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Objectives: We present a case report of medical intensivist driven ECMO program using ECMO as a pre-procedural tool to maintain oxygenation in a patient with critical tracheal stenosis during tracheostomy placement. Method(s): VV ECMO is primarily used to support patients when mechanical ventilation is unable to provide adequate gas exchange. Alternatively, it has been used pre-procedurally when intubation is required in anticipation of a difficult airway. Described here is the first intensivist preformed awake VV ECMO cannulation to facilitate tracheostomy in a patient with severe tracheal stenosis. Result(s): The patient is a 41-year-old female with the relevant background of COVID19 pneumonia status post tracheostomy and subsequently decannulated after prolonged intubation and ICU stay. As a result, the patient developed symptomatic tracheal stenosis and presented two years after her ICU stay for scheduled bronchoscopy and balloon dilation. However, the patient developed worsening stridor and shortness of breath requiring heliox and BPAP. After multidisciplinary discussion between the critical care team ENT teams, the decision was made to cannulate for VV ECMO as a pre-procedural maneuver to allow for oxygenation during open tracheostomy in the OR. Dexmedetomidine and local anesthesia were used for the procedure with the patient sitting at 30 degrees on non-invasive ventilation and heliox. The patient was cannulated with a 21F right internal jugular return cannula and 25F right common femoral drainage cannula by medical intensivists in the intensive care unit using ultrasound guidance. The patient went for operative tracheostomy the next day and was subsequently decannulated from ECMO the following day without complication. She was discharged home on trach collar. Conclusion(s): Intensivist performed ECMO cannulation has been shown to be safe and effective. We anticipate the indications and use will continue to expand. This case is an example that intensivist driven preprocedural ECMO is a viable extension of that practice.
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Background: At our hospital, people with COVID-19 (coronavirus disease 2019) had a high rate of pulmonary barotrauma. Therefore, the current study looked at barotrauma in COVID-19 patients getting invasive and non-invasive positive pressure ventilation to assess its prevalence, clinical results, and features. Methodology: Our retrospective cohort study comprised of adult COVID-19 pneumonia patients who visited our tertiary care hospital between April 2020 and September 2021 and developed barotrauma. Result(s): Sixty-eight patients were included in this study. Subcutaneous emphysema was the most frequent type of barotrauma, reported at 67.6%;pneumomediastinum, reported at 61.8%;pneumothorax, reported at 47.1%. The most frequent device associated with barotrauma was CPAP (51.5%). Among the 68 patients, 27.9% were discharged without supplemental oxygen, while 4.4% were discharged on oxygen. 76.5% of the patients expired because of COVID pneumonia and its complications. In addition, 38.2% of the patients required invasive mechanical breathing, and 77.9% of the patients were admitted to the ICU. Conclusion(s): Barotrauma in COVID-19 can pose a serious risk factor leading to mortality. Also, using CPAP was linked to a higher risk of barotrauma.Copyright © 2021 Muslim OT et al.
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Introduction: Orogastric tube insertion is a routine procedure in medical care. However, misplacement of the tube can cause a variety of complications, which can be life threatening in some instances. Case Description/Methods: 71-year-old male presented with dyspnea, fever, chills, cough, and myalgia for 2 weeks. He had tachycardia, tachypnea, and was hypoxic to 66% in room air. He was found to have acute hypoxic respiratory failure secondary to COVID-19 Pneumonia and was admitted to ICU. But, he continued to be hypoxic and was started on BiPAP. He eventually became altered, and was intubated. Post intubation orogastric tube (OGT) placement was unsuccessful on the first attempt due to resistance. On the second attempt, the nurse was able to advance partially (Figure). But, a chest XR showed OGT in the mediastinum, and OGT was removed. CT of neck and chest revealed pneumomediastinum with possible mid-thoracic esophageal perforation. The patient was started on broad-spectrum antibiotics and thoracic surgery was consulted. Given his mechanical ventilation requirement, surgery deemed him unfit to tolerate thoracotomy and the endoscopic procedure was not available in the hospital. So, recommendation was to manage conservatively. His hospital course was complicated by hypotension requiring vasopressors and metabolic acidosis in setting of acute renal failure requiring CRRT. Code status was changed by the family to Do Not Resuscitate due to his deteriorating condition. Eventually, he had a PEA arrest and was expired. Discussion(s): OGT intubation is performed at hospitals for feeding, medication administration or gastric decompression. Although it is considered a safe procedure, complications can arise due to OGT misplacement or trauma caused by the OGT itself or the intubation process. OGT misplacement is typically endotracheal or intracranial. Misplacement within the upper GI lumen is usually detected by a kink in the oropharynx or esophagus. The subsequent complications are identified by the structure that is perforated (e.g., mediastinitis or pneumothorax). Regardless of whether counteraction is perceived, the physician must be careful not to apply excessive force. The location of the OGT tip should be determined by a chest radiograph;visualization of the tip below the diaphragm verifies appropriate placement. Complications of OGT insertion are uncommon;however, the consequences are potentially serious, and the anatomy of the upper GI tract should be understood by all who are involved in the care.
