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Objectives: Analgosedation of patients with severe respiratory failure due to coronavirus disease 2019 (COVID-19) proved to be challenging. Patients supported with venovenous extracorporeal membrane oxygenation (VV ECMO) seemed to require analgosedative drugs in high doses. This study reviews analgosedation practices in patients with COVID-19 associated severe respiratory failure supported with VV ECMO. Method(s): This is a retrospective, single-center registry study including all patients with COVID-19 associated severe respiratory failure that were supported with VV ECMO at our center. All sedative and analgetic drugs administered intravenously or via inhalation to patients for at least two hours were recorded and analyzed. Result(s): Between March 2020 and January 2022, 88 patients with COVID-19 associated severe respiratory failure were supported with VV ECMO at our center. Propofol and sufentanil were used most frequently for analgosedation in this cohort. Both drugs were co-administered following treatment standards established prior to the emergence of COVID-19 at our center. Sedative and analgetic drugs were switched to alternative regimens after a median time of 3 and 12.5 days. Alternative regimens included Isofluran, alpha-2- agonists (clonidine or dextomidine) or esketamine. Alpha-2- agonists were initiated at a median time of 2 days after starting VV ECMO support. Benzodiazepines were used primarily as last resort treatment option for sedation at our center. During the four waves of the pandemic experienced at our center, we experienced an increased average number of drugs needed for analgosedation. Conclusion(s): Analgosedation in critically ill COVID-19 patients supported with ECMO is challenging. It remains unclear, whether the standard analgosedation regimen with sufentanil and propofol established at our center prior to the COVID-19 pandemic is optimal for this patient cohort. Further studies are needed to determine optimal and long term safe analgosedation regimens in critically ill patients supported by VV ECMO. Furthermore, changes experienced during the course of the pandemic need to be scrutinized in comparison to other cohorts. (Table Presented).
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Background: Many EP procedures are moving from the hospital to the ambulatory surgery center (ASC) outpatient setting. The COVID-19 pandemic and the CMS Hospitals Without Walls (HWW) program has been an impetus in accelerating this transition. Anesthesia provider perioperative management is critical in facilitating safe procedures with rapid, same-day discharge. Our EP-dedicated 2-OR ASC completed more than 3,000 procedures and more than 500 left-sided ablations utilizing general anesthesia with endotracheal intubation with same-day discharge. To our knowledge, this experience is unique within an ASC setting in both volume and complexity. Objective(s): We present our comprehensive anesthesia strategy and lessons learned to facilitate safe, efficient procedures and discharge in an EP ASC. Method(s): A nurse anesthesiologist with more than a decade of EP-dedicated experience developed and taught a perioperative anesthesia strategy to facilitate high volume, safe and quick discharge care. Fundamental to this is the avoidance of opioids and benzodiazepines whenever possible. Propofol or general anesthesia with sevoflurane and complete reversal with sugammadex allow for quick recovery. Mandatory video laryngoscope utilization minimizes airway trauma, while liberal antiemetic use eliminates most nausea. All femoral access is device closed. Positive inotropes are used liberally during anesthetic to avoid heart failure. The goal is to deliver all patients to PACU on room air with stable hemodynamics. Anesthesia providers manage the preop and recovery area. Result(s): More than 90% of all patients undergoing general anesthesia and heparinization for left-atrial ablation were discharged home in under 3 hours. Nearly all procedures not requiring femoral access were discharged within 30-60 minutes. High procedure volumes with efficiencies far exceeding our in-hospital experience were thus facilitated with improved patient safety. Since HWW began, five patients have required transfer to the hospital without any deaths. All others were discharged same day. Conclusion(s): We suggest that a dedicated anesthesia team with a tailored perioperative anesthesia plan facilitates performing nearly all EP-related surgical procedures in an ASC. This success is facilitated by appropriate patient selection, preoperative evaluation, intraoperative care prioritizing quick return to baseline, and end-to-end anesthesia perioperative management. We believe this type of anesthesia management is critical to the transition of EP procedures to ASCs.Copyright © 2023
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INTRODUCTION AND OBJECTIVE: Psychotropic medications have a significant impact on sexual health. Long-term usage is strongly associated with dyspareunia, decreased libido, hypogonadism and erectile dysfunction. We hypothesized that the prescription rates for psychotropic medications increased in adolescent patients during the COVID-19 pandemic because of the unprecedented stress levels on youth in isolation. Therefore, we evaluated the prescription rates of psychotropic medications as well as concurrent use of PDE5i in adolescent patients during the COVID-19 pandemic compared to the pre-pandemic era. METHOD(S): We utilized data generated from TriNetX Research Network to conduct a retrospective matched cohort study. Adolescent patients aged 10-19 presenting for outpatient evaluation were placed into two cohorts: 1) outpatient evaluation before and 2) during the COVID-19 pandemic. Patients with prior psychiatric diagnoses and those with prior use of psychotropic medications were excluded. The outcomes of interest were new prescriptions within 90 days of outpatient evaluation. Propensity score matching was performed using logistic regression to build cohorts of equal size. RESULT(S): A total of 1,612,283 adolescents pre-COVID-19 and 1,008,161 adolescents presenting during the COVID-19 pandemic for outpatient evaluations were identified. After propensity matching, a total of 1,005,408 adolescents were included in each cohort each withan average age of 14.7 +/- 2.84 and 52% female and 48% male. Prescribing of antipsychotics and benzodiazepines were more frequent during the pandemic for adolescents (RR: 1.58, 95% CI 1.01-2.2). However, they were less likely to receive antidepressants (Risk Ratio (RR): 0.6, 95% Confidence Interval (CI) 0.57-0.63), anxiolytics (RR: 0.78, 95% CI 0.75-0.81), stimulants (RR: 0.26, 95% CI 0.25-0.27), as well as mood stabilizers (RR: 0.44, 95% CI 0.39-0.49). Erectile dysfunction requiring oral PDE5i in this cohort was more frequent during the pandemic for adolescents (RR: 1.53, 95% CI 1.05-2.01). CONCLUSION(S): The rates of antipsychotic and benzodiazepine prescriptions increased during the COVID-19 global pandemic compared to preceding years. This coincided with a statistically significant increase in the prescription of PDE5i for erectile dysfunction. Adolescents may face an increased risk of sexual dysfunction as both their illness and the medications they are prescribed both have a positive association with sexual dysfunction. Clinicians must be cognizant of the fact that adolescents may face an increased risk of medication related sexual dysfunction.
