invasive options exist to avert mechanical ventilation and ICU admission. This is a clinical review of these options and their applicability in adult COVID-19 patients. Summary recommendations include: (1) Avoid nebulized therapies. Consider metered dose inhaler alternatives. (2) Provide supplemental oxygen following usual treatment principles for hypoxic respiratory failure. Maintain awareness of the aerosol-generating potential of all devices, including nasal cannulas, simple face masks, and venturi masks. Use non-rebreather masks when possible. Be attentive to aerosol generation and the use of personal protective equipment. (3) High flow nasal oxygen is preferred for patients with higher oxygen support requirements. Non-invasive positive pressure ventilation may be associated with higher risk of nosocomial transmission. If used, measures special precautions should be used reduce aerosol formation. (4) Early intubation/mechanical ventilation may be prudent for patients deemed likely to progress to critical illness, multi-organ failure, or acute respiratory distress syndrome (ARDS).Copyright © 2020 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of the American College of Emergency Physicians.

Hyperglycemia and Hypoglycemia Contributions to Acute Respiratory Distress Syndrome

Purpose of Study Non-diabetic COVID-19 patients with elevated admission fasting blood glucose levels ('hyperglycemia') inexplicably have an increased 28 day mortality and higher inhospital complications including the Acute Respiratory Distress Syndrome (ARDS) but potentially contributing blood glucose changes during ARDS development were not reported (Wang S et al: Diabetologia 2020). Our goal was to determine blood glucose alterations before and during acute lung injury development in a rat model used to study ARDS. Methods Used We sequentially evaluated blood glucose levels for 24 hours and lung lavage protein levels (lung permeability) and lung lavage neutrophil numbers (lung inflammation) at 24 hours to assess acute lung injury ('ARDS') in young (~3 month) and old (~12 month) control and a novel strain of hyperoxia surviving 'resistant' rats before and after administering high and low insulin doses and before and after interleukin- 1/lipopolysaccharide (IL-1/LPS) insufflation. Summary of Results Glucose levels increase rapidly and sequentially in young control, but not young resistant, rats peaking ~2 hours after insufflation. Glucose levels also increase in old control and old resistant rats after insufflation compared to young control and young resistant rats after insufflation. The pattern of glucose levels at 2 hours after insufflation resembles lung lavage proteins and neutrophils at 24 h after insufflation (table 1). Administering high insulin (High In) doses decreases glucose levels ('hypoglycemia') and worsens ARDS while administering low insulin (Low In) doses correct glucose levels and improve ARDS. Conclusions Hyperglycemia develops in both young and old rats developing ARDS and high or low glucose levels parallel worse acute lung inflammation and acute lung injury ('ARDS'). Controlling glucose judiciously with insulin may be beneficial in combatting ARDS caused by SARS-CoV-2 infection and other insults.

Modification of the Aeration-Supplied Configuration in the Biodrying Process for Refuse-Derived Fuel (RDF) Production

Biodrying is an essential part of the mechanical–biological treatment process that minimizes moisture content and simultaneously maximizes heating value for refuse-derived fuel (RDF) production. Although the mechanical separation process operates effectively in Thailand's RDF production, high organic content levels and their degradation cause moisture contamination in RDF, producing wet RDF. Aeration is essential for an effective biodrying process, and can reduce RDF's moisture content as well as increase its heating value. To maximize the biodrying effect, aeration should be optimized based on the waste conditions. This study proposes a modified aeration-supplied configuration for wet RDF biodrying. The aeration rate was modified based on the period within the biodrying operation;the first period is from the beginning until day 2.5, and the second period is from day 2.5 to day 5. The optimal aeration supply configuration was 0.5 m3/kg/day in the first period and then 0.3 m3/kg/day until the end of the process;this configuration yielded the greatest moisture content decrease of 35% and increased the low heating value of the biodried product by 11%. The final moisture content and low heating value were 24.07% and 4787 kcal/kg, respectively. Therefore, this optimal aeration-supplied configuration could be applied to meet the moisture content and low heating value requirements of the RDF production standard for Thailand's local cement industry.