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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.
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Aim: To study the characterization of the CT Brain in COVID 19. Material(s) and Method(s): Patients of COVID 19 who had neurological signs either before they were admitted or while they were in the hospital had a CT brain plain once during their time in the hospital. CT Brain plain presentations were shown to correspond with CNS symptoms, progression throughout the patients' hospital stays, and outcomes. Several tests, such as RT-PCR for COVID 19, CT Brain plain, complete blood count, liver function tests, renal function tests with electrolytes, and others were performed. Result(s): In the current investigation, there were a total of 50 patients, 46 (92%) of whom were male, while just 4 (8%), on the other hand, were female. The patients' ages ranged anywhere from 35 to 82 years old, with a mean of 65.85+/-8.69 years. NLR was 14.98+/-2.69 (range 1.31-47.5), mean LDH 992.17+/-25.69 (range 221-5125), and Hs-CRP was 171.22+/-22.69 (range 2.9-321.5). Mean haemoglobin of the patients was 11.12+/-1.85 (range 4-15 g/dl), total leukocyte count was 16580.63+/-5896.45, mean platelet count was 2.11+/-1.02 / lacs (0. 27 patients, or 54%, were discovered to have had an ischemic stroke, whereas 5 patients, or 10%, were found to have had a hemorrhagic stroke. The CT brain results were found to be abnormal in 30 individuals (or 60%), whereas in 20 patients (or 40%), they were determined to be normal. 11 (22%) of the patients required the assistance of a ventilator, 6 (12%), of the patients used a BiPAP, 2 (4%), of the patients used a Hudson mask, and 10 (20%) of the patients had NRM. Conclusion(s): In conclusion, we were surprised to find that the proportion of patients with severe COVID-19 infection who had abnormal brain CT scans was rather significant. Ischemic stroke was the most common kind of stroke that occurred in conjunction with aberrant CT results. We believe that the connection between aberrant brain CT and the fate of patients warrants further validation in a wider patient population.Copyright ©2022Int. J. Life Sci. Biotechnol. Pharma. Res.
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The RUTIROX clinical trial aims to determine clinical predictors of respiratory failure using high-flow nasal cannula (HFNC) for acute respiratory failure (ARF) P/F ratio<200 due to COVID-19 pneumonia. Study protocol includes a change to NIV after HFNC failure, prior to endotracheal intubation (ETI). Local ethics committee approval NCT05094661. Method(s): Interventional randomized study in PICU during Mar-Nov 21. In supine position HFNC was started at 60l/min Fio2 0.9, ABG and analysis were controled. If respiratory failure (defined as RR>30 or Sat<92% or P/F<80) occurred, participants were randomized to CPAP/BPAP. At day 28 ETI and death were evaluated. Statistical analysis SPSS. Chi-square tests, U-Mann Whitney and ROC analysis. Result(s): n=128 63% Men. Mean age 62. Mean P/F 164. 49% required NIV (28 CPAP/35 BIPAP). 21.9% required ETI. Mortality 9.3%. Advanced age, diabetes, neoplasia, low P/F ratio, low pO2 and high initial LDH value, were significantly more frequent in HFNC failure group (p-value <0.05). Area Under the ROC curve (AUC) of initial LDH is 0,65 (level of 300 U/L) and LDH at 48h 0,67. AUC of P/F is 0,69 for survival. No differences were found between NIV groups. Conclusion(s): Older age, higher degree of ARF and high LDH value are factors associated with HFNC failure. Despite presenting high intragroup failure frequency values, ETI rate and mortality rate were lower than those reported in other series. (Figure Presented).
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Introduction: The occurrence of pneumomediastinum (PNMMD) or pneumothorax (PNMTX) was evaluated in patients with severe SARS-CoV-2 pneumonia. Method(s): This is a prospective observational descriptive study that was carried out on patients admitted to the IRCU of a COVID-19 monographic hospital in Madrid from 14/01/2021 to 27/09/2021. All of them had a diagnosis of severe SARS-CoV-2 pneumonia and required NIRS (HFNC, CPAP, BPAP). The incidences of PNMMD and PNMTX, total and according to NIRS, and their impact on the probability of IMV and death were studied. Result(s): (tables 1 and 2) 4.3% (56/1306) developed PNMMD or PNMTX, 3.8% (50) PNMMD, 1.6% (21) PNMTX, and 1.1% (15) PNMMD+PNMTX. 16.1% of patients with PNMMD or PNMTX had HFNC alone (vs 41.7% without PNMMD or PNMTX;p<0.001) and 83.9% CPAP (vs 57.5%;p<0.001). There was a probability of needing IMV of 64.3% among patients with PNMMD or PNMTX (vs 21.0%;p<0.001), and a mortality of 33.9% (vs 10.5%;p<0.001). Conclusion(s): In patients admitted to the IRCU for severe SARS-CoV-2 pneumonia who required NIRS, incidences of 3.8% for PNMMD and 1.6% for PNMTX were observed. LDH was a risk factor for developing PNMMD or PNMTX (median 438 vs 395;p=0.013), and PNMMD (median 438 vs 395;p=0.014). The majority of patients with PNMMD or PNMTX had CPAP as the NIRS device, much more frequently than patients without PNMTX or PNMMD. However, the pressures used in CPAP were even lower in patients with PNMMD or PNMTX (median 8 vs 10;p=0.031). The probabilities of IMV and mortality among patients with PNMMD or PNMTX were 64.3% and 33.9%, respectively, higher than in patients without PNMMD or PNMTX, 21.0% and 10.5%.