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Background/Purpose: Pediatric Acute Lymphoblastic Leukemia (ALL) affects ~4000 young Americans each year. Steroids are essential to curative ALL treatment yet have significant neuropsychiatric side effects that decrease quality of life for patients and families. However, incidence and predisposing risk factors are not well understood. This review aims to describe the current literature on neuropsychiatric side effects of steroids in Pediatric ALL. Method(s): A precise search in PubMed and Embase was cultivated using controlled vocabulary terms (MeSH, Emtree) and keywords for the following concepts: pediatrics, steroids, side effects, cancer, and neurobehavioral manifestations. Keywords and controlled vocabulary for each subject were arranged logically and combined with other concepts by Boolean Logic, using the Boolean operator AND, resulting in 642 precise results exploring neurobehavioral side effects of steroids in children with cancer. Results (2010 to date of search) were imported into Covidence systematic review software, and reviewed by SB and AM. Result(s): Twenty-three articles met inclusion criteria. There is marked variability in research methodology and no standard measurement of neuropsychiatric symptoms. Commonly reported symptoms include mood swings, irritability, depression, anxiety, aggression, insomnia, mania, and psychosis with prevalence between 5% and 75%. Heterogeneous research methodology and descriptions of psychiatric symptoms make it difficult to determine risk factors, though dexamethasone, family psychiatric history, and younger age are consistently associated with greater risk of behavioral dysregulation. Genetic predisposition (Bcl1 polymorphism, SNPs in GR gene) may increase susceptibility to developing depression during treatment. Data suggest variable efficacy of antipsychotics, benzodiazepines, hydrocortisone, and potassium-chloride. Conclusions and Implications: Existing data about neuropsychiatric side effects of steroids in pediatric ALL is extremely heterogeneous, creating challenges for standardized assessment and treatment. The burden of these symptoms necessitates further research to identify and treat vulnerable patients. Standard measurement of these symptoms could be a first step in eventually alleviating this source of distress.
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Introduction: The first six months of the COVID-19 pandemic saw a nearly 50% increase in pediatric mental health emergencies. Specific factors contributing to this rise remain poorly characterized. One frequently cited contributor is pandemic-related interruptions of in-person schooling. Early studies indicate that students have experienced significantly greater psychological distress during such disruptions. We set out to investigate what correlation, if any, exists between school modality (ranging from exclusively virtual to exclusively in-person) and pediatric mental health status. Method(s): This is a retrospective, descriptive study combining patient chart review and parental telephone survey, exploring the prevalence and severity of mental illness among inpatients at a single urban, academic, midwestern tertiary care center. The study population included all patients ages 6-18 admitted to the study site during the 2015-19 and 2020- 21 school years who received Psychiatry and/or Psychology consults and/or were admitted to the inpatient psychiatry unit. Parents/guardians of participants from 2020-21 were surveyed regarding their child' educational experiences. We describe and compare participants between school years prior to and during the pandemic using descriptive demographic data and clinical data highlighting monthly admission rates and proxies for illness severity. We then assess for any correlation between these measures and recent virtual schooling. Result(s): Total mental health-related admissions rose from an average of 1070 during pre-pandemic school years to 1111 in 2020-21. Patients admitted in 2020-21 were more likely to be female, non-white, and from ZIP codes with higher median income. Primary diagnosis was more likely to be a mood or eating disorder. Patients were less likely to present primarily for suicidal ideation or self-harm. Proxies of illness severity, including utilization of PRN antipsychotics/benzodiazepines and readmission rates, rose in 2020-21. 255 of 800 (31.9%) families responded to the telephone survey. Respondents were more likely to have a child who was female and slightly younger compared to non-respondents. 98% of respondents reported some virtual schooling for their child, with 77% reporting virtual schooling for the majority of the three months prior to their child' first hospital admission. 61% indicated their child was exclusively in virtual school. No significant relationships were observed between virtual schooling and any outcome measures relating to mental health. Conclusion(s): Pediatric mental health emergencies and hospitalizations have grown and evolved since the start of the COVID-19 pandemic. This study characterizes some of the changes in patient demographics and experience with virtual schooling prior to and following the pandemic. Our results do not support any correlation between virtual schooling and mental illness requiring emergent care or hospitalization. However, this study has many significant limitations. Respondents were not representative of all admitted patients, and survey data were gathered for only one-third of families whose children were admitted at one site. Very few respondents remained in school in person throughout the pandemic, complicating efforts to make meaningful comparisons. Future work should attempt to capture a broader subject pool and obtain prospective data regarding the effects of school modality on mental health.
