ECMO in acute fulminant myocarditis in pediatrics

Objectives: To describe our experience in ECMO for acute myocarditis Methods: Descriptive, retrospective study (2018-2022) of a cohort of 8 patients < 16 years with acute myocarditis who were assisted on ECMO. Result(s): 8 patients were collected, (6 females), with a mean age 7;8 years [range 0;1-13;8]. In 7/8, the reason for cannulation was hemodynamic instability refractory to medical treatment, with a mean inotropic score of 70 [range 10-122]. Sixty-two percent presented cardiorespiratory arrest prior to cannulation and 2 of them needed ECRP. The mean precannulation troponin level was 1498 ng/ml [range 89-6212]. Primary transport was performed in 4 patients. ECMO was peripheral veno-arterial in 100%, jugulo-carotid in 2/8 and femoro-femoral in 6/8. All patients underwent atrioseptostomy. They received treatment with levosimendan, immunoglobulins, corticoids and carnitine. In 4 acute infectious etiology was confirmed (parvovirus, influenza and SARSCoV2), another one was due to PIMS-TS and in 3 no etiology was found. Six patients underwent myocardial biopsy and 5 of them showed inflammatory infiltrates. The mean time on ECMO was 8 days [range 3-14], 2 of them requiring 2 ECMO courses. The mean length of PICU stay was 21 days [range 10-50]. Two were transferred to a heart transplant center. The main complications were arterial hypertension (88%), bleeding (63%), neurological (50%), arrhythmias (38%), coagulopathy (38%) and infectious (38%). One patient required renal replacement therapy. 1 patient died, 2 had moderate neurological sequels. Conclusion(s): ECMO is a therapeutic option in patients with fulminant myocarditis refractory to medical treatment and may help improve their prognosis.

Acquired hemophilia in a patient with SARS-CoV-2 infection, a case report

Acquired hemophilia (AH) is a potentially life-threatening hemorrhagic disorder. We report the second confirmed case of COVID-19-associated AH in a 45-year-old female which, unfortunately, expired as her treatment failed. She presented to the emergency department with abnormal bleeding and spontaneous hemoptysis about ten days after a removal surgery of her epiglottis tumor. Aggregation tests, such as partial thromboplastin time (PTT), are recommended in patients with COVID-19 infection that have bleeding episodes.Copyright © 2022 The Author(s);Published by Society of Diabetic Nephropathy Prevention.

Change in Code Status Orders of Hospitalized Adults with COVID-19 Throughout the Pandemic: A Retrospective Cohort Study.

Aim: Our aim was to examine how code status orders for patients hospitalized with COVID-19 changed over time as the pandemic progressed and outcomes improved. Methods: This retrospective cohort study was performed at a single academic center in the United States. Adults admitted between March 1, 2020, and December 31, 2021, who tested positive for COVID-19, were included. The study period included four institutional hospitalization surges. Demographic and outcome data were collected and code status orders during admission were trended. Data were analyzed with multivariable analysis to identify predictors of code status. Results: A total of 3615 patients were included with full code (62.7%) being the most common final code status order followed by do-not-attempt-resuscitation (DNAR) (18.1%). Time of admission (per every six months) was an independent predictor of final full compared to DNAR/partial code status (p = 0.04). Limited resuscitation preference (DNAR or partial) decreased from over 20% in the first two surges to 10.8% and 15.6% of patients in the last two surges. Other independent predictors of final code status included body mass index (p < 0.05), Black versus White race (0.64, p = 0.01), time spent in the intensive care unit (4.28, p = <0.001), age (2.11, p = <0.001), and Charlson comorbidity index (1.05, p = <0.001). Conclusions: Over time, adults admitted to the hospital with COVID-19 were less likely to have a DNAR or partial code status order with persistent decrease occurring after March 2021. A trend toward decreased code status documentation as the pandemic progressed was observed.

The impact of COVID-19 on myocardial infarctions, strokes and out-of-hospital cardiopulmonary arrests: an observational retrospective study on time-sensitive disorders in the Friuli Venezia Giulia region (Italy).

