Current Healthcare Policy and Environmental Status of Digital Health Medical Devices in South Korea

Objectives: COVID 19 and increasing unmet needs of health technology had accelerated an adoption of digital health globally and the major categories are mobile-health, health information technology, telemedicine. Digital health interventions have various benefit on clinical efficacy, quality of care and reducing healthcare costs. The objective of the study is to identify new reimbursement policy trend of digital health medical devices in South Korea. Method(s): Official announcements published in national bodies and supplementary secondary research were used to capture policies, frameworks and currently approved products since 2019. Result(s): With policy development, several digital health devices and AI software have been introduced as non-reimbursement by utilizing new Health Technology Assessment (nHTA) pathway including grace period of nHTA and innovative medical devices integrated assessment pathway. AI based cardiac arrest risk management software (DeepCARS) and electroceutical device for major depressive disorders (MINDD STIM) have been approved as non-reimbursement use for about 3 years. Two digital therapeutics for insomnia and AI software for diagnosis of cerebral infarction were approved as the first innovative medical devices under new integrated assessment system, and they could be treated in the market. In addition, there is remote patient monitoring (RPM) reimbursement service fee. Continuous glucose monitoring devices have been reimbursed for type 1 diabetes patients by the National Health Insurance Service (NHIS) since January 2019. Homecare RPM service for peritoneal dialysis patients with cloud platform (Sharesource) has been reimbursed since December 2019, and long-term continuous ECG monitoring service fee for wearable ECG monitoring devices (ATpatch, MEMO) became reimbursement since January 2022. Conclusion(s): Although Korean government has been developed guidelines for digital health actively, only few products had been reimbursed. To introduce new technologies for improved patient centric treatment, novel value-based assessment and new pricing guideline of digital health medical devices are quite required.Copyright © 2023

Refractory circulatory failure in COVID-19 patients treated with veno-arterial ECMO: A retrospective single-center experience

Objectives: Data about COVID-19 patients treated with veno-arterial-ECMO (VA-ECMO) is limited. Reported survival rates range from 27.9% to 77.8%, depending on VA-ECMO indication. A subgroup of patients suffers from circulatory failure due to a COVID-19 associated hyperinflammatory state (CovHI). In these patients, differentiation between inflammation and sepsis is difficult but important. In this retrospective case series, differential diagnoses of COVID-19 associated refractory circulatory failure and survival rates in different indications for VA-ECMO are investigated. Method(s): Retrospective analysis of 28 consecutive COVID-19 patients requiring VA-ECMO at the University Hospital Regensburg between March 2020 and May 2022. Specific treatment for COVID-19 was in accordance with respective guidelines. Mycotic infections were either invasive or met current definitions of COVID19-associated-pulmonary aspergillosis. Result(s): At VA-ECMO initiation, median age was 57.3 years (IQR: 51.4 - 61.8), SOFA score 16 (IQR: 13 - 17) and norepinephrine dosing 0.53mug/kg/min (IQR: 0.32 - 0.78). Virus-variants were: 61% wild-type, 14% Alpha, 18% Delta and 7% Omicron. Survival to hospital discharge was 39%. 17 patients were primarily supported with VA-ECMO only (survival 42%), 3 patients were switched from VV to VA-ECMO (survival 0%), and 8 patients were converted from VA to VAV or VV-ECMO (survival 50%). Indications for VA-ECMO support were pulmonary embolism (PE) (n=5, survival 80%), right heart failure due to secondary pulmonary hypertension (n=5, survival 20%), cardiac arrest (n=4, survival 25%), acute left heart failure (ALHF) (n=11, survival 36%) and refractory vasoplegia (n=3, survival 0%). Inflammatory markers at VA-ECMO initiation were higher in patients with ALHF or vasoplegia;in these patients a higher rate of invasive fungal infections (10/14, 71% vs. 4/14, 29%;p=0.023) compared to the other patients was found. Conclusion(s): Survival on VA-ECMO in COVID-19 depends on VA-ECMO indication, which should be considered in further studies and clinical decisions making. Circulatory failure due to vasoplegia should be considered very carefully as indication for VA-ECMO. A high rate of mycotic infections mandates an intense microbiological workup of these patients and must be considered as an important differential diagnosis to CovHI.