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Background Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is an extremely rare disorder. Case A 20-year-old, 36-week pregnant female (G1P0) presented with acute shortness of breath, sharp chest pain and fever. She was COVID-19 positive and required BiPAP. Echocardiogram showed 40% EF, dilated LV with global hypokinesis and moderate mitral regurgitation (MR). She was hypotensive and on oxygen despite diuresis, emergent cesarean and COVID-19 treatment. Left heart catheterization showed anomalous takeoff of the left main coronary artery (LCA) from the dilated pulmonary artery (PA) with coronary steal (Figure 1). She had ALCAPA repair with LIMA to LAD bypass grafting. Decision-making Differential diagnoses included peripartum cardiomyopathy, Covid-myocarditis, pulmonary embolism, and spontaneous coronary artery dissection. LHC was performed only when symptoms failed to improve and troponin kept rising. ALCAPA has two major clinical subtypes - Infantile type and adult type. Adult type presents as dyspnea, chest pain, reduced exercise ability, and sudden cardiac death. Despite having good RCA to LCA collaterals, adult patients can still have ongoing ischemia of the LV myocardium, causing ischemic MR, malignant ventricular dysrhythmias. Diagnosis was delayed due to pregnancy and COVID-19 infection. Conclusion ALCAPA is a lethal coronary disorder. Elevated troponin and dilated cardiomyopathy with acute MR should raise suspicion of ALCAPA in young adults. [Formula presented]Copyright © 2023 American College of Cardiology Foundation
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Background: Non-invasive ventilation (NIV) has been tried in COVID-19 ARDS (CARDS), and its role is being increasingly recognised. If proven, it could be a game-changer in resource limited settings. We report our experience with administration of respiratory support using a tabletop NIV device in a respiratory intermediate care unit (RIMCU). Methodology: We retrospectively studied a cohort of hospitalised COVID-19 patients, who received protocolised management with positive airway pressure using a tabletop NIV device in the RIMCU as a step-up rescue therapy for deterioration despite low flow oxygen support. Treatment was commenced with continuous positive airway pressure (CPAP) mode up to a pressure of 10 cm H2O and if required inspiratory pressures were added with the bilevel positive airway pressure (BPAP) mode. Success was defined as weaning from NIV and stepping down to the ward. Failure was defined as escalation to the intensive care unit (ICU) or need for intubation or death. Result(s): In all, 246 patients were treated in the RIMCU during the study period. Of these, 168 received respiratory support via tabletop NIV device as a step-up rescue therapy. Their mean age was 54 years, and 83% were males. Diabetes Mellitus (78%) and hypertension (44%) were the commonest comorbidities. Treatment was successful with tabletop NIV in 77%;of this, 41% was on CPAP alone and 36% after receiving increased inspiratory pressures on BPAP mode. Conclusion(s): Respiratory support using a tabletop NIV device is an effective, and economical treatment for CARDS. Further studies are required to assess the appropriate time of initiation for maximal benefit and judicious resource utilisation.
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Introduction: COVID-19 can lead to acute respiratory failure (ARF) requiring admission to intensive care unit (ICU). This study analyzes COVID-19 patients admitted to the ICU, according to the initial respiratory support. Its main aim is to determine if the use of combination therapy: high-flow oxygen system with nasal cannula (HFNC) and non-invasive ventilation (NIV), is effective and safe in the treatment of these patients. Methods: Retrospective observational study with a prospective database. All COVID-19 patients, admitted to the ICU, between March 11, 2020, and February 12, 2022, and who required HFNC, NIV, or endotracheal intubation with invasive mechanical ventilation (ETI-IMV) were analyzed. HFNC failure was defined as therapeutic escalation to NIV, and NIV failure as the need for ETI-IMV or death in the ICU. The management of patients with non-invasive respiratory support included the use of combined therapy with different devices. The study period included the first six waves of the pandemic in Spain. Results: 424 patients were analyzed, of whom 12 (2.8%) received HFNC, 397 (93.7%) NIV and 15 (3.5%) ETI-IMV as first respiratory support. PaO2/FiO2 was 145 ± 30, 119 ± 26 and 117 ± 29 mmHg, respectively (p = 0.003). HFNC failed in 11 patients (91.7%), who then received NIV. Of the 408 patients treated with NIV, 353 (86.5%) received combination therapy with HFNC. In patients treated with NIV, there were 114 failures (27.9%). Only the value of SAPS II index (p = 0.001) and PaO2/FiO2 (p < 0.001) differed between the six analyzed waves, being the most altered values in the 3rd and 6th waves. Hospital mortality was 18.7%, not differing between the different waves (p = 0.713). Conclusions: Severe COVID-19 ARF can be effectively and safely treated with NIV combined with HFNC. The clinical characteristics of the patients did not change between the different waves, only showing a slight increase in severity in the 3rd and 6th waves, with no difference in the outcome. © 2022 Elsevier Ltd