Robotic Inguinal Hernia Repair - Update 2022 during the SARS-COVID-19 Pandemic

INTRODUCTION: Inguinal hernia repair is one of the most common surgical procedures performed by general surgeons. Numerous articles have shown that robotic inguinal hernia repair is safe and effective, but also more costly than other hernia repair techniques. The robotic platform uses high-definition visualization and articulating instruments. A growing number of surgeons are using this technology to refine and obtain a critical view of the myopectineal orifice for hernia repair while lessening the pain associated with the open surgical approach. Lower insufflation pressures and good results without Foley catheterization have been reported. This report presents an update, with a focus on the past 3 years during the SARS COVID-19 pandemic, of a series of robotic, laparoscopic inguinal hernia repairs by a single surgeon with extensive laparoscopic hernia experience at a single institution, along with a review of the recent current literature. METHOD(S): Over 3000 laparoscopic inguinal hernia operations have been performed by the author since 1990. One hundred-fifty-eight were performed from April 2020 to November 2022, in addition to the previously reported 420 robotic TAPP (trans-abdominal pre-peritoneal) procedures performed from April 2012 to March 2020. Hospital records and follow-up care were prospectively reviewed and the patient's age, sex, American Society of Anesthesia (ASA) class and operative time were obtained. Follow-up was done at 2 weeks and 6 weeks following surgery. All patients consented to the use of their data in the study. RESULT(S): Ninety-four percent (94%) of the patients were male. The average age was 64.3 years (range 18-91). Co-morbidities included hypertension, hypercholesterolemia, prostatism and GERD, among others. BMI was between 19 and 37.1 (mean 26.1). In 23 patients (15%), an umbilical hernia repair was performed concomitantly. OR time ranged from 25 to 90 minutes (mean 51.8). Complications were uncommon and urinary retention (2.5%) was an infrequent post-operative occurrence. CONCLUSION(S): 1) Use of a lower insufflation pressure (8-12 mm Hg) was routine. 2) Use of a structural mesh (4x6 inches) gave satisfactory results. 3) While fixation of the mesh was not necessary, fibrin sealant was used routinely. 4) Urinary retention was infrequent, and did not require pre- or intra-op Foley catheterization if the patient voided immediately prior to surgery. Finally, 5) OR time was consistently less than 1 hour. These results support the conclusion that robotic inguinal hernia repair is safe and effective.

Distribution of Aeration and Pulmonary Blood Volume in Healthy, ARDS and COVID-19 Lungs: A Dual-Energy Computed Tomography Retrospective Cohort Study.

RATIONALE AND OBJECTIVES: Few reports have studied lung aeration and perfusion in normal lungs, COVID-19, and ARDS from other causes (NC-ARDS) using dual-energy computed tomography pulmonary angiograms (DE-CTPA). To describe lung aeration and blood-volume distribution using DE-CTPAs of patients with NC-ARDS, COVID-19, and controls with a normal DE-CTPA ("healthy lungs"). We hypothesized that each of these conditions has unique ranges of aeration and pulmonary blood volumes. MATERIALS AND METHODS: This retrospective, single-center study of DE-CTPAs included patients with COVID-19, NC-ARDS (Berlin criteria), and controls. Patients with macroscopic pulmonary embolisms were excluded. The outcomes studied were the (1) lung blood-volume in areas with different aeration levels (normal, ground glass opacities [GGO], consolidated lung) and (2) aeration/blood-volume ratios. RESULTS: Included were 20 patients with COVID-19 (10 milds, 10 moderate-severe), six with NC-ARDS, and 12 healthy-controls. Lung aeration was lowest in patients with severe COVID-19 24% (IQR13%-31%) followed by those with NC-ARDS 40%(IQR21%-46%). Blood-volume in GGO was lowest in patients with COVID-19 [moderate-severe:-28.6 (IQR-33.1-23.2); mild: -30.1 (IQR-33.3-23.4)] and highest in normally aerated areas in NC-ARDS -37.4 (IQR-52.5-30.2-) and moderate-severe COVID-19 -33.5(IQR-44.2-28.5). The median aeration/blood-volume ratio was lowest in severe COVID-19 but some values overlapped with those observed among patients with NC-ARDS. CONCLUSION: Severe COVID-19 disease is associated with low total aerated lung volume and blood-volume in areas with GGO and overall aeration/blood volume ratios, and with high blood volume in normal lung areas. In this hypothesis-generating study, these findings were most pronounced in severe COVID disease. Larger studies are needed to confirm these preliminary findings.