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Recent years have been associated with the development of various sensor-based technologies in response to the undeniable need for the rapid and precise analysis of an immense variety of pharmaceuticals. In this regard, special attention has been paid to the design and fabrication of sensing platforms based on electrochemical detection methods as they can offer many advantages, such as portability, ease of use, relatively cheap instruments, and fast response times. Carbon paste electrodes (CPEs) are among the most promising conductive electrodes due to their beneficial properties, including ease of electrode modification, facile surface renewability, low background currents, and the ability to modify with different analytes. However, their widespread use is affected by the lack of sufficient selectivity of CPEs. Molecularly imprinted polymers (MIPs) composed of tailor-made cavities for specific target molecules are appealing complementary additives that can overcome this limitation. Accordingly, adding MIP to the carbon paste matrix can contribute to the required selectivity of sensing platforms. This review aims to present a categorized report on the recent research and the outcomes in the combinatory fields of MIPs and CPEs for determining pharmaceuticals in complex and simple matrices. CPEs modified with MIPs of various pharmaceutical compounds, including analgesic drugs, antibiotics, antivirals, cardiovascular drugs, as well as therapeutic agents affecting the central nervous system (CNS), will be addressed in detail.Copyright © 2023 Elsevier B.V.
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SESSION TITLE: What's New in Critical Care? SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: Alcohol withdrawal syndrome (AWS) is a common etiology of intensive care unit (ICU) admission(Vigouroux et al 2021). Emergency Department (ED) related alcohol visits have increased in incidence dramatically since the beginning of the SARS-CoV2 pandemic. A median ICU length of stay (LOS) of 8 days for severe AWS has been previously reported. The increase in substance abuse observed during the pandemic may prolong future patients’ LOS. Pandemic staffing and bed shortages have made it even more evident the need to research efficient and safe treatment options of common hospital admission diagnosis such as AWS. Current national guidelines recommend benzodiazepines as first-line therapy for inpatient management of AWS (American Society of Addiction Medicine Clinical Practice Guidelines). However, historically phenobarbital (PB) and other barbiturates have been utilized with varying success. Recent evidence has demonstrated phenobarbital loading followed by symptom-triggered benzodiazepines may reduce LOS and ICU admission (Rosenson et al 2012). We retrospectively evaluated ED and ICU data to further guide our future research on PB in AWS, specifically;LOS, location of admission, and high risk side effects frequently associated with PB such as intubation. METHODS: Patients admitted for AWS and who received PB from 8/1/2021 to 02/01/2022 were identified. Subsequently, these subjects were then matched to themselves for historical AWS admissions without receipt of PB. Exclusion criteria included: admission with concomitant diagnosis with expected admission LOS longer than AWS treatment course;no separate admission for AWS. Pertinent patient demographics were collected including cumulative dosing of benzodiazepines, disposition from the ED, hospital LOS, ICU LOS, relative hypotension, and intubation. Data was analyzed using descriptive statistics and one-sided Student T-test. RESULTS: Total of 16 patients received PB during the six month identification period. Six were excluded due to lack of previous admission for AWS. Three were excluded for previous admissions with concomitant disease states requiring prolonged admissions. These included endoscopy, long-bone fracture, and subdural hematoma. Seven patients (14 unique admissions) met inclusion criteria. Patients were all male with a mean age of 58. Compared to non-PB admissions a trend in mean reduction of hospital LOS was 39.3 hours shorter in the PB cohort (p-value=0.068). Mean benzodiazepine reduction (lorazepam equivalents) was 26.3mg less in the PB cohort (p-value = 0.064). No intubations or hypotensive events were observed in either cohort. CONCLUSIONS: When PB was utilized there was reduction in total hospital LOS with no increase in intubations. Preliminary patient matched data of PB in AWS appears efficacious and safe. CLINICAL IMPLICATIONS: PB may decrease overall hospital LOS in AWS. DISCLOSURES: No relevant relationships by Yara Albair No relevant relationships by Nicholas Barreras No relevant relationships by Jessica Kim No relevant relationships by Marc McDowell No relevant relationships by Joshua Posner No relevant relationships by Mariana Silva