Non-trauma uses of viscoelastic hemostatic assays in critical care: A narrative review and primer for pharmacists

Thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are point-of-care viscoelastic tests of whole blood that provide real-time analyses of coagulation. TEG and ROTEM are often used to guide blood product administration in the trauma and surgical settings. These tests are increasingly being explored for their use in other disease states encountered in critically ill patients and in the management of antithrombotic medications. As the medication experts, pharmacists should be familiar with how to interpret and apply viscoelastic tests to disease state and medication management. The purpose of this narrative review is to provide a primer for pharmacists on viscoelastic tests and their interpretation and to explore non-trauma indications for viscoelastic testing in critical care. Literature evaluating the use of TEG and ROTEM for patients with acute and chronic liver disease, ischemic and hemorrhagic stroke, myocardial infarction, cardiac arrest, coronavirus disease 2019, and extracorporeal membrane oxygenation are described. Current applications of viscoelastic tests by pharmacists and potential future roles of critical care pharmacists in expanding the use of viscoelastic tests are summarized.Copyright © 2023 The Authors. JACCP: Journal of the American College of Clinical Pharmacy published by Wiley Periodicals LLC on behalf of Pharmacotherapy Publications, Inc.

Complications Associated with Catheter Ablation of Atrial Fibrillation in Current Practice: Insights from a Large, Real-World Collaboration

Background: Catheter ablation is a cornerstone treatment for symptomatic atrial fibrillation (AF) with major improvements in safety over time. However, rates of adverse events with use of current techniques in a contemporary quality-focused network remain undefined. Objective(s): Across a large, real-world sample, we sought to describe (1) rates of major, adverse events associated with catheter ablation of AF and (2) patient-level factors associated with complications. Method(s): Utilizing the REAL-AF collaboration, a registry of contemporary AF ablation procedures with granular patient, procedural and follow-up data comprised of cases from over 50 operators across academic and non-academic sites, we evaluated all patients undergoing their first ablation procedure from January 2018 - June 2022. Risk-adjusted analyses were conducted to evaluate the relationship between patient factors and complications. Result(s): Among 3144 patients (age 66.1 +/- 11.0 years, 42% female, 67.1% paroxysmal, 32.9% persistent) who underwent AF ablation, procedure-related complications (n =77) were identified in 65 patients (2.1%) with multiple complications occurring in 9 patients (0.2%). Most complications (n=70, 93.5%) occurred in the peri-procedural (within 30 days) period and 6.5% (n=5) after 30 days, the latter of which all represented vascular injuries (Figure). Major complications (18 of 72 peri-procedural complications, 25.0%) are defined, detailed, and associated data reported in the Figure. Unadjusted (16.0% without CHF vs. 33.3% with CHF, p = 0.045) and risk-adjusted (OR 2.8, 95% CI 1.03-7.60, p=0.045) analyses indicated history of CHF was associated with a composite outcome of major complications. Analyses of independent complications showed those who suffered from peri-procedural stroke (n=3) were of significantly greater age (77.3 +/- 5.5 years vs. 66.1 +/- 10.9 years, p=0.035). Risk-adjusted analyses showed history of vascular disease (OR 2.9, 95% CI 1.02-8.20, p=0.045) was associated with vascular injury (n=18). From 0-695 days post-procedure, 31 deaths occurred (unknown cause: 17, COVID-19 related: 4, heart failure: 2, cardiac arrest: 2). Conclusion(s): Major complications represent rare events among those undergoing AF ablation in current practice. Risk-adjusted analyses suggest a history of CHF is associated with major complications. Similarly, older age and a history of vascular disease are associated with stroke and vascular complications, respectively. [Formula presented]Copyright © 2023

ST-SEGMENT-ELEVATION MYOCARDIAL INFARCTION in COVID-19

Introduction: The Severe Acute Respiratory Syndrome Coronavirus-2 have been associated with cardiovascular adverse events including acute myocardial infarction due to a prothrombotic and hypercoagulable status, and endothelial dysfunction. Case report: We report the case of a 62-year-old women, admitted to the hospital via the emergency room for acute chest pain and dyspnea. A nasopharyngeal swab was positive for COVID19 real-time reverse transcriptase-polymerase chain reaction 11 day ago. On admission, she was hypotensive with systolic blood pressure measering 87 mmHg and tachycardic with 117 beats/min, oxygen saturation (SO2) was 94%. An 18-lead ECG revealed an infero-postero-lateral ST-elevation myocardial infarction with right ventricular involvement and a seconddegree- Mobitz Type 1 atrioventricular block. The coronary angiography from the right femoral artery showed acute thrombotic occlusion of the first diagonal branch with TIMI 0 flow and acute thrombotic occlusion of proximal right coronary artery with TIMI 0 flow. The most likely diagnosis was myocardial infarction secondary to a non-atherosclerotic coronary occlusion. The angioplasy was performed with dilatations with a semi compliant balloon, bailout implant of BMS, manual thrombus aspiration and intracoronary injection of tirofiban in the right coronary artery. The myocardial revascularization was ineffective. The patient developed significant severe hemodynamic instability and cardiac arrest for pulseless electric activity after 24 hours. Conclusion(s): The COVID-19 outbreak implies deep changes in the clinical profile and therapeutic management of STEMI patients who underwent PCI. At present, the natural history of coronary embolism is not well understood;however, the cardiac mortality rate are hight. This suggests these patients require further study to identify the natural history of the condition and to optimize management to improve outcome.