US catfish production is becoming more efficient

In this article the authors discussed how catfish producers in Mississippi, Arkansas, and Alabama were able to maintain and even increase their production despite of Covid-19 by adopting new intensive production systems and complementary technologies such as intensively aerated small ponds, use of hybrids, automated oxygen monitoring systems, and vaccinations.

Approach to Common Pediatric Upper Respiratory Tract Infections

Upper respiratory tract infection (URI) is one of the most frequent diseases observed at centers for pediatric care and results in significant morbidity worldwide. URI is the most common cause in children treated against acute respiratory infection. The difficulty found by clinicians in establishing the differential and etiologic diagnosis of URIs and the occasionally indiscriminate use of antimicrobial drugs. URIs range from the common, cold-typically a mild, self-limited, catarrhal syndrome of the nasopharynx to life-threatening illnesses such as epiglottitis. Viruses account for most URIs. Appropriate management in these cases may consist of reassurance, education, and instructions for symptomatic home treatment. Diagnostic tests for specific agents are helpful when targeted URI therapy depends on the results. Bacterial primary infection or superinfection may require targeted therapy. The upper respiratory tract includes the sinuses, nasal passages, pharynx, and larynx, gateways to the trachea, bronchi, and pulmonary alveolar spaces. Rhinitis, pharyngitis, sinusitis, epiglottitis, laryngitis, and tracheitis are specific manifestations of URIs. Most URIs are viral in origin. Typical viral agents that cause URIs include the Rhinoviruses, Coronaviruses, Adenoviruses, and Coxsackieviruses. In the emergency department, attention should be paid to the patient's vital signs, including temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation (if obtained). Neonates are obligate nose breathers and may be at greater risk for respiratory distress;hence practitioners should auscultate the lungs for adequate aeration and assess breathing quality. The cardiovascular examination should assess adequate distal perfusion and an appropriate-for-age heart rate. Finally, dehydration can be a complication of any viral illness, and therefore, an assessment of hydration should be a part of the initial evaluation. Tests of nasopharyngeal specimens for specific pathogens are helpful when targeted therapy depends on the results (e.g., group A streptococcal infection, gonococcus, pertussis). Specific bacterial or viral testing is also warranted in other selected situations, such as when patients are immunocompromised, during inevitable outbreaks, or provide specific therapy to contacts. Symptombased therapy represents the mainstay of URI treatment in immunocompetent adults. Antimicrobial or antiviral therapy is appropriate in selected patients.

Ultrasound assessment of diaphragmatic dysfunction in patients with SARS-COVID-19 as a parameterorotracheal intubation