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SESSION TITLE: Cases of Overdose, OTC, and Illegal Drug Critical Cases Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Hydroxychloroquine (HCQ) is commonly prescribed for the management of connective tissue disorders such as systemic lupus erythematosus and rheumatoid arthritis. Despite its widespread use, there are limited case reports describing HCQ intoxication and management. HCQ toxicity presents predominantly with cardiovascular manifestations, including hypotension, arrhythmias, and QT interval prolongation on electrocardiogram (EKG). Other findings include visual disturbances, altered mental status, and hypokalemia. CASE PRESENTATION: We present the case of a 60-year-old female with a history of rheumatoid arthritis and depression. She presented to the emergency department (ED) after ingesting 10-15 tablets of HCQ 200 mg in a suicide attempt. In the ED, she was noted to be lethargic and tachycardic. EKG revealed sinus tachycardia with a heart rate of 127 beats per minute and prolonged QTc of 680msec. The diagnostic evaluation also revealed hypokalemia with potassium 3.7mmol/l. Initial management in the ED included administration of activated charcoal, potassium supplementation, and intravenous bicarbonate infusion. The patient was admitted to the ICU for monitoring and supportive care. Serum electrolyte panel and EKG were monitored. The patient made an uneventful recovery after 2-3 days. The QT interval normalized, and hypokalemia improved. She was subsequently discharged to an inpatient psychiatric unit. DISCUSSION: Although HQC is commonly prescribed, there is limited data describing overdose. Our case of HCQ overdose presented as changes in mental status, QT interval prolongation, and hypokalemia. Similar findings have been reported in previous case reports. Management includes early gastric decontamination with activated charcoal, potassium supplementation, and supportive care. Intravenous bicarbonate infusion has been utilized for prolonged QT intervals, and benzodiazepines have been used for agitation and sedation. CONCLUSIONS: Although rare, HCQ toxicity can be life-threatening. It is a commonly prescribed agent, and therefore the clinician should be aware of its toxicity profile and management. Reference #1: Bakhsh HT. Hydroxychloroquine Toxicity Management: A Literature Review in COVID-19 Era. J Microsc Ultrastruct. 2020;8(4):136-140. Published 2020 Dec 10. doi:10.4103/JMAU.JMAU_54_20 Reference #2: McKeever R. Chloroquine/hydroxychloroquine overdose. Vis J Emerg Med. 2020;21:100777. doi:10.1016/j.visj.2020.100777 Reference #3: Lebin JA, LeSaint KT. Brief Review of Chloroquine and Hydroxychloroquine Toxicity and Management. West J Emerg Med. 2020;21(4):760-763. Published 2020 Jun 3. doi:10.5811/westjem.2020.5.47810 DISCLOSURES: No relevant relationships by Priyaranjan Kata No relevant relationships by Wajahat Khan No relevant relationships by Pratiksha Singh
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Introduction: Comparatively little is known about drug requirements in patients admitted to ICU with COVID-19 pneumonitis. We analysed drug usage for patients admitted during the first wave of the pandemic, comparing these with a retrospective cohort admitted with Influenza pneumonia. Methods: Forty-nine ventilated patients with COVID-19 pneumonitis were identified through ICNARC, ten were excluded as duration of stay < 7 days or not needing ventilation. Further three were excluded due to missing data and one due to ECMO escalation. Results: The median age was 61 years;length of stay 22 days and 68% survived ICU. Table 1 describes the use of Infusions and enteral medications. Discussion: Propofol was used in most (43% patient-hours in ICU/median duration = 234 hours). All patients received opiate infusions (mainly morphine or alfentanil in similar proportions) and 91% received muscle relaxants, for prolonged periods. Over half received Midazolam (median 106 hours) as an adjunct or substitute to Propofol as patients were difficult to sedate, required longer ventilation, paralysis and concerns with Propofol associated hypertriglyceridemia. Over two-third received alpha agonist infusions (median 68.5 hours) as adjunctive sedation or delirium management. Three quarters of patients received a furosemide infusion (median 90 hours), the evidence extrapolated from studies such as FACTT.1 Around three quarters received Human Albumin (median 100 grams over 3 days). Nearly a quarter received nebulized Prostacyclin for refractory hypoxia, often associated with saturation of HME filters and ventilatory difficulties.2 Over half of patients received Carbocisteine (median 13 days). Clonidine and Risperidone to manage delirium were used in a third (median 10.5 and 11 days respectively), as was Acetazolamide to restore pH and aid weaning. Over a third were prescribed enteral opiates and nearly a quarter received benzodiazepines to manage withdrawal symptoms. Just under a half of patients received Melatonin. Antibiotic usage was high with a median of 3 Antibiotics used (median duration 15 days/61% of patient days). Diagnosing superadded infection such as VAP was challenging3 and we did not routinely monitor serum Procalcitonin levels. We also compared prescribing habits with 12 influenza patients (11 survivors) identified using similar inclusion criteria and found patients with COVID-19 were older (61 versus 51 years ) with longer ICU stays (median 22 versus 20 days). They were also more likely to receive enteral Carbocisteine, Clonidine, Acetazolamide, Morphine and Diazepam. Conclusion: We were able to generate valuable data on prescribing in ventilated patients with COVID-19 pneumonitis during the first wave. Through this, we are able to use drug usage as a surrogate for issues such as delirium, drug withdrawal, antibiotic prescribing and nursing workload in general.