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INTRODUCTION: Intensivists have faced difficult decisions about when to intubate patients during the Covid 19 pandemic. Initial studies had suggested that early intubation may be beneficial, as patients would avoid self induced lung injury, whereas later studies indicated that delaying intubation could be advantageous in some patients by avoiding the inherent risks of mechanical ventilation. This study aims to assess if NIPPV and HiFlow NC are safe methods of oxygenation in patients with Covid 19 ARDS and can prevent intubation. METHOD(S): A retrospective chart review of 693 patients was conducted. These patients tested positive for Covid 19 during hospitalization AND required supplemental oxygen via either HiFlow or NIPPV (including CPAP and BiPAP). Demographic and clinical characteristics were compared between intubated and nonintubated patients. Associations between days on NIPPV/HiFlow and hospital outcomes were assessed by univariable linear regression for continuous outcomes and by univariable logistic regression for dichotomous outcomes. Subgroup analysis was conducted on patients who were intubated, those who were in the ICU, and those who died. All analyses were conducted using R v. 4.0.3. RESULT(S): Among all patients, each additional day on NIPPV/HiFlow was associated with a 0.14 day decrease in overall hospital length of stay and reduced odds of intubation. Furthermore, each additional day on NIPPV/HiFlow was NOT associated with increased odds of complications such as VTE, PE, cerebral thrombosis, pneumothorax, GI bleeding or ICU admission. This held true in the subgroups as well. We also found that when compared against nonintubated patients, intubated patients had a significantly shorter median length of time on NIPPV/HiFlow (5 days vs 7) and a longer total median hospital length of stay (23 days vs 11), along with a significantly higher rate of VTE (15% vs 4.9%), pneumothorax (8.1% vs 1.5%), cerebral thrombosis (4.5% vs 1.5%), and PE (4.5% vs 1.1%). CONCLUSION(S): Our results suggest that NIPPV/ HiFlow does not worsen patient outcomes in patients with Covid 19 and may save some patients from intubation. Nonetheless, intubation should not be withheld in patients who decompensate on NIPPV/HiFlow as these patients have more Covid related complications and require additional support.
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Background. Pneumothorax (PTX) and pneumomediastinum (PM) have been reported among hospitalized patients with COVID-19. It can occur among patients breathing spontaneously or as a result of barotrauma from invasive positive-pressure ventilation or from medical procedures. We aim to study the clinical features and outcomes of pneumothorax and pneumomediastinum within 48 hours of hospitalization among COVID-19 patients. Methods. We conducted a multicenter retrospective study among the hospitalized adults with COVID-19 who had pneumothorax and pneumomediastinum within 48 hrs. of admission between November 2020 and December 2021. Cases were identified using ICD 10 codes. Electronicmedical records were reviewed after Institutional Board approval. Results. We identified a total of 21 patients, 12 (57%) only had PTX, 6 (28%) only had PM, and 3(14%) had both. Mean age for the cohort was 57 yrs, 13 (62%) were females, and 14 (67%) were whites. Chronic lung and end-stage renal diseases were noted among 9 (43%) patients followed by obesity in 9 (43%) and diabetes in 4 (19%). A total of 12 (57%) patients have smoked tobacco. At the time of hospitalization, 12 (57%) patients had oxygen saturation <=94% and 9 (43%) had <=90%. PTX and PM on admission chest x-ray were noted in 12(57%) and 4 (19%) respectively. 3 (14%) developed them after intubating and/ or after BiPAP. Patients were treated with steroids (90%), remdesivir (62%), interleukin-6 inhibitors (24%), and convalescent plasma (9%). Chest tube was placed in 7 (33%) patients and thoravent in 1 (5%) patient. Complications were septic shock (14%) and deep venous thrombosis (10%). There were 4(19%) deaths. Conclusion. Spontaneous PTX can be a presenting sign for COVID-19. We noted higher complications and mortality among the COVID-19 patients with PTX and PM than reported in literature. Clinicians should be aware of this potential occurrence, requiring close monitoring and aggressive management. Larger studies can further validate the findings of our study.
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Background: To assess effectiveness of Bain's circuit attached to a NIV mask for assisting spontaneous ventilation. Material(s) and Method(s): Fifty- six adult COVID- 19 patients were divided into 2 groups of twenty- eight each. In group I, patients were ventilated using the modified Bain's circuit attached to an appropriately sized NIV mask and in group II patients were continued on ventilation using BiPAP. Hemodynamic variables such as partial pressure of CO2 (pCO2), partial pressure of O2 (pO2), SO2, heart rate and pH values were recorded at baseline, after 30 minutes and after 2 hours. Result(s): There was non- significant difference in mean heart rate, SpO2, pH, pO2, pCO2 and SO2 at baseline, after 30 minutes after 2 hours in group I and group II (P> 0.05). Conclusion(s): Modified Bain's circuit can be considered as an alternative to non-invasive ventilation in COVID- 19 patients. Copyright © 2022 Necati Ozpinar. All Rights Reserved.