Objective: To correlate by ultrasound the diaphragmatic dysfunction in patients with SARS-COVID-19 with the patterns of pulmonary aeration and oxygenation status, as a parameter of orotracheal intubation. Design: Prospective, observational cohort study, carried out between the months of July to September 2020. Setting: emergency area of the “Hospital de Especialidades Dr. Teodoro Maldonado Carbo”. Patients: 15 patients with epidemiological link and clinical picture of respiratory failure due to suspected SARS-COVID-19 were included, who underwent the BLUE protocol, measurement of diaphragmatic excursion, thickness and diaphragmatic thickness delta to perform the correlations having as a cohort point a value of < 1.5 cm of diaphragmatic excursion as the main parameter, in addition to PaFi and gradient Aa as measures of oxygenation status. Variables: Pulmonary involvement and diaphragmatic dysfunction, state of oxygenation by arterial blood gas. Results: Of the patients studied, 10 were men and 5 women, their average age being 44 years old, the average value of the pulmonary aeration score was 27, diaphragmatic excursion 1.29 cm, both diaphragmatic thickness with Delta of diaphragmatic thickening were not presented greater variation. There was a marked decrease in diaphragmatic excursion in patients with greater compromise of oxygenation and perfusion, demonstrating diaphragmatic dysfunction in the presence of hypercapnia and hypoxia hypoxia with an inverse correlation coefficient of -0.841. Conclusions: It was evidenced that patients with higher pulmonary aeration patterns who had lower diaphragmatic excursion and little variability in the Delta of diaphragmatic thickening ended up in orotracheal intubation, so this parameter can be considered when assessing the severity of patients with SARS-COVID 19 especially when deciding orotracheal intubation. © 2022 Sociedad de Anestesiologia de Chile. All rights reserved.

Water usage pattern in the aftermath of COVID-19

Maintenance of good health and avoiding a viral infection is the prime focus for an individual during COVID-19 pandemic. Water being a universal solvent is used widely to clean the disinfectants in public places and individual household level. This study was designed to find any change in the water consumption pattern among the households after the emergence of COVID-19. To study this, a questionnaire was prepared and sent to the respondents through Google Forms. Collected data was analysed using suitable statistical methods and the results indicate that there was a significant change in the consumption pattern of drinking water from cold to hot (37.98%) among the respondents and also with respect to the total water usage. As the disease is communicable in nature, more water is needed to clean and disinfect the surface areas, washing hands etc. This eventually has a significant burden on the water resources in countries where water is already deficient, like India. It is recommended to adopt water conservation practices/technologies at the individual level by means of rain water harvesting techniques or use of efficient water aerator taps etc. to reduce water consumption.

Making CABG Less Invasive: Endoscopic Vessel Harvesting in Scotland

Background: We present our early experience of introducing state-of-the-art endoscopic vessel harvesting (EVH) into a hospital in Scotland. Coronary arteries bypass grafting (CABG) is the most frequently performed adult cardiac surgical operation and circa. 1200 cases were performed across Scotland in 2019/20, prior to the COVID-19 pandemic. Although internal thoracic artery (ITA) is the preferred conduit, most CABG operations require long saphenous vein (LSV) to be harvested from one or both legs. The radial artery (RA) is also used less frequently. Conduits are currently harvested by open technique, representing one of the longest incisions in surgery. Even when expertly performed, this is a major source of morbidity and delayed hospital discharge. Known risk factors for wound complications include age > 75 years, female sex, BMI > 28, history of smoking, diabetes mellitus and peripheral vascular disease. Both LSV and RA can be successfully harvested endoscopically via 2 cm incision with expected reduction in post-operative morbidity. In our quest to make CABG less invasive, we decided to embark upon a programme of EVH and hereby present our early clinical experience and vision for future roll-out across centres routinely performing cardiac surgery in Scotland. Methods: Consecutive patients undergoing isolated elective CABG surgery at one institution were consented for endoscopic vessel harvesting (EVH). We used a novel on-screen imaging (CoreVista, CardioPrecision), along with latest EVH harvesting tools (HemoPro 2, Getinge) and standard imaging/CO2 insufflation (Stryker). Data on risk factors, wound complications, patient satisfaction and length of stay were collected. Results: A short video will be used to demonstrate key steps of the procedure. Nine patients were recruited into the study. The mean age was 61 years [95% CI 53-69 years]. Six out of 9 (66%) patients had one or more risk factors for post-operative wound complications. LSV was harvested endoscopically in 6 patients (66%) and RA in 3 (33%) patients. The median number of grafts was 3 [range 2-5]. There were no immediate wound complications. All patients expressed a high level of satisfaction with the surgical result. Median post-operative length of stay was 5 days [range 5-6 days]. At a median follow-up of 2 months there were no late wound complication or adverse events reported. Conclusions: EVH was successfully delivered without complications in our series with high degree of patient satisfaction and consistently short length of stay. The combination of devices was easy to use and integrate into the standard CABG theatre footprint and procedure. Plans are now being made to implement EVH more widely across Scotland.