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BACKGROUND: Catatonia is a psychomotor syndrome characterized by abnormal movements and decreased responsiveness. Diagnosis is made by observing or eliciting at least 3 of the following 12 criteria: stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerism, stereotypy, agitation, grimacing, echolalia, and echopraxia. It is commonly associated with psychiatric disorders but can also be secondary to a medical condition, more commonly neurologic or metabolic conditions. CASE DESCRIPTION: Patient was a 17-year-old female brought in by her guardian for evaluation at a psychiatric assessment center following a month of regressive behavior and concerns of possible hallucinations. While at the assessment center, the patient began hyperventilating and had 3 seizures. She was transferred to a nearby hospital and continued to seize, becoming hypoxic and requiring intubation. Computed tomography was unremarkable;urine drug testing was positive for THC and benzodiazepines. The patient was transferred to the intensive care unit of a children's hospital. She continued to have poverty of speech, decreased responsiveness, and disorganized behavior after extubation. Child psychiatric services was consulted for these concerns, and differential included psychotic disorder and catatonia, either secondary to psychiatric or medical cause. Patient underwent extensive medical evaluation, which was overall unremarkable, to rule out medical causes (including electroencephalography, cerebrospinal fluid studies, complete blood counts, C-reactive protein, and anti-NMDA antibodies). She did test positive for COVID, which resulted in delay of brain magnetic resonance imaging (MRI) being obtained. She had partial response to lorazepam challenge, and scheduled doses of lorazepam were started after. Bush Francis Catatonia Scale scores did lower partially with scheduled lorazepam, but full resolution of symptoms was not observed. MRI done on day 10 showed findings suspicious for superior sagittal thrombosis. Brain magnetic resonance venography showed superior sagittal and bilateral transverse venous thrombosis. The patient was started on anticoagulation therapy and discharged from hospital with the recommendation of psychiatry and neurology outpatient follow-up. She did not follow up with neurology but did have slow resolution of symptoms per outpatient psychiatry records. DISCUSSION: Catatonia typically results in resolution of symptoms with treatment of underlying cause along with benzodiazepines or electroconvulsive therapy. It is commonly associated with psychiatric disorders, but it is important to evaluate for medical causes as well, especially when there are concerning signs/symptoms. In this patient, there was only a partial response to benzodiazepines, but further improvement with anticoagulation therapy. This along with no previous psychiatric history supports an underlying medical cause. This patient had no history of health conditions associated with hyper-coagulopathies. However, COVID has been associated with risk for arterial and venous thromboembolic complications.
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Depression is the most common psychiatric disorder in the general population, and emergency room visits for depression have been increasing for several years. In addition, the Covid-19 pandemic may lead to an explosion of psychiatric emergency room visits for this reason, with an overall prevalence of anxiety and depression that appears to be increasing since 2020. The Centre Psychiatrique d'Orientation et d'Accueil is a regional psychiatric emergency service located in Paris which records approximately 10,000 consultations per year. Among these consultations, the main symptoms are those of depression (depressive ideations, anxiety) and nearly 40 % are diagnosed with mood disorders, including depression. The management of the patient in the emergency room is based on a global evaluation, which should not be limited to the psychiatric interview. In the best case, and if compatible with the organization of the service, an initial evaluation by the nursing reception staff determines the context of the arrival of the patient, the reason and the degree of urgency of the consultation can thus be assessed from the outset. The request for care can come from the patient themself, but also from family and friends who are worried about a decline in the patient's previous condition. The consultation may also be triggered by the intervention of emergency services, particularly in the case of attempted suicide or agitation. The context of arrival, the environment, and the patient's entourage must be taken into account in order to achieve an optimal orientation. Particular attention must be paid to the first episodes (elimination of a differential diagnosis, screening for a possible bipolar disorder). The existence of an external causal factor or a comorbid personality disorder should not trivialize the consultation and lead to a faulty diagnosis of a characterized depressive episode. Drug treatment in the emergency room is usually symptomatic (anxiolytic treatment with benzodiazepines or neuroleptics, depending on the situation), and outpatient referral should always be preferred. Therapeutic adaptations can then be considered. The decision to hospitalize must always be justified, and consent for care must be rigorously evaluated. It is almost always necessary to take the patient's entourage into account as well as the potential support of the patient by the entourage. All these elements must be recorded in the file. Suicide risk assessment must be systematic for all patients consulting psychiatric emergencies, and the use of the RUD (Risk, Urgency, Dangerousness) grid can be useful. Any decision to release a patient with suicidal tendencies must be made strictly following certain conditions:a rapid psychiatric re-evaluation of the crisis, with for example the proposal of a post-emergency consultation, a supportive entourage, accepted symptomatic treatment. The registration of the suicidal patient in a monitoring system such as VigilanS can also be beneficial and reduce the risk of recidivism.