Nurse perception on ECMO care: A literature review

Objectives: The nursing care is more complex in relation to new technologies, new diseases, new globally emergencies. In relation to technology, nurses acquired more competences in relation to advanced therapy, in respiratory, circulatory, and renal support. The nursing workload increases in complexity and in responsibilities, without a staff increasing in relation to nursing activities. ECMO was widely applied to manage acute respiratory distress syndrome and circulatory failure, in case of cardiac arrest or cardiogenic shock, configuring as a therapy bridge to decision, to restore, to transplant or to nowhere. During the last years, nurses were involved to a rapid and continuous changing, to respond adequately to new health challenges, understanding or not their role and responsibilities in globally health care system. Nurse manages different variables, well represented by nursing activities score, but in nursing ECMO care, these variables are more complicated, in relation to ECMO device and to ECMO patient. What is the globally perception of nurses involved in ECMO care? Methods: A literature review was applied on PubMed. The inclusion criteria were all articles about ECMO, including pediatric and/or adult population, with a publication less than ten years. Result(s): A total of sixteen articles were found, with reduction to ten for relevance. The excluded articles talked about non ECMO care or patient;s perceptions. Articles included in the research talk about nursing perceptions (40%), education (30%), ethics in ECMO care (20%), professional experience in ECMO Covid (10%). Conclusion(s): The nursing perception on ECMO nursing care are different. They recognize the central role in ECMO care, but over workload, without staff increasing, less peer support, a low teamwork and personal differences in technical and non-technical skills increase some barriers to nursing perception of themselves. Nurses allocate their competence on experience and continuous training, but also a good teamwork and a professional recognition by other health care professions or by nursing supervisors can increase nursing perception and reduce the abandonment of nursing profession.

A baby girl with TBX1 haploinsufficiency who died after elective cardiac repair surgery due to suspected enteroviral meningitis

Introduction: TBX1 haploinsufficiency is an inborn error of immunity with the phenotype of DiGeorge Syndrome. DiGeorge Syndrome has variable immunodeficiency associated with grade of thymic hypoplasia ranging from mild with no infections to severe requiring thymus implant. Enterovirus is an example of an opportunistic infection that can be fatal in these patients. Case Presentation: A 1 year old girl with TBX1 haploinsufficiency complicated by Tetralogy of Fallot, pulmonary atresia, high arched palate, and vesicovaginal fistula presented for elective cardiac repair surgery from another country due to failure to thrive and cyanosis. She had no prior infectious history but was on sulfamethoxazole-trimethoprim for prophylaxis. She was asymptomatic with a negative COVID test but no other infectious studies performed. Immediately postoperatively, she was febrile and nasal respiratory viral panel was positive for rhinovirus/enterovirus with increased procalcitonin and leukocytosis with left shift. She decompensated with multi-organ failure and cardiac arrest on postoperative day two. She was cannulated to veno-arterial extracorporeal membrane oxygenation (ECMO). Pre-operatively, she had a normal absolute lymphocyte count. No thymus tissue was observed in surgery. She had profound CD3 lymphopenia to 130 cells/cmm when critically ill. Enteroviral meningitis was suspected as no infectious, cardiac, or other pathology could be identified causing decompensation. Enteroviral serum polymerase chain reaction (PCR) test was negative while lumbar puncture deferred due to clinical status. She was treated with immunoglobulin. Offlabel investigational drug pocapavir was considered but deferred to patient's irreversible neurological status. The patient was disconnected from ECMO and expired. Discussion(s): Though we cannot confirm that this patient had enteroviral meningitis, invasive enteroviral infections are associated with elevated transaminases, coagulopathy, and seizures all present in our patient. There has also been reported negative serum enteroviral PCR but positive CSF enteroviral PCR in an immunodeficient patient. Additionally, this case highlights the importance of immunologic evaluation in patients with DiGeorge Syndrome and questions if asymptomatic viral screening for viruses like enterovirus should be considered pre-operatively in patients with inborn errors of immunity. This case highlights potential treatment options for invasive enteroviral infections in patients with inborn errors of immunity: high dose immunoglobulin, fluoxetine, and pocapavir.Copyright © 2023 Elsevier Inc.