Ultrashort Hydraulic Retention Time of Aeration and Nonaeration Constructed Wetlands for a Large Volume of Primary-Treated Wastewater from a Medical Rubber Glove Factory

A substantial volume of primary-treated wastewater from a medical rubber glove factory caused public freshwater to become sewage. The ultrashort hydraulic retention time in constructed wetlands was urgently employed for wastewater remediation. Pilot-scale, aeration, and nonaeration horizontal surface flow constructed wetlands (HSFCWs) with emergent plants were designed, compared, and optimized. Activated carbon, coconut shells, and oyster shells were subsequently transferred into a plastic basket as a substrate layer, while Typha angustifolia L. was used as an emergent plant. The experiments were conducted at a hydraulic retention time of 2, 4, 6, and 8 hr. per effluent recirculation. Sampling data were collected for each of the four effluent recirculations. The removal efficiencies of BOD, COD, FOG, TKN, TSS, TDS, EC, and salinity in the aeration HSFCWs were high—53.25, 67.28, 97.93, 78.93, 95.87, 87.52, 86.36, and 90.38%—at the first effluent recirculation of sampling, respectively, while the removal efficiencies in the nonaeration HSFCWs were also high—55.12, 57.38, 94.62, 83.10, 95.95, 88.09, 89.54, and 93.46%, respectively. Increasing the hydraulic retention time increased removal efficiencies. The removal efficiency of BOD in aerated HSFCWs was higher than in nonaerated HSFCWs in the second effluent recirculation of sampling. This is because the oxygen supplied by aeration in the system increased the organic and inorganic pollutant removal efficiencies. Other pollutants were removed more effectively during the second effluent recirculation. Excluding BOD and COD, Duncan’s multiple test revealed that the number of effluent recirculations for removal efficiencies of FOG, TKN, TSS, TDS, EC, and salinity was nonsignificant at the p≤0.001 level. These findings led to optimization of the medical rubber glove wastewater treatment at an ultrashort hydraulic retention time of 2–4 hr. This process and the control of CWs may be the best industrial wastewater treatment practice and a long-term solution for the industrial sector.

The Role of Lung Ultrasound Monitoring in Early Detection of Ventilator-Associated Pneumonia in COVID-19 Patients: A Retrospective Observational Study.

Specific lung ultrasound signs combined with clinical parameters allow for early diagnosis of ventilator-associated pneumonia in the general ICU population. This retrospective cohort study aimed to determine the accuracy of lung ultrasound monitoring for ventilator-associated pneumonia diagnosis in COVID-19 patients. Clinical (i.e., clinical pulmonary infection score) and ultrasound (i.e., presence of consolidation and a dynamic linear-arborescent air bronchogram, lung ultrasound score, ventilator-associated lung ultrasound score) data were collected on the day of the microbiological sample (pneumonia-day) and 48 h before (baseline) on 55 bronchoalveolar lavages of 33 mechanically-ventilated COVID-19 patients who were monitored daily with lung ultrasounds. A total of 26 samples in 23 patients were positive for ventilator-associated pneumonia (pneumonia cases). The onset of a dynamic linear-arborescent air bronchogram was 100% specific for ventilator-associated pneumonia. The ventilator-associated lung ultrasound score was higher in pneumonia-cases (2.5 (IQR 1.0 to 4.0) vs. 1.0 (IQR 1.0 to 1.0); p < 0.001); the lung ultrasound score increased from baseline in pneumonia-cases only (3.5 (IQR 2.0 to 6.0) vs. -1.0 (IQR -2.0 to 1.0); p = 0.0001). The area under the curve for clinical parameters, ventilator-associated pneumonia lung ultrasound score, and lung ultrasound score variations were 0.472, 0.716, and 0.800, respectively. A newly appeared dynamic linear-arborescent air bronchogram is highly specific for ventilator-associated pneumonia in COVID-19 patients. A high ventilator-associated pneumonia lung ultrasound score (or an increase in the lung ultrasound score) orients to ventilator-associated pneumonia.