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Background: Pediatric patients with increasing psychiatric needs introduce a substantial challenge for inpatient care. This study illustrates how the COVID-19 pandemic has influenced the number and acuity of psychiatry and psychology consults among pediatric inpatients at a tertiary care hospital. Methods: The study population included all pediatric patients (ages 0-25) admitted to University of Michigan's C.S. Mott Children's Hospital between March 2019 and March 2021 who received a psychology and/or psychiatry consult. Three time periods were defined: pre-pandemic, 3/1/19-3/15/20;early pandemic, 3/16/20-6/30/20;and steady-state pandemic, 7/1/20-2/28/21. The patients were described demographically and clinically. To assess differences among time periods, ANOVA testing was conducted for numeric variables and chi-square tests were used for categorical variables. The number of pediatric inpatients receiving psychiatry and/or psychology consults was reported for each month of the study period as a count and as a percent of all pediatric admissions. Psychiatric acuity was described in terms of length of stay and use of restraints and as-needed medication. Logistic regression was used to estimate the odds of requiring restraints based on time period, controlling for relevant demographic and clinical variables (age, sex, race, length of stay, and use of benzodiazepines and psychotropics). Logistic regression was also used to estimate the odds of patients requiring as-needed medications (midazolam, lorazepam, diazepam, clonazepam, alprazolam, haloperidol, chlorpromazine, quetiapine, risperidone, aripiprazole, olanzapine, and ziprasidone) based on time period, controlling for clinical and demographic variables (age, sex, race, length of stay, and restraint use). Results: Among the 1,636 patients in the study, average age was 14.0 years (IQR 8.1 to 17.2) and 57.9% were female. Overall, 68.6% were White, 13.6% were Black, and 2.4% were Asian. Among all races, 5.7% identified as Hispanic. Percent of pediatric patients receiving psychiatry and/or psychology consults was higher on average during the pandemic months (71.2% during steady-state pandemic compared to 47.9% pre-pandemic). Across all participants, 2.1% required restraints, 34.4% used psychotropics, and 42.6% used benzodiazepines. During the pandemic, admissions became proportionally more female (64.1% during steady-state pandemic vs. 55.3% pre-pandemic) and older (average age 14.8 years during steady-state pandemic vs. 13.4 years pre-pandemic). During steady-state pandemic, children admitted had 5.70 times higher odds of requiring restraints and 1.78 times higher odds of using psychotropics, compared to children admitted pre-pandemic. Length of stay decreased during the pandemic, and was associated with psychotropic use, benzodiazepine use, male sex, and younger age. Conclusion: A higher proportion of pediatric admissions during the COVID-19 pandemic required psychiatry and/or psychology consults. Additionally, these patients were of higher psychiatric acuity, based on increased use of as-needed medications and restraints. These findings highlight the dramatic changes experienced by individual patients and their healthcare teams during the pandemic.
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CASE: A previously healthy, 27-year-old Caucasian male presented with erythema and edema in his extremities. He endorsed multiple years of injecting heroin into numerous areas from his chest to his toes, including both upper extremities. The patient was seen six months ago at local urgent care for swelling of both of his dorsal feet and a small abscess with surrounding cellulitis of the right hand. He was given a dose of Ceftriaxone and a 2-week course of Augmentin, which he completed with moderate improvement. A month prior to his presentation, he reported that this swelling started asymmetrically;it started in his legs, then in his right arm, and then in his left arm. He denied any discharge from any site on his skin. He last injected heroin the morning of his admission. He denied fever, shortness of breath, pleuritic chest pain, orthopnea, dyspnea on exertion, and any urinary symptoms. On presentation, he was afebrile and saturated 98% on room air. His extremities were warm, normal capillary refill, and distal pulses were strong and symmetric. There were also pitting edema in the right hand with associated volar erythema, pitting edema in the right foot, and left-hand edema with a punctate area around the mid-arch with associated tenderness to palpation without overlying redness, crepitus, or fluctuance. Blood cell count revealed mild leukocytosis to 12.0. CMP was unremarkable. While the infectious disease team was consulted for further evaluation, he was started on cefazolin 1g for 10 days. The urine drug screen was positive for benzodiazepines, THC, cocaine, and opiates. HIV negative, Covid negative, and blood cultures showed no growth. Histoplasma/ Blastomyces urine antigens were negative. Urinalysis without evidence of proteinuria, and transaminases were within the normal limit. Ultrasound showed occlusive cephalic vein thrombosis in the right upper extremities. Cefazolin was discontinued. Based on the presentation, the history, and the evaluation, it was concluded to be Puffy Hand Syndrome. IMPACT/DISCUSSION: Puffy hand syndrome is a form of lymphedema caused via the sclerosing nature of intravenously administered drugs, which our patient extensively utilized. Described by Abeles in 1965 as seen in New York prisoners, it affects between 7 to 16% of intravenous drug users. Its pathology is suspected to be caused due to a combination of lymphatic and venous insufficiency. Differential diagnosis of this syndrome involves identification of infection alongside cardiac or renal insufficiency, and edematous scleroderma. Treatment is mostly symptomatic. Patients are advised to stop IV drug use. Long-term use of low-stretch bandages and compression may be useful in decreasing the puffiness of the extremities. CONCLUSION: With the quality of care for drug addicts being a critical area of interest, this case displays a common drug abuse complication clinicians raise awareness for. This observation presents an opportunity to identify a possible drug abuser and intervene accordingly.