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The proceedings contain 910 papers. The topics discussed include: characteristics and risk factors associated with mortality during the first cycle of prone secondary to ARDS due to SARS CoV 2 pneumonia;comparison of clinical characteristics between respiratory failure patients who admitted to the ICU caused by COVID 19 and seasonal infuenza;the role of EphA2/ephrinA1 pathway in hyperoxia induced lung injury;practice of awake prone positioning in critically ill COVID-19 patients - insights from the PRoAcT-COVID study;evaluation of the performances of new generation of heated wire humidifiers;utilization of automated oxygen titration in patients managed at the emergency department (ED) for suspected or confirmed COVID-19;hygrometric performances of heat and moister exchangers with low dead space;risk factors for weaning failure in COVID 19 patients: a multicenter, observational study in Greece;design and testing of a novel, low cost, non invasive, pediatric bi level positive airway pressure ventilation device;and occurrence and risk factors of major complication in critically adults requiring endotracheal intubation. a nationwide, prospective study in Spain: INTUPROS study.
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Introduction/Background COVID-19 and influenza typically present in a very similar clinical picture. The co-infection of influenza among COVID-19 patients (i.e., flurona) can occur in the fall and winter of the year. The prevalence of flurona was estimated to be 0.4% and 4.5% in America and Asia, respectively. The damage of respiratory ciliated cells by the influenza virus can facilitate COVID-19 infection. Few studies reported COVID-19 co-infection with influenza virus. The majority of flurona cases affected older patients with co-morbidities. The co-infection of influenza among COVID-19 patients was associated with more severe disease, especially among older patients with co-morbidities. Young and healthy adults are less likely to develop severe COVID-19 leading to ARDS even with co-infection. However, severe COVID-19 can still occur regardless of age and co-morbidities. Herein, we report a case of severe ARDS in a young and previously healthy adult secondary to flurona that was successfully treated with targeted combination therapy with oseltamivir and remdesivir. Objective(s) A 21-year-old Caucasian male patient without significant past medical history presented the ED with a chief complaint of fatigue, cough, and generalized body aches. The patient mentioned that symptoms started a few days before his presentation. He suspected it was the flu, so he did not seek medical care initially. However, his symptoms continued to worsen, to the point that he could not move without getting severely out of breath. He was tachycardic, tachypneic in the emergency department (ED). His COVID-19 swab returned positive, and a respiratory pathogen panel was also positive for influenza A infection. Initial CTA was negative for PE but showed extensive multifocal bilateral infiltrates consistent with viral pneumonia. He was started on a high-flow nasal cannula. Still, his oxygen was peaking around 85% with increased work of breathing. The patient also did not tolerate BiPAP. Therefore, the patient was intubated in the ED and admitted to the intensive care unit (ICU). He was started on a five-day course of oseltamivir, remdesivir, and intravenous methylprednisolone. The patient remained intubated and mechanically ventilated on the next day, and PaO2/FIO2 ratio was 100. He was started on ARDS treatment protocol, and daily prone positioning was initiated. Gradually the patient started to improve. On day nine, he successfully passed a CPAP trial and was extubated. His ICU stay was complicated by the development of a small segmental PE that was treated with IV heparin. He also had upper GI bleeding, and esophagogastroduodenoscopy revealed a bleeding gastric ulcer, which was successfully managed with endoscopic clipping. The patient gradually improved, and his oxygen requirements decreased significantly over the next few days. He was discharged home with no supplemental oxygen on apixaban and pantoprazole. Methods Our study highlights the importance of screening for co-infecting influenza virus in COVID-19 patients, which could be the leading cause of disease severity. Early detection of flurona can play an important role in managing these patients, especially if they develop ARDS. Targeted combined therapy against influenza and COVID-19 with oseltamivir and remdesivir may effectively mitigate the morbidity and mortality of these patients. Improving compliance with flu vaccination is highly recommended to reduce influenza virus transmission during this long COVID-19 pandemic and reduce the risk of COVID-19 severity.