Pregnant and postpartum women requiring intensive care treatment for COVID-19-first data from the CRONOS-registry

Background Critical illness during pregnancy puts mother and fetus at serious risks. Current literature regarding the effect of coronavirus 2 (SARS-CoV-2) describes an increased risk for maternal mortality as well as high rates of preterm delivery, however data vary and depend on the respective health care system. We aimed to describe maternal characteristics and clinical presentation of SARS-CoV-2 positive pregnant and postpartum women requiring intensive care treatment for COVID-19 in Germany, in order to explore risk factors for severe COVID-19 courses as well as to provide an overview on treatments applied. Methods COVID-19 Related Obstetric and Neonatal Outcome Study (CRONOS), an ongoing prospective multicenter registry for SARS-CoV-2 positive pregnant women from 150 centres in Germany was analyzed with respect to intensive care treatment for COVID-19. We extracted information for all women requiring intensive care treatment for COVID-19 and compared maternal characteristics, course of disease, as well as maternal and neonatal outcomes. Results Out of 2445 cases in CRONOS registry, 96 women (4%) had a documented intensive care unit (ICU) stay and were analyzed. While 75 (78%) women were pregnant when receiving ICU treatment, 21 (22%) were admitted post-delivery. Median maternal age was 33 (IQR, 30-36) years. COVID-19 was diagnosed at a median gestational age of 32 (IQR, 28-35) weeks. We observed the following interventions as highest form of treatment required for COVID-19: continuous monitoring of vital signs (n=6 (6%)), insufflation of oxygen (n=32 (33%)), non-invasive ventilation (n=17 (18%)), invasive ventilation (n=29 (30%)) and escalation to extracorporeal membrane oxygenation (ECMO, n=12 (13%)). Maternal characteristics such as maternal age, ethnicity, body mass index at admission, history of smoking, comorbidities and concomitant medication, as well as gestational age were analyzed. No significant differences between patients receiving different forms of respiratory therapy for COVID-19 could be identified. Preterm delivery was observed in 45 women (47%). Two women (2%) died of COVID-19 and four fetuses (4%) were stillborn. Conclusions Our cohort shows that progression of COVID-19 in pregnant and postpartum women requiring ICU treatment is rare. Preterm birth rate is high and COVID-19 requiring respiratory support is not necessarily related to poor maternal or neonatal outcome. But, as one in ten patients admitted to ICU might require ECMO therapy, all pregnant women suffering from COVID-19 should be closely monitored. In future studies, detail about obstetric women requiring intensive care treatment for COVID-19 should be further evaluated.

Preliminary Experience with Continuous Negative Pressure Ventilation (CNEP) in Covid-19 patients requiring respiratory support