The COVID-19 global pandemic has changed considerably the way time-sensitive disorders are treated. Home isolation, people's fear of contracting the virus and hospital reorganisation have led to a significant decrease in contacts between citizens and the healthcare system, with an expected decrease in calls to the Emergency Medical Services (EMS) of the Friuli-Venezia Giulia (FVG) region. However, mortality in clinical emergencies like acute ST-elevation myocardial infarction (STEMI), stroke and out-of-hospital cardiopulmonary arrest (OHCA) remained high. An observational retrospective cross-sectional study was carried out in FVG, taking into account the period between March 1, 2020, and May 31, 2020, the first wave of the COVID-19 pandemic, and comparing it with the same period in 2019. The flow of calls to the EMS was analysed and COVID-19 impact on time-sensitive disorders (STEMIs, ischemic strokes and OHCPAs) was measured in terms of hospitalisation, treatment and mortality. Despite a -8.01% decrease (p value ˂0.001) in emergency response, a 10.89% increase in calls to the EMS was observed. A lower number of advanced cardiopulmonary resuscitations (CPR) (75.8 vs 45.2%, p=0.000021 in April) and ROSC (39.1 vs 11.6%, p=0.0001 in April) was remarked, and survival rate dropped from 8.5 to 5%. There were less strokes (-27.5%, p value=0.002) despite a more severe onset of symptoms at hospitalisation with NHISS˃10 in 38.47% of cases. Acute myocardial infarctions decreased as well (-20%, p value=0.05), but statistical significances were not determined in the variables considered and in mortality. Despite a lower number of emergency responses, the number of calls to the EMS was considerably higher. The number of cardiac arrests treated with advanced CPR (ALS) was lower, but mortality was higher. The number of strokes decreased as well, but at the time of hospitalisation the clinical picture of the patient was more severe, thus affecting the outcome when the patient was discharged. Finally, STEMI patients decreased; however, no critical issues were observed in the variables taken into account, neither in terms of response times nor in terms of treatment times.

Central Venous Catheter Placement in a Prone Positioned Patient: Posterior Lateral Approach

INTRODUCTION: A significant number of patients with ARDS secondary to Covid-19 pneumonia require prone positioning. Common practice is to return patients to a supine position prior to performing invasive bedside procedures such as central venous access. This may present prohibitive risk in patients with refractory hypoxemia. DESCRIPTION: We present the case of a 46 year old male, admitted to the ICU with Covid-19 pneumonia complicated by ARDS. Intermittent prone positioning was initiated. The patient remained with refractory hypoxemia despite prone positioning, optimal ventilator settings and inhaled epoprostenol. The length of time the patient could be supine progressively decreased. The patient developed AKI necessitating hemodialysis (HD) catheter placement. Attempts to supine patient to perform HD catheter placement resulted in near cardiorespiratory arrest. It was decided to attempt HD catheter placement in the RIJ vein via a posterior lateral approach with the patient prone. Patient was brought to the head of the bed allowing the chin to rest on the edge of the bed with head turned laterally and endotracheal tube supported by the respiratory therapist. The patient was placed in an oblique "swimming position" by aid of a pillow under the center torso and right shoulder girdle. An optimal insertion site was selected via real time ultrasound guidance. Utilizing a micropuncture needle, guidewire, and dilator, a 15cm 12 Fr BARD hemodialysis catheter was placed using a standard Seldinger technique. DISCUSSION: Our experience indicates that a posterior lateral approach for CVC placement is a viable option. Given the complexity of this procedure and the paucity of case reports describing it, we felt it prudent to share our approach. Structures of interest to avoid in posterior approach to the RIJ include the phrenic nerve traveling along the scalenus anterior muscle tissue posterior to the internal jugular vein. Accessing the vein below the omohyoid muscle offers the best opportunity to avoid the phrenic nerve and the scalenus. A steep 90 degree angle to access the RIJ was intentionally attempted to minimize the amount of soft tissue to dilate. Utilizing this approach allowed us to safely and effectively place the line without immediate complications.