Cool Your Jets Bro

History: Twenty-two year old male basic trainee was brought to the ED after collapsing during a routine ruck march. At mile 8/12, soldier was noted to develop an unsteady gate and had witnessed loss of consciousness. A rectal core temperature was obtained and noted to be >107degreeF. Cooling initiated with ice sheets and EMS was activated. On arrival to the ED, patient demonstrated confusion and persistently elevated core temperatures despite ice sheeting, chilled saline and cold water bladder lavage. Cooling measures were discontinued after patient achieved euthermia in the ED;however, his temperatures subsequently spiked>103degreeF. Given rebound hyperthermia, an endovascular cooling (EVC) device was placed in the right femoral vein and patient was transferred to the ICU. Multiple attempts to place EVC device on standby were unsuccessful with subsequent rebound hyperthermia. Prolonged cooling was required. Physical Exam: VS: HR 121, BP 85/68, RR 22 SpO2 100% RA, Temp 102.4degreeF Gen: young adult male, NAD, shivering, A&Ox2 (person and place only) HEENT: Scleral anicteric, conjunctiva non-injected, moist mucus membranes Neck: Supple, no LAD Chest: CTAB, no wheezes/rales/rhonchi CV: tachycardia, regular rhythm, normal S1, S2 without murmurs, rubs, gallops ABD: NABS, soft/non-distended, no guarding or rebound EXT: No LE edema, tenderness SKIN: blisters with broad erythematous bases on bilateral heels Neuro: CN II-XII grossly intact, 5/5 strength in all extremities. Differential Diagnosis: 216. Septic Shock 217. Hypothalamic Stroke 218. Exertional Heat Stroke (EHS) 219. Neuroleptic Malignant Syndrome 220. Thyroid Storm Test Results: CBC: 18.2>14.5/40.6<167 CMP: 128/3.5 88/1831/2.7<104, AST 264, ALT 80, Ca 8.8 Lactate: 7.1 CK: 11 460 Myoglobin: 18 017 TSH: 3.16 CXR: No acute cardiopulmonary process Blood Cx: negative x2 CSF Cx: Negative COVID/Influenza/EBV: Negative Brain MRI: wnl. Final Diagnosis: Exertional Heat Stroke. Discussion(s): No EVC protocols exist for the management of EHS or rebound/refractory hyperthermia. As a result, the protocol used for this patient was adapted from post-cardiac arrest cooling protocols. It is unclear if this adapted protocol contributed to his delayed cooling and rebound hyperthermia as it was not intended for this patient demographic/ pathophysiology. Furthermore, despite initiating empiric antibiotics upon admission, delayed recognition and tailored therapy for his bilateral ankle cellulitis may have contributed to the difficulty in achieving euthermia. In summary, more research needs to be done to evaluate and develop an EVC protocol for EHS. Outcome(s): Euthermia was achieved and maintained after 36 hours of continuous EVC, at which point it was discontinued. His CK, AST/ALT, creatinine and sodium down-trended after discontinuation of EVC. Patient's antibiotics were transitioned to an oral formulation for treatment of ankle cellulitis and he was prepared for discharge. He was discharged with regular follow-up with the Fort Benning Heat Clinic. Follow-Up: After discharge, patient had regularly scheduled visits with the Fort Benning Heat Clinic. His typical lab markers for exertional heat stroke were regularly monitored. He had continued resolution of his Rhabdomyolysis, acute kidney injury and hyponatremia with typical treatment. Soldier returned to duty after 10 weeks of close monitoring and rehabilitation.

2022 CAS Virtual Annual Meeting

The proceedings contain 63 papers. The topics discussed include: a retrospective study to optimize post-anesthetic recovery time after ambulatory lower limb orthopedic procedures at a tertiary care hospital in Canada;a virtual airway evaluation as good as the real thing?;airway management during in hospital cardiac arrest by a consultant led airway management team during the COVID-19 pandemic: a prospective and retrospective quality assurance project;prevention of cautery induced airway fire using saline filled endotracheal tube cuffs: a study in a trachea airway fire model;smart phone assisted retrograde illumination versus conventional laryngoscope illumination for orotracheal intubation: a prospective comparative trial;time to single lung isolation in massive pulmonary hemorrhage simulation using a novel bronchial blocker and traditional techniques;cannabinoid type 2 receptor activation ameliorates acute lung injury induced systemic inflammation;bleeding in patients with end-stage liver disease undergoing liver transplantation and fibrinogen level: a cohort study;endovascular Vena Cavae occlusion in right anterior mini-thoracoscopic approach for tricuspid valve in patients with previous cardiac surgery;and mesenchymal stem cell extracellular vesicles as a novel, regenerative nanotherapeutic for myocardial infarction: a preclinical systematic review.