Background: The recent pandemic has forced hospitals to explore alternative ways of providing respiratory support, to prevent intubation or reduce time on mechanical support. Continuous negative pressure therapy (CNEP) using a simple thoracic shell, (-5 to-25 cmsH20), applied to the thorax has been purported to increase FRC, reduce atelectasis and improve oxygenation. Electrical Impedance Tomography (EIT) used conco-mitantly can allow for the visualization of the recruitment of lung zones in real-time by the bedside (thoracic belt) during CNEP. We sought to assess the feasibility of CNEP-EIT, whether it allowed for periods of pause during CPAP mask therapy, and any improvements in oxygenation during mechanical ventilation. Methods: A negative pressure shell was applied to 20 patients (10 intu-bated patients/10 non-intubated patients with CPAP). Therapy lasted from 30 mins to 2 hours. EIT images were visualized in real-time, (baseline measures compared to CNEP). In non-intubated patients, compliance and comfort during CNEP was assessed. For intubated patients, interference with mechanical ventilation and ease of application were evaluated. Results: There were no complications related to CNEP-EIT in any patients All non-intubated patients tolerated CNEP well. Therapy lasted from 1-2 hours, twice daily. CPAP mask time was reduced by approx.3-4 hours/day. Lung zone aeration shifted from the apical zones to basal zones during CNEP sessions, (>15-20% increase in EIT quadrants 3-4). A moderate increase in oxygen saturations (90.3%-93.4%) was observed. Intubated patients: CNEP allowed for improvements in oxygenation saturations (90.1-93.4%) and reduction in airway pressures (35.7;30.2 cmH20 Paw) without interfering with mechanical ventilation (triggering). P/F ratios increased from 19.2 to 21.2 during CNEP-EIT. In patients where oxygen saturations or P/F ratios increased minimally, (n = 2), there was also little change visualized in EIT lung zone images (<5%). CNEP reduced esophageal pressures in 2 obese patients (BMI 64, BMI 30: 18 to 10 cmH20, and 15 to 10 cmH20 respectively). Conclusion: Our first experience with CNEP-EIT in Covid-19 patients requiring respiratory support appears promising. The use of EIT as a feedback system during CNEP therapy allows for the immediate visualization of the benefits of the therapy for that particular patient. Trials should determine whether CNEP can prevent intubation, or reduce time on mechanical respiratory support.

GAS LEAKS FROM BIOPSY VALVES OF GASTROINTESTINAL ENDOSCOPY-ITS VISUALIZATION AND SEMI=QUANTIFICATION UTILIZING SCHLIEREN OPTICAL SYSTEM

<Background> With the global epidemic of COVID-19, there has been a growing concern about the risk of exposure to the virus among healthcare workers. Gastrointestinal (GI) endoscopy has been considered as one of the high infectious procedures because of the high risk of aerosol exposure. However, that caution is mainly directed at secretions and aerosols from the patient's mouth, and less attention is currently paid to air leaks from the endoscopic system itself. Although a few reports have been published on air leaks from GI endoscopic systems, no systematic and quantitative studies of air leaks have been conducted. Schlieren system is an optical device for visualizing minute changes in airflow that are invisible to the naked eye, by using differences in the refractive index of the medium, and has been mainly used in the field of engineering. We aimed to systematically evaluate air leaks from GI endoscopic systems using Schlieren system, and to determine the relationship between the amount of leakage and insufflation conditions including the types of biopsy valves. <Methods> The following experiments were performed on explanted swine stomachs while maintaining an intra-gastric pressure at each preset value. We attempted to visualize air leaks using System Schlieren (SS100, Kato Koken, Kanagawa, Japan). In all experiments, biopsy forceps were inserted and withdrawn 3 cm per 3 seconds. This action was repeated five times in each experiment. Experiment 1: Examined the feasibility of the Schlieren device in visualizing air leaks from biopsy valves. Experiment 2: The intragastric pressure was varied in the range of 4 to 15 mmHg and the air leaks were quantified and compared in each pressure. Experiment 2: Compared the air leaks between the types of biopsy valves, e.g. reusable, disposable, universal, deteriorated reusable valves after more than 10 times of uses. Image J (National Institute of Health, US) was used to measure the initial velocity and area of the leak on obtained images. The average values of initial velocity and leakage area over five sessions were calculated. For the leak area analysis, image analysis was performed for both forceps insertion and withdrawal. <Results> Experiment 1: Air leaks were seen at the moment of forceps insertion and withdrawal (Fig 1). Experiment 2: There was a linear relationship between intragastric pressure and initial velocity/diffusion range of the leak (Fig2A). Experiment 3: Disposable and deteriorated reusable biopsy valves had larger initial velocity/diffusion range of the leak (Fig2B). <Conclusions> We successfully visualized air leaks from GI endoscopic systems using the Schlieren system. We herein recommend the use of lower intragastric pressure at the times of insertion/withdrawal of forceps, and avoidance of using disposable/deteriorated biopsy valves, for less gas leakage and possibly less aerosol exposure.(Figure presented)Figure1. Visualization of air leak from biopsy valve(Figure presented)Figure 2. Results of analysis on air leakage from biopsy valve