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Aims Literature describes that most neonates with SARS-CoV-2 infection are asymptomatic or present with mild symptoWe describe an ex-preterm twin infant, born at 31+5 with birthweight 1600g, who deteriorated with COVID pneumonitis at 34 weeks corrected gestational age. They were an inpatient in a level 3 neonatal centre, with an uncomplicated stay prior to becoming unwell and had never been ventilated in their early neonatal course. Methods They acquired postnatal covid on day 24 of life, and deteriorated over the next 72 hours, escalating from high flow to CPAP then BiPAP, and finally requiring intubation. They were empirically commenced on antibiotics and required sedation and muscle relaxation to manage their worsening respiratory failure. Given their acute respiratory decompensation in the context of COVID, and with negative extended virology and bacterial testing otherwise, they were managed on a presumptive diagnosis of COVID pneumonitis. CXRs were consistent with this diagnosis. Despite further escalation in their ventilation strategies, including high frequency oscillatory ventilation and inhaled nitric oxide, they continued to deteriorate with severe hypoxic respiratory failure. Inotropic support was required to maintain cardiac stability. There was extensive MDT discussion between NICU, PICU and the Infectious Diseases teaDue to the severity of their condition, Remdesivir was commenced and the parents were fully informed of the trial nature of the drug and the guarded prognosis. Hydrocortisone was also commenced. Results Due to ongoing deterioration, the patient was transferred to PICU for ongoing care and consideration of ECMO. However, the infant stabilised and the hydrocortisone that had been commenced was switched to methylprednisolone. The Remdesivir was discontinued after 2 doses due to a worsening in LFTs. The situation was further complicated by COVID isolation guidelines while keeping family centred care at the heart of our approach, working within infection control policies and managing a relatively unfamiliar pathology in the neonatal population. Conclusion The infant progressed well and was extubated onto nasal cannula oxygen on day 40 of life and repatriated to our neonatal unit on day 41 at 37+4 corrected gestational age. They had an uneventful stay in our SCBU, establishing feeding, until discharge with home oxygen at 41+1 weeks corrected gestational age.
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SESSION TITLE: COVID-19 Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: SARS-CoV-2 pandemic has shown rare and varied presentations of known pathology and infectious processes. We discuss the case of a patient developing bronchial tree ulcerations in the backdrop of SARS-CoV-2 and superimposed infections. CASE PRESENTATION: This was a 59-year-old male with past medical history of B-cell lymphoma, diagnosed with SARS-CoV-2 infection. He was admitted with shortness of breath and increased oxygen requirement. In brief, his hospital course included bilevel positive airway pressure noninvasive ventilation along with steroids, baricitinib and therapeutic anticoagulation. His clinical status worsened to severe acute respiratory distress syndrome and he progressed to mechanical ventilation. While on the ventilator he was treated with paralysis and proning. Due to worsening hypoxia and secretions, he underwent bronchoscopy showing copious thick mucoid white patches and secretions in trachea extending to the right and left mainstem bronchi and extensive mucus plugging. Baricitinib was discontinued and he was placed on empiric micafungin, broad spectrum antibiotics while results were pending. He required repeat bronchoscopy for therapeutic suctioning of recurrent copious thick white secretions with mucus plugging. Cultures resulted as aspergillus fumigatus and micafungin was switched to voriconazole. Two weeks later, in an ongoing prolonged intubated state, he developed cuff leak requiring tube exchange and repeat bronchoscopy, which showed development of multiple bilateral ulcerations with central necrosis and sloughing in the right and left bronchial tree. Repeat lab evaluation of the bronchoscopy samples now resulted in growth of nocardia along with aspergillus species. DISCUSSION: Ulceration of bronchial tree may be seen in malignant lesions, autoimmune conditions, poisoning or toxicology cases. Occurrence of pulmonary ulcerations are rare in infectious cases as sequalae in the SARS-CoV-2 pandemic. Patient's immunocompromised state, with history of B-cell lymphoma, prolonged steroid and JAK inhibitor administration, predisposes to higher propensity of infections. Bronchial tree ulceration also leads to suspicion of viral infections such as herpes, varicella which were found to be negative from bronchial samples. It remains difficult to ascertain if the prolonged aspergillus infection led to progression of white plaques into ulcerations, or the newly diagnosed secondary infection of nocardia caused bronchial tree ulcers. Historically, aspergillus has been associated with blackened ulcerations as opposed to the findings here. Also, patient had been receiving treatment with voriconazole for 2 weeks prior to diagnosis of ulcers, therefore raising suspicion for a rare nocardial etiology as well. CONCLUSIONS: Prolonged intubation in immunocompromised patients may lead to superimposed nocardial and aspergillus infections causing airway ulcerations and increased mortality. Reference #1: Judson MA, Sahn SA. Endobronchial lesions in HIV-infected individuals. Chest. 1994;105(5):1314-1323. doi:10.1378/chest.105.5.1314 Reference #2: Abdel-Rahman N, Izhakian S, Wasser WG, Fruchter O, Kramer MR. Endobronchial Enigma: A Clinically Rare Presentation of Nocardia beijingensis in an Immunocompetent Patient [published correction appears in Case Rep Pulmonol. 2016;2016:1950463]. Case Rep Pulmonol. 2015;2015:970548. doi:10.1155/2015/970548 DISCLOSURES: No relevant relationships by Habiba Hussain No relevant relationships by Matthew Sehring