Case Report of a Transfusion-Associated Circulatory Overload Leading to Cardiac Arrest in a COVID-19 Positive Patient

Although case reports have been made regarding adverse transfusion reactions, few have been made regarding blood transfusions leading to cardiac arrest. Today, we present a case of a COVID-19 positive Bahraini male, triple vaccinated, transfused with packed red blood cell (pRBC) after finding out he has low haemoglobin levels (64 g/dl) after routine laboratory investigations. During the blood transfusion, he developed hypertension, tachycardia and tachypnoea. The patient went into cardiac arrest within a few minutes of this presentation. Return of spontaneous circulation was achieved, and the patient was managed as transfusion-associated circulatory overload (TACO) with a good overall outcome.Copyright © 2023, Bahrain Medical Bulletin. All rights reserved.

Impact of Atrial Fibrillation and Flutter on the in-Hospital Outcomes of Patients with Covid-19: A Nationwide Retrospective Cohort Study

Background: Atrial fibrillation and/or flutter is a common comorbidity in hospitalized patients with COVID-19. Objective(s): We aimed to assess the effect of atrial fibrillation and/or flutter on the outcomes of COVID-19 patients in a nationally representative sample. Method(s): We conducted a population-based analysis utilizing data from the national inpatient sample database. Hospitalized adults >= 18 years who were hospitalized with COVID-19 during the year 2020 were included. We used multivariate logistic regression models to investigate the outcomes in patients who had atrial fibrillation or flutter. Result(s): Among 1,018,115 (Nationally weighted sample) admissions with COVID-19, 154795 cases (15.2%) had atrial fibrillation and/or flutter. Patients with atrial fibrillation and/or flutter had significantly higher adjusted odds of all-cause in-hospital mortality (Odds Ratio [OR], 1.78 [confidence interval (CI), 1.75-1.80]), acute stroke (OR, 1.96 [CI, 1.85-2.07]), acute coronary syndrome (OR, 1.43 [CI, 1.37-1.48]), acute heart failure (OR, 4.24 [CI, 4.15-4.34]), cardiogenic shock (OR, 3.07 [CI, 2.85-3.30]), need for vasopressors (OR, 2.14 [CI, 2.06-2.22]), cardiac arrest (OR, 1.95 [CI, 1.89-2.02]), need for mechanical ventilation (OR, 1.79 [CI, 1.77-1.82]), acute kidney injury (OR, 1.25 [CI, 1.23-1.27]), major bleeding (OR, 1.82 [CI, 1.73-1.92]) compared to those patients without atrial fibrillation or flutter. On subgroup analysis, the risk for mortality was highest among atrial flutter (OR, 2.91), followed by atrial flutter and fibrillation group (OR, 2.38), followed by only atrial fibrillation group (OR, 1.71) (P value <0.001 for all) when compared to non-atrial fibrillation, non-atrial flutter in patients with COVID-19. Conclusion(s): Atrial fibrillation and flutter are associated with higher inpatient mortality and worse outcomes in COVID-19 patients. [Formula presented]Copyright © 2023

Cardioneuroablation in a Woman with Ictal-Induced Cardiac Asystole

Background: Ictal-induced cardiac bradyarrhythmia and asystole is a rare phenomenon. The exact mechanism of ictal-induced cardiac bradyarrhythmia and asystole remains unclear. It was postulated that stimulation of central autonomic network during ictal episode may trigger an abrupt burst of hypervagotonia. Prolonged episode of cardiac bradyarrhythmia and asystole may result in syncope or death due to impairment of cerebral perfusion. The role of cardioneuroablation (CNA) in this condition has not been well-described in the literature. Objective(s): To describe a case of successful CNA in a patient with ictal-induced bradyarrhythmia and asystole. Method(s): n/a Results: A 47-year-old female has a 1.5-year history of intractable focal epilepsy and COVID-19 infection. She started having multiple episodes of seizures following a mild COVID-19 infection. Electroencephalogram (EEG) and brain MRI revealed right temporal onset seizures without structural lesions. Due to ongoing uncontrolled seizures with multiple semiologies despite multiple anti-epileptic drugs, she was admitted to Epilepsy Monitoring Unit for seizure classification. Her ictal EEGs (Figure 1) showed onset of ictal rhythm in the right temporal region with episodes of severe sinus bradycardia (15-30 bpm) and sinus pauses (15-16 seconds). Telemetry tracings demonstrated PP interval slowing with PR interval prolongation prior to the pauses consistent with a vagally-mediated mechanism. Cardiac electrophysiology team recommended CNA for treating the episodes of ictal-induced bradyarrhythmia and asystole. 3D anatomic maps of the right atrium (RA) and left atrium (LA) were created using CARTO system (Biosense Webster). Right superior ganglionated plexus (RSGP) was localized with fractionation mapping and intracardiac echocardiography guidance. RSGP was targeted from the RA using an irrigated radiofrequency catheter with power limit of 25 W. Post-ablations of RSGP, her heart rate increased from 60 - 99 bpm. Additional lesions were delivered from the LA site but no additional heart rate increase was not seen. An implantable loop recorder was implanted post-ablation procedure. During follow-up of 8 months, she had recurrent focal epilepsy, but no bradyarrhythmias or asystole was noted on her loop recorder. Resting heart rates at long-term follow up were between 70 - 100 bpm. Conclusion(s): This case highlights the utility of CNA in patient with ictal-induced cardiac bradyarrhythmia and asystole. CNA may be an approach to avoid permanent pacemakers in this population. [Formula presented]Copyright © 2023