Automate to Resuscitate: Outcomes of Mechanical Cpr Two Years after Acute Care Implementation

INTRODUCTION: Expert Guidelines endorsed Mechanical Cardiopulmonary Resuscitation (mCPR) devices in response to the COVID-19 pandemic. In April, 2020, a regional hospital received grant-funding for mCPR devices to reduce team exposure during CPR events. METHOD(S): We aimed to evaluate patient outcomes and teammate perceptions associated with mCPR. The primary clinical outcome measured was 1 hour survival post CPR event among inpatients experiencing a cardiopulmonary arrest before & after mCPR implementation, including subset analysis of CPR events where mCPR was specifically noted as being used. Teammate perceptions comparing resuscitation events with and without the mCPR device, barriers to use, and impact on communication and teamwork were assessed using an electronic survey approximately one year post-implementation. RESULT(S): Respondents to the team survey (n=22) were primarily nurses (81%) in the critical care unit or the critical care code team, Respiratory Therapists (9.5%) & physicians or APPs (9.5%). One third of participants self-reported using the mCPR device 60% or more of the time. Most (72%) indicated a reduction in teammates required in the room for CPR events in the ICU. Participants rated improvement in communication and ability to focus on their role during a Code Blue. Most (76%) "Agreed" or "Strongly Agreed" that the quality of resuscitation is improved when the mCPR is in use. We defined event survival as return of spontaneous circulation (ROSC) plus survival >1 hour after the CPR event to align with historic institutional data. Baseline survival (2019) at 1 hour across all inpatient areas was 53.1%. During the 2 years post-implementation, inpatient event survival was similar at 52.9% with confirmed mCPR. In critical care, post implementation non-mCPR codes had 54.2% survival compared with 57.14% confirmed mCPR ICU Codes. mCPR was documented only in about 8% of ICU and non- ICU codes. Data are limited by onconsistent documentation of mCPR Utilization. Measures were implemented May 1 2022 and following to better capture utilization. CONCLUSION(S): Staff report benefits with mCPR. mCPR outcomes should be monitored as a variable in ongoing quality improvement. Further study of quantitative outcomes with subgroup analysis & staff perception of mCPR devices in inpatient CPR events is needed.

Bilateral Cortical Blindness Following Hypoxic Ischemic Brain Injury Related to COVID-19: A Case Report

Case Diagnosis: Bilateral Cortical Blindness. Case Description or Program Description: A 44-year-old male chef suffered cardiopulmonary arrest following COVID-19 pneumonia. His airway was not secured for about ten minutes. Consequent complex acute care course involved a prolonged period of nonresponsiveness. Complications included hypoxicischemic brain injury, with bilateral occipital infarcts and edema, which led to significant encephalomalacia. Setting(s): He arrived at the rehabilitation unit about two months later. Assessment/Results: As his mental status improved, he reported inability to see. Exam findings included intact light perception and pupillary reaction, inability to see hand motion or differentiate colors, no discernible blink reflex and negative optokinetic nystagmus drum response. Management involved a multidisciplinary team. Along with his speech, cognition, and motoric status, his vision slowly improved to 20/20 after correction and a central visual field of less than 20 degrees. He could reliably detect colors, large print, and objects. This improvement allowed him to participate in activities he liked, including cooking. Discussion (relevance): Cortical blindness (CB) occurs following damage to the primary visual pathway (V1). Often, the extra-striate pathway (V2) is also affected. Damage to V1 or its afferents could occur in 27-57% of new strokes and is characterized by contralateral homonymous hemianopia with macular sparing. Bilateral destruction of V1 is rare. Some improvement with vision is anticipated within the first few months. However, significant residual deficits usually persist. There is sparse evidence for CB rehab modalities. Approaches to consider include restitution therapies (using computer-based training programs to recover visual field deficits), compensation therapies (using saccadic eye movements to capture blind fields), substitution therapies (using prisms to redirect stimuli to intact visual fields), and pharmacology to optimize neuroplasticity (fluoxetine appears to have shown some benefit for visual pathway in rodents). Conclusion(s): Bilateral CB is a rare complication following brain injury. Although evidence-based treatment modalities are needed, support in a multidisciplinary framework was beneficial for optimizing outcomes in this unique case.