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SESSION TITLE: Severe and Unusual Blastomycosis Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: This is a case of a patient 74-year-old immunosuppressed woman presenting with a one-week history of skin lesions. CASE PRESENTATION: A 74-year-old woman with Crohn's disease (on weekly adalimumab);pulmonary hypertension (RVSP 76 mmHg);OHS/OSA, on home BPAP 17/7 cmH2O;and morbid obesity presented with a one-week history of skin lesions. She was seen by her primary care physician two days prior with skin lesions, shortness of breath, and decreased vision. She was hypoxic during the visit and given doxycycline for empiric treatment of pneumonia. She denied recent travel or exposure to animals. On admission, she was afebrile (36.9C) and saturating 98% on 2 L nasal cannula. She appeared chronically ill with mouth ulcers and an eroded nodule with overlying hemorrhagic crusting and peripheral pustular area above her right eyebrow (figure 1). Throughout her skin, she had multiple erythematous papules, some with overlying vesicles/pustules. Labs were significant for a leukocytosis of 19.3 with left shift, lactate of 3.5, serum creatinine of 1.9 (likely higher than patient's previous baseline of 1.7 with previous history of recurrent AKIs on CKD), elevated inflammatory markers, and normal ALT/AST. Influenza and COVID were negative. A CT chest showed consolidations and numerous pulmonary nodules highly suspicious for an infectious or inflammatory process (figure 2). She was treated empirically with vancomycin, piperacillin-tazobactam, valacyclovir, and amphotericin B, the latter given the concern of blastomycosis. During her hospitalization, she had further respiratory failure requiring intubation and multiorgan failure. Disseminated blastomycosis was confirmed via a skin biopsy which demonstrated pyogranulomatous inflammation with numerous broad-based budding yeasts (figure 3) and supported with a bronchoalveolar lavage (BAL) culture growing the same. Given her continued decline, her medical decision maker decided to transition the patient to hospice care. DISCUSSION: Blastomycosis is a systemic pyogranulomatous infection that is caused from the inhalation of the conidia form of the dimorphic fungus. It can manifest as asymptomatic infection, acute or chronic pneumonia, or extrapulmonary disease. BAL yields a positive diagnosis in 92% of patients and definitive diagnosis requires growth of the organism from a clinical specimen. Without appropriate treatment of amphotericin B or one of the azole antifungals, the disease had a 90% mortality rate. CONCLUSIONS: Prompt recognition of multiorgan failure secondary to blastomycosis is important for early treatment and improved survival in immunocompromised patients Reference #1: 1)Chapman, S W et al. "Endemic blastomycosis in Mississippi: epidemiological and clinical studies.” Seminars in respiratory infections vol. 12,3 (1997): 219-28. Reference #2: 2)Saccente, Michael, and Gail L Woods. "Clinical and laboratory update on blastomycosis.” Clinical microbiology reviews vol. 23,2 (2010): 367-81. doi:10.1128/CMR.00056-09 Reference #3: 3)Chapman, Stanley W et al. "Clinical practice guidelines for the management of blastomycosis: 2008 update by the Infectious Diseases Society of America.” Clinical infectious diseases : an official publication of the Infectious Diseases Society of America vol. 46,12 (2008): 1801-12. doi:10.1086/588300 DISCLOSURES: No relevant relationships by Jennifer Duke No relevant relationships by Ashley Egan
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SESSION TITLE: Procedures in Chest Infections Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Pneumonia is a common condition that is seen in hospitals. Pneumocystis Jirovecii is an opportunist fungal pathogen. Bordetella bronchiseptica is a gram negative bacteria that causes infectious bronchitis in dogs and other animals, but rarely infects humans. CASE PRESENTATION: Patient is a 34 year old African American female with history of sickle cell trait, reported Lupus (not on treatment), asthma, COVID pneumonia who was admitted for worsening shortness of breath & productive cough with yellow sputum. She was previously hospitalized and discharged after being treated for Community-Acquired Pneumonia. In the ER, she was febrile, tachycardic, tachypneic, & hypoxic requiring BiPAP. CXR obtained showed findings concerning for multifocal pneumonia. Chest CT Angiogram was negative for PE. Patient was started on Vancomycin & Meropenem for treatment of her pneumonia. Blood cultures, Legionella, Strep pneumoniae, Aspergillus, Beta-D-glucan, Sputum culture, & MRSA screen were ordered for further evaluation of her infection. ANA screen reflex panel, lupus anticoagulant, anticardiolipin antibodies, beta-2 glycoprotein antibodies were also ordered given patient's reported history of SLE and the concern for SLE pneumonitis: ANA & Sjogren's Anti-SSA were positive;otherwise, autoimmune workup was unremarkable. During hospitalization, patient was eventually weaned down to nasal cannula and antibiotic was de-escalated to levaquin. However, sputum culture eventually grew Bordetella Bronchiseptica that was resistant to Levaquin so antibiotic regimen was switched to Doxycycline. In addition, Beta-D-glucan was noted to be elevated. Bronchoscopy was done