Intubation of Critically Ill COVID-19 Patients Using Conventional Laryngoscope in the ICU

Background: Video laryngoscopy is recommended for critically ill COVID-19 patients due to safety concerns and avoid complications. It is not available in some places and thereby forcing the operator to rely on conventional laryngoscope. Intubations in critically ill COVID-19 patients are challenging and may lead to adverse complications which may be affected by the laryngoscope used. The aim of the study was to analyse predictors of difficult intubation, complexity of intubation and complications of using conventional laryngoscopy in intubations of COVID-19 patients in ICU. Method(s): A prospective observational study was done in COVID Intensive Care Unit of the Base Hospital-Teldeniya, Sri Lanka from 1st of January 2021 to August 2021. The data was collected using a Performa filled by operator at the end of the intubation. Apart from demographic data and clinical parameters, data related to intubation including MACOCHA score which is a validated score predicting difficult intubation in ICU(3) and Intubation difficulty scale (IDS) which measures the actual complexity of intubation(4) were collected. The complications related to intubation were also analysed. Result(s): Approximately 84 out of 91 emergency intubations were done using conventional laryngoscope. Out of them 50.72 % were male and 49.27% Were female. Mean age was 50.75 years. First pass success rate was 83.3%. 25% had MACOCHA score more than 3. Most patients scored on the desaturation component of the score. Despite this only 50% of the predicted difficult intubations actually had major difficulty in intubation. The commonest complication was hypotension. 12 had suffered cardiac arrest, and 4 of them were fatal. Conclusion(s): Intubation of Critically ill COVID-19 patients are challenging but can be done successfully with conventional laryngoscope. However, one must prepare for complications including cardiac arrest.Copyright © 2023, College of Anaesthesiologists of Sri Lanka. All rights reserved.

The Impact of COVID-19 Infection on Diabetic Ketoacidosis Acidosis Hospitalization: A Nationwide Analysis

Objective: One of the potentially fatal consequences for diabetic patients is diabetic ketoacidosis acidosis (DKA), which is also linked to poor hospital outcomes. There is no much information in literature about COVID-19 and how it relates to other hospitalizations. The impact of COVID-19 on in-hospital mortality and other clinically relevant outcomes for DKA patients is being investigated for the first time in this study. Method(s): Patients admitted with a primary diagnosis of DKA with or without a subsequent diagnosis of COVID-19 Infection were found in the National Inpatient Sample (NIS) Database 2020. Patients were divided into two groups: those who have COVID-19 and those who don't. Univariate and multivariate logistic regression models were utilized to account for frequent confounders and assess the risk of mortality and in-hospital outcomes between the two groups. Result(s): The total of 110,130 DKA admissions were identified between Jan and Dec 2020. COVID-19 Infection was diagnosed in 2,504 patients (2.2%). The average age of the cohort sample was 35 years old, 51% were male, and 60% were white. The average length of stay (LOS) was 3 days, and the average total hospital charges were 33,132 US dollars. The total number of patients who died was 225 patients. When the two groups were compared, COVID-19 Infection was associated with an increased risk of in-hospital mortality among DKA patients (OR 5.3, 95% CI 1.7-15.9, p=0.003). COVID-19 patients had a higher risk of acute respiratory failure (OR 2.9, 95% CI 1.7-3.9, p< 0.001) and septic shock (OR 3.9, 95% CI 1.5-9.8, p=0.003). There was no significant difference between the COVID-19 and non-COVID-19 groups in the risk of acute coronary syndrome (OR 1.2, 95% CI 0.49-3, p=0.66), cardiac arrest (OR 2, 95% CI 0.5-7.9, p=0.31), hypokalemia (OR 1.14, 95% CI 0.92-1.4, p=0.214), deep vein thrombosis (OR 0.59, 95% CI 0.14-2.4, p=0.47), or pulmonary embolism (OR 3.6, 95% CI 0.84 - 15.4, p=0.083). COVID-19 patients had a longer mean LOS (4.2 vs 2.9 days, p< 0.001) and higher mean total hospital charges (41,216 vs 32,973 $, p=0.004). Discussion/Conclusion: Patients admitted with DKA and concomitant COVID-19 infection found to have a higher risk of in-hospital mortality and worse hospital outcomes, particularly acute respiratory failure and septic shock. In comparison to non-COVID patients, COVID-19 patients have a longer mean LOS and a higher mean of total hospital charges.Copyright © 2023