Severe Pulmonary Hemorrhage in a 3 Weeks Old Neonate with Covid-19 Infection

Aims To describe a case of 3 weeks old neonate presenting with severe pulmonary hemorrhage due to COVID-19 infection and its outcome. Methods We report an interesting case of pulmonary hemorrhage presenting at a young age of 3 weeks, in a previously healthy neonate who was infected with COVID-19 virus;Literature review and investigation results are included. This is a 3-week-old female, a product of full-term pregnancy and an uneventful perinatal course. She was admitted from the emergency department initially as a case of late neonatal sepsis, where a full septic workup was done. Her presenting complaints were low-grade fever and a blocked nose for one day. She was hemodynamically stable in the emergency department except for tachycardia secondary to fever, which improved once the fever was controlled. Her initial blood workup, including blood gas and CSF study, was reassuring (table 1a). Her COVID PCR was positive with a CT value of 17.77. She was treated with IV antibiotics and supportive management. Later that day, the patient developed cardiopulmonary arrest, CPR was initiated, and the patient was intubated. The patient was found to have pulmonary hemorrhage as evident by the fresh blood coming out of the endotracheal tube and the chest X-Ray findings of ground-glass opacities and dense consolidation (figure 1). After initial brief stabilization, the patient started deteriorating requiring escalation of respiratory support to HFOV. The patient continued to deteriorate and developed bilateral pneumothorax requiring bilateral chest tube insertion. After chest tube insertion, there was a mild transient improvement in oxygenation. The patient was put on the maximum ventilatory settings, but she kept having frequent desaturation, requiring frequent manual bag to tube ventilation. Later, she started developing progressive hypotension, that required support with maximum doses of inotropes. Her urine output started decreasing, for which frusemide were started with no response. Blood investigations showed severe DIC picture (table 1b and 1c). She was empirically covered with Meropenem and Vancomycin along with Remdesivir and Dexamethasone for COVID 19 pneumonia. Eventually, the child developed progressive desaturation, hypotension, and poor perfusion. Shortly after that, she developed cardiac arrest and was declared dead. Results The clinical picture of COVID 19 infection is more indistinct in children than in adults, with the most common symptoms being fever, cough, dyspnea, and malaise. In the few published cases of COVID-19 in the neonate, the presentation was that of late neonatal sepsis;interestingly, the lung involvement was not described as frequently as in older age groups. Pulmonary hemorrhage has been reported in adults but rarely in children. Some reports in adults suggested that patients with COVID infection had an increased inflammatory state that led to the development of vasculitis and pulmonary hemorrhage. Up to our knowledge, this is the youngest age at which a patient with COVID-19 infection developed pulmonary hemorrhage with no other underlying cause of it. Conclusion While many of the cases of COVID infection in children are mild, fatal complications like pulmonary hemorrhage can be present. Adding new challenges to the management of this viral infection.

A New Chapter in an Evolving Pandemic: Successful Pediatric Liver Transplantation with COVID+ Donors

Purpose: We report the first two pediatric liver transplants utilizing allografts from COVID+ donors, infected at time of organ procurement, demonstrating a pivotal step toward donor pool maximization amid a viral pandemic with poorly understood transmissibility in the pediatric patient. Method(s): This is a prospective and retrospective review of two pediatric liver transplants and their donors who tested positive for SARS-CoV-2 at time of procurement. Data was obtained through the electronic medical record system and UNet DonorNet platform. Result(s): The first donor is a 3-year-old male succumbing to head trauma. 1 of 5 nasopharyngeal swab RT-PCR tests demonstrated COVID-19 positivity while 1 of 3 bronchoalveolar lavage RT-PCR tests indicated SARS-CoV-2 infection. Preceding procurement in the second donor, a 16-month-old male with unknown etiology of cardiorespiratory arrest, 2 nasopharyngeal swab RT-PCR tests and 1 bronchoalveolar lavage RT-PCR test failed to detect SARS-CoV-2 infection. Diagnosis was not made until the Medical Examiner's office repeated a nasopharyngeal swab RT-PCR and archive plasma RT-PCR which were both positive for SARS-CoV-2. The two 2-yearold pediatric liver recipients underwent transplantation in November 2021. Continued follow-up demonstrates successful transplant void of viral transmission or hepatic artery thrombosis as liver chemistries have anticipatorily