for further evaluation;multiple transbronchial biopsies were positive Pneumocystis Jirovecii. Patient was then initiated on Bactrim for treatment of PJP Pneumonia along with a steroid taper. Patient was tested for HIV and it was negative. DISCUSSION: In this case, patient was found to have two rare pathogens, that are more common in immunocompromised patients such as those with HIV/AIDS, on high-dose corticosteroids or malignancy. This patient had a unconfirmed diagnosis of SLE and past COVID Pneumonia. Patient had Bordetella bronchiseptica pneumonia that is frequently isolated in the respiratory tract of animals but can cause severe respiratory infection in humans. This microorganism can cause upper respiratory tract infections, pneumonitis, endocarditis, peritonitis, meningitis, sepsis and recurrent bacteremia. Upon further discussion with the patient, she was found to have a recent pet dog. CONCLUSIONS: High level of clinical suspicious is needed in patient presenting with recurrent pneumonia with chest imaging findings suggestive of multifocal pneumonia. The mainstay of treatment for PJP is TMP-SMX and steroid. We recommend Fluoroquinolones or tetracycline for Bordetella bronchiseptica pneumonia. Reference #1: Benfield T, Atzori C, Miller RF, Helweg-Larsen J. Second-line salvage treatment of AIDS-associated Pneumocystis jirovecii pneumonia: a case series and systematic review. J Acquir Immune Defic Syndr. 2008 May 1;48(1):63-7. Reference #2: de la Fuente J, Albo C, Rodríguez A, Sopeña B, Martínez C. Bordetella bronchiseptica pneumonia in a patient with AIDS. Thorax. 1994 Jul;49(7):719-20. doi: 10.1136/thx.49.7.719. PMID: 8066571;PMCID: PMC475067. DISCLOSURES: No relevant relationships by Priya George No relevant relationships by ELINA MOMIN No relevant relationships by Mohammedumer Nagori
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SESSION TITLE: Extraordinary Cardiovascular Reports SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Hypercoagulability is a well-known complication of COVID-19, with the most common vascular events being pulmonary embolism and deep vein thrombosis (1). Arterial thrombotic events, specifically aortic thrombosis, are rarely observed in COVID-19 infections. Literature review reveals less than 10 cases of aortic thrombosis have been reported in patients with COVID-19 infection. Here, we report a unique case of acute aortic thrombosis despite administration of therapeutic anticoagulation. CASE PRESENTATION: A 77 y.o. female with no known medical history presented to the hospital after a diagnosis of COVID-19 five days prior. Upon arrival, she was hypoxic requiring supplemental oxygen via non-rebreather (NRB) mask. CT chest with contrast revealed bilateral ground-glass opacities without evidence of pulmonary embolism or aortic thrombus. She was treated with remdesivir, dexamethasone, baricitinib and enoxaparin 40mg BID (essentially therapeutic dosing based on patient's body weight of 45kg). Adequate oxygenation was maintained with nasal cannula and NRB. However, on day eight of admission she was noted to desaturate to 80% requiring BiPAP. D-dimer and CRP drastically increased from 0.36ug/ml to 1.75ug/ml and 13.0 to 102.2, respectively. Repeat CT chest with contrast revealed multiple intraluminal thrombi in the distal thoracic aorta. Treatment with clopidogrel was initiated, however patient remained BiPAP dependent. Due to DNR/DNI status, intubation was not pursued. Ultimately, patient was transitioned to comfort care and expired. DISCUSSION: Thrombotic events are poorly understood but remain a well-documented sequela of COVID-19 infection. The pathophysiology of thrombosis in COVID-19 patients has not been fully elucidated, however, it likely involves amplification of the hypercoagulable state due to viral infection. Some of the proposed theories regarding this effect include endothelial dysfunction secondary to direct virus invasion and immuno-thrombosis due to viral mediated endothelial inflammation with resultant platelet activation (2,3). Regarding COVID-19 associated arterial thrombi, myocardial infarction and stroke are the most commonly encountered events. The few reported cases of aortic thrombi occurred almost exclusively in males with significant cardiovascular risk factors and not on anticoagulation (1,3). CONCLUSIONS: Due to the increased risk of venous thromboembolic events, prophylaxis is routinely used in patients with COVID-19. However, in our case, the patient developed multiple aortic thrombi without any typical risk factors for endothelial lesions despite being fully anticoagulated. This case highlights the need for continued research and trials related to appropriate anticoagulation therapies in hospitalized patients with COVID-19. Additionally, physicians should be aware of potential arterial thrombi in patients infected with COVID-19. Reference #1: de Carranza M, Salazar DE, Troya J, et al. Aortic thrombus in patients with severe COVID-19: review of three cases. J Thromb Thrombolysis. 2021;51(1):237-242. doi:10.1007/s11239-020-02219-z Reference #2: Loo J, Spittle DA, Newnham MCOVID-19, immunothrombosis and venous thromboembolism: biological mechanismsThorax 2021;76:412-420. doi:10.1136/ thoraxjnl-2020-216243 Reference #3: Woehl B, Lawson B, Jambert L, Tousch J, Ghassani A, Hamade A. 4 Cases of Aortic Thrombosis in Patients With COVID-19. JACC Case Rep. 2020;2(9):1397-1401. doi:10.1016/j.jaccas.2020.06.003 DISCLOSURES: No relevant relationships by Chelsey Bertrand- Hemmings No relevant relationships by Alyssa Foster No relevant relationships by Kyle Foster No relevant relationships by Yelena Galumyan No relevant relationships by Veronica Jacome No relevant relationships by Viet Nguyen