COVID-19 and Type II NSTEMI: A Comprehensive Overview

Introduction: Data on the incidence of type 2 NSTEMI (T2MI) in hospitalized patients with COVID-19 infection has been limited to single-center studies. We propose to define the incidence of T2MI in a national cohort and identify pre-hospital patient characteristics associated with a diagnosis of T2MI in hospitalized patients with COVID-19. We will also examine the impact of T2MI on morbidity and mortality. Method(s): We performed a retrospective analysis on data from the American Heart Association COVID-19 Cardiovascular Disease Quality Improvement Registry. This national registry contains data on tens of thousands of patients hospitalized with COVID-19 from at least 122 centers across the United States. From January 2020 through May 2021, there were 709 (2.2%) out of 32,015 patients with a coded diagnosis of T2MI. We performed Wilcoxon tests, chi-squared test, and multivariable logistic regression to (1) identify predictive pre-hospital patient characteristics (Table 1) of T2MI for patients hospitalized with COVID-19 and (2) investigate the impact of T2MI on mortality and morbidity. Result(s): Patients in the T2MI group were older (71 vs. 63 years, p<0.001), and in forward selection analyses, patients with a diagnosis of T2MI had higher odds of known HTN (OR 1.79 [1.01-3.1], p=0.026) and heart failure (OR 3.46 [2.24-5.34], p<0.001). Increased age, admission troponin, CRP, and d-dimer were also associated with higher odds of T2MI. Hispanic race (OR 0.517 [0.289-0.924], p=0.026) and use of antihyperglycemics (OR 0.562 [0.377-0.836], p=0.005) were both associated with lower odds of T2MI. T2MI led to increased mortality (HR 1.32, [1.17-1.5], P<0.001) and morbidity including cardiac arrest, major bleeding, and stroke. Conclusion(s): A history of heart failure was the strongest predictor of T2MI in hospitalized COVID19 patients. Patients with a T2MI compared to those without, had significantly higher mortality and morbidity. Limitations include the heterogenous ascertainment of the T2MI diagnosis across sites in this registry.

Rise in Out-of-Hospital Cardiac Arrest Cases in Chicago in 2020

Background: Italy, France and New York City have reported an increase in out-of-hospital cardiac arrest (OHCA) incidence during the COVID-19 pandemic. The purpose of our study was to assess the effect of COVID-19 on OHCA cases in Chicago. Method(s): Cardiac Arrest Registry to Enhance Survival (CARES) database was used. Bivariate analysis was conducted to assess changes in demographic and other characteristics. We excluded the cases that occurred in a healthcare facility or a nursing home. We compared the cases reported in 2020 to 2019 (and prior years). ArcGIS was used to geocode incident addresses and to show the temporal distribution by community areas. Bivariate analysis was done using chi-square tests. Result(s): A total of 3221 OHCA cases were reported in Chicago in 2020, which is 31.5% higher than those reported in 2019 (n=2450 cases). This increase was higher than what has been noticed historically (for instance, the increase from 2018 to 2019 was only 17%). There was an increase in Hispanic OHCA cases (17.3% in 2020 vs. 13.5% in 2019, p<0.01) but a decrease in White cases (20.5% vs. 23.1%). The cases in 2020 were less likely to be reported at public location (22% vs. 26%, p<0.001) or have shockable rhythm (10% vs. 13%, p=0.0002). There was a marked increase in those that were declared dead in the field in 2020 (37% vs. 27%, p<0.001). However, there were no statistically significant differences in age distribution, gender, witnessed arrest (49% vs. 51%, p=0.07) or bystander cardiopulmonary resuscitation (BCPR) (23% vs. 22%, p=0.3). Conclusion(s): A better understanding of the causes of the excess cardiac arrest numbers will be important to help plan and better prepare for future public health interventions. The effect of COVID19 on OHCA survival needs to be examined further in future studies.