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Background: Coronavirus disease 2019 (COVID-19) is associated with a number of psychiatric problems in patients;however, mental healthcare in these patients does not appear to be adequate. Objectives: This study aimed to evaluate the extent of psychological care provided to COVID-19 patients admitted to the hospital and the most common reasons for psychiatric counseling. Methods: This study examined the electronic medical records of all COVID-19-positive patients admitted to Rasoul-e-Akram hospital in Tehran, Iran, within April 1 and September 30, 2020 (approximately 2200 cases). Results: Psychiatric consultation was requested for 5.45% of admitted patients with COVID-19 diagnosis based on a positive real-time reverse transcription-polymerase chain reaction. More than half of those who received psychiatric counseling had a previous psychiatric disorder. The most common reason for requesting psychiatric counseling in patients with a previous psychiatric disorder was the patient’s evaluation and management;the most common reason in patients without a psychiatric disorder was agitation and lack of cooperation. The most common diagnosis in patients with a positive history of psychiatric disorder was bipolar disorders (33.9%), followed by opioid use disorder (29%). Adjustment disorder (54%) and delirium (26%) were the most common diagnoses in patients without a history of psychiatric disease. Conclusions: The current study showed that psychiatric counseling in COVID-19 patients was limited to a small number, including those with a positive history of psychiatric illnesses and prominent psychiatric symptoms.
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Background: The Azores, an autonomous region of Portugal, is an nine islands archipelago in the Atlantic Ocean, were mental health concerns have long been present. The pandemic of COVID-19, declared in march 2020, has put additional strain health systems. Moreover, there are initial signs that depression and anxiety's prevalence is expected to increase. Monitoring consumption can be an indirect way of assessing medicines' adherence and accessibility. Purpose: To explore how the pandemic of COVID-19 impacted the consumption of anxiolytics, the aim of this study was to assess patterns of Benzodiapezine consumption in the Azorean population, one year before and one year after the beginning of the COVID-19 pandemic. Method: For this ecological study, the Benzodiazepines consumption database was obtained from hMR, a health market research company. This database contains information relative to the total number of all benzodiazepines acquired in the Portuguese market, organized by Anatomical Therapeutic Chemical (ATC) classification, and information relative to dosage and package size. The number of total sold packages per drug was obtained for the years 2019 and 2020. Azorean population was obtained from government official data. The defined daily dose (DDD) was obtained from the WHO ATC/DDD index website, and the DDD/1000hab./day was calculated. Only oral dosage forms were analysed. Descriptive and inferential statistical analysis was performed to assess yearly, biannual and quarterly drug consumption and uncover seasonal trends. Findings: Total benzodiazepine acquisition pattern in DDD/1000hab/day was not different between 2019 and 2020 (p = 0.987). The most consumed benzodiazepines were alprazolam 69.5 DDD/1000hab/day (± 4.3), followed by diazepam 27.1 (± 1.7) and lorazepam 26.7 (± 1.5).Only clonazepam and potassium clorazepate showed a significant increase from 2019 to 2020 (p = 0.001 and p = 0.003). The maximum of total DDD/1000hab/day was registered at the onset of the pandemic (march 2020). For the remaining of 2020, higher standard deviations were observed. Two other peaks are noticed in july 2019 and july 2020, exceptions to the apparent seasonal effect with a biannual period of higher DDD/1000hab/day in the winter months (r2 = 0.567). Conclusion: The pandemic of COVID-19 did not aggravate the consumption of benzodiazepines in the Azorean population. However, a change in the pattern of benzodiazepines' acquisition during 2020, was noticed. Patients might have avoided frequent visits to health services and pharmacies in order to decrease the risk of COVID-19 infection. Nevertheless, the adherence is unclear, and should be further investigated. A weak seasonal pattern in benzodiazepine consumption in the Azorean population was also found.
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Introduction: Reports of vestibular syndrome have been associated with COVID vaccination in the recent literature. In this study, we aimed to evaluate the association between COVID-19 vaccines and vestibular disorders using Vigibase®, the WHO pharmacovigilance database. Material and methods: On January 5th, 2022, we extracted in a deduplicated dataset of VigiBase® reports of vestibular disorders for tozinameran (Pfizer®), elasomeran (Moderna®), Ad26.COV2.S (Janssen®) and ChadOx1nCov-19 (Astra-Zeneca®), using MedDRA preferred terms neuronitis vestibular, acute vestibular syndrome, vestibular disorder and the low level term vestibular vertigo. Seriousness was analyzed and reported odds ratio (ROR) were calculated. We also reviewed the management of COVID-vaccine associated vestibular disorders reported in Caen Regional Pharmacovigilance Center. Results: In Vigibase®, 226 reports of vestibular disorders were found for ChadOx1nCov-19, 40 for Ad26.COV2.S, 254 for elasomeran and 1,050 for tozinameran. The ROR were respectively 2.5 (2.2-2.8), 2.5 (1.8-3.2), 3.6 (3.2-4.0) and 7.0 (6.6-7.4). Reports were considered serious in 74.3% for ChadOx1nCov-19, 70.0% for Ad26.COV2.S, 60.6% for elasomeran and 56.01% for tozinameran. Finally, we collected 13 reports of COVID-19 vaccines associated vestibular disorders in our pharmacovigilance center. Concerning the management of those vestibular disorders, 4 patients received antiemetics, 1 received betahistine, 7 received acetylleucine, 2 received corticoids and 6 had vestibular physiotherapy sessions. After 1 month of follow-up, only one patient had recovered. Discussion/Conclusion: The Vigibase® analysis showed a statistically significant association between the 4 COVID-19 vaccines under study and vestibular disorders. Short-term anticholinergics, antiemetics, antihistamines or benzodiazepines, and a corticosteroid burst with rapid taper as well as vestibular rehabilitation are usually recommended treatments. In our case series we noticed the long duration of the symptoms despite the treatments received and the heterogeneity of the adopted therapeutic strategy. Physicians should be aware and careful of the potential association of COVID-19 vaccines and vestibular disorders. Management guidelines are needed given the wide exposure to COVID-19 vaccines.