Asymmetric Cerebral Perfusion in Comatose Extracorporeal Membrane Oxygenation Patients

Asymmetric cerebral perfusion can occur when extracorporeal membrane oxygenation (ECMO) flow competes with native cardiac circulation. It is unclear whether this phenomenon associates with brain injury. Diffuse correlation spectroscopy (DCS) provides continuous, laser-based, non-invasive, bedside monitoring of relative cerebral blood flow (rCBF). This study measured rCBF in ECMO patients via DCS to determine whether comatose patients experience asymmetric cerebral perfusion. Adults receiving ECMO for any indication were prospectively recruited from 12/2019-3/2021. Patients with prior neurologic injury, scalp/facial lacerations, and SARS-CoV-2 infection were excluded. DCS monitoring was performed daily during ECMO support with sensors placed on bilateral foreheads. Mean arterial pressure (MAP) was continuously recorded from the bedside monitor. The Glasgow Coma Scale (GCS) was assessed by clinical staff multiple times daily with sedation pauses, if possible, per standard of care. rCBF was calculated by comparing continuous cerebral blood flow (CBF) measurements to the daily median CBF, then averaged at each MAP value. Daily rCBF asymmetry was calculated by summing the absolute difference of rCBF between the two hemispheres at each MAP value, normalized for the total MAP range experienced by the patient that day. Twelve subjects were enrolled in this study (ages 21-78, 6 with cardiac arrest, 4 with acute heart failure, 2 with ARDS) and grouped by maximum GCS motor (GCS-M) score during ECMO, with 3 "comatose" subjects (GCS-M <= 4), and 9 "awake" subjects (GCS-M > 4). DCS was performed over 66 sessions with a mean duration of 131.83 +/- 1.13 minutes. Comatose subjects exhibited more rCBF asymmetry than awake subjects (0.28 +/- 0.06 mmHg-1 vs. 0.10 +/- 0.001 mmHg-1, p=0.045). No difference in asymmetry was noted between patients with or without cardiac arrest. We found that comatose ECMO subjects exhibited higher inter-hemispheric rCBF asymmetry over a range of blood pressures than awake subjects. Though our comatose sample is small, further validation of this finding and its causes, such as cerebrovascular dysregulation, is warranted.

Comparison Of Hospital Outcomes Between Covid 19 Myocarditis And Non-covid-19 Myocarditis

Introduction: Myocarditis commonly results from viral infections, which causes inflammation of the heart muscles. This could lead to adverse outcomes such as prolonged hospitalizations, cardiogenic shock, cardiac arrest, and event death. Studies have shown that COVID-19 could lead to myocarditis. However, the differences between COVID-19 myocarditis and non-COVID-19 myocarditis have not been explored. Hypothesis: We hypothesized that adverse hospital outcomes such as in-hospital mortality, cardiogenic shock, cardiac arrest, mechanical ventilation, and acute respiratory distress syndrome would be higher among hospitalizations for COVID-19 myocarditis, compared to non-COVID-19 myocarditis. Method(s): We conducted a retrospective analysis of data collected in California State Inpatient Database (SID) during 2019 and 2020. We included data from all hospitalizations for COVID-19 myocarditis during 2020 and compared with data from all hospitalizations for non-COVID-19 myocarditis during 2019. ICD-10-CM diagnosis codes were used to identify procedures and conditions. Cox proportional and logistic regression analyses were done to compare the outcomes between the two groups. Result(s): A total of 1,165 non-COVID-19 myocarditis and 575 COVID-19 myocarditis hospitalizations were included for the analysis. Nearly 45% of COVID-19 myocarditis hospitalizations were >=65 years, while 52.3% of non-COVID-19 myocarditis hospitalizations were between 18-44 years of age. The rates of in-hospital mortality (4.2% versus 31.5%, P<0.001), cardiac arrest (2.0% versus 8.8%, P<0.001), mechanical ventilation (10.4% versus 41.2%, P<0.001), and acute respiratory distress syndrome (0.3% versus 17.5%, P<0.001) were significantly higher among COVID-19 myocarditis hospitalizations, compared to non-COVID-19 myocarditis hospitalizations. Kaplan Meier survival analysis showed that survival rates among COVID-19 myocarditis hospitalizations were significantly lower than non-COVID-19 myocarditis hospitalizations, compared to non-COVID-19 myocarditis hospitalizations (logrank P<0.001). Cox proportional regression analysis showed that in-hospital mortality (hazard ratio [HR], 2.15;CI: 1.41-3.28) was significantly higher among COVID-19 myocarditis hospitalizations. Logistic regression analysis showed that the odds of cardiac arrest (odds ratio [OR], 3.23;95% CI: 1.75-5.94), mechanical ventilation (OR, 5.65 95% CI: 4.09-7.81), and acute respiratory distress syndrome (OR, 72.56;95% CI: 21.52-244.68) were significantly higher among COVID-19 myocarditis hospitalizations. Conclusion(s): Our study using a large administrative database found that COVID-19 myocarditis compared to non-COVID 19 myocarditis affected older individuals and was associated with greater rates of in-hospital mortality and adverse hospital outcomes. These findings highlight the different nature of COVID related myocarditis compared to other forms of acute myocarditis.Copyright © 2022