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Introduction: Incidence of hospitalisations related to psychoactive substance intoxication (H-SPA) might have been differently impacted by the Covid-19 pandemic according to age-groups. This study aimed to describe (i) the incidence of H-SPA during and after the first 2020 lockdown in adults aged 18-29 years or 30+ then (ii) their characteristics specifically associated with the pandemic period by comparing 2020 with 2017-2019 baseline period. Material and methods: This historical cohort study was conducted in adults admitted to the University Hospital of Bordeaux with main or secondary diagnosis codes of intoxication with benzodiazepine, methadone, buprenorphine, codeine, morphine, heroin, cocaine, ecstasy and alcohol. Data were collected locally through the discharge database. Incidence and characteristics of H-SPA were described according to patients age, in 2020 before (01/01-16/03), during (17/03-10/05), and after the first lockdown (11/05-31/07). Results: Among the 5824 stays included over the study period, SPA most involved were alcohol and benzodiazepines. Compared to baseline, the decrease in H-SPA's incidence was more important in young adults (-40%;nbaseline = 450) in comparison to those aged 30+ (-18%;nbaseline = 1,101) during the pandemic period, especially during the lockdown compared to 2017 (-59%;n2017 = 145 vs-35%;n2017 = 166) with far decrease in alcohol and ecstasy intoxications. Seriousness of hospitalization indications was increased regardless of age during the pandemic. Particularly in young adults, the proportion of suicides increased during lockdown compared to the baseline period (almost 50% vs 29%) and the proportion of accidents in context of intoxication (3.5 vs 0.7%) after lockdown. Discussion/Conclusion: The period following lockdown should be considered at risk for hospitalizations due to accident in context of SPA use. Strong decrease in the incidence of H-SPA in young adult during the lockdown highlights the health burden of recreational use of alcohol and ecstasy in this population and the need for prevention.
ABSTRACT
Background: Catatonia, a motor dysregulation syndrome with behavioral components, has undergone many conceptual changes since its inception as a syndrome by Kahlbaum in 1874. Prevalence of catatonia in consultation-liaison services is approximately 5.5 percent in patients aged 65 and older.1 Stuporous catatonia is most common, but catatonia may present in excited or malignant subtypes. Together, the subtypes have over 40 documented signs and symptoms, making catatonia difficult to diagnose and appropriately treat.2 Catatonia involves hyperactivation of the orbitofrontal cortex (OFC) and ventromedial prefrontal cortex. GABA, NMDA, and dopamine have been implicated. GABA-A agonism by benzodiazepines improve catatonia by normalizing OFC activity.3 Case: A 66-year-old male with schizophrenia was admitted to a medical unit for failure to thrive after not eating for three days. He had not taken his medications for 2 weeks including chlorpromazine, quetiapine, oxcarbazepine, and clonazepam. Upon psychiatric consult, the patient exhibited staring, grimacing, echopraxia, and negativism. He was diagnosed with stuporous catatonia. 30 minutes after lorazepam challenge (2 milligram intravenous lorazepam), the patient was moving, conversing, and eating. After second dose of lorazepam, the patient became difficult to redirect, displaying stereotypy, verbigeration, and hitting. Additional doses of lorazepam were unsuccessful in breaking excited catatonia. History revealed previous catatonic episodes, including nine months prior when the patient was admitted to a gero-psychiatric unit. He initially presented in stuporous state, normalized with lorazepam, then transitioned to excited state. He received 16 milligrams of lorazepam in 24 hours without successful termination of excited catatonia. Lorazepam in combination with carbamazepine, clozapine, or valproic acid was unsuccessful. Catatonia was successfully treated with 10 sessions of electroconvulsive therapy (ECT) with lorazepam, clozapine, and valproic acid. Maintenance ECT was not continued because of the COVID pandemic, and the patient was admitted to a state facility after regression. Discussion: Catatonia is often encountered on consultation-liaison services in general hospital settings. We observed conversion of stuporous catatonia to excited catatonia after administration of lorazepam. This treatment-resistant catatonia ultimately required ECT. No reported cases of stuporous catatonia transitioning to excited catatonia were found on thorough literature review. Recognition of this conversion may be difficult and may require development of a catatonia scale that clearly identifies the presenting subtype. This is a challenge;clinical signs are not mutually exclusive among subtypes. This patient’s clinical course may provide insight into the identification of treatment-resistant catatonia, and accurate identification is necessary to allow for timely escalation of treatment. References: 1. Solmi M, et al. Prevalence of catatonia and its moderators in clinical samples: Results from a meta-analysis and meta-regression analysis. Schizophrenia Bulletin. 2017;44(5):1133–50. 2. Fink M, Taylor MA. The catatonia syndrome. Archives of General Psychiatry. 009;66(11):1173. 3. Ellul P, Choucha W. Neurobiological approach of Catatonia and Treatment Perspectives. Frontiers in Psychiatry. 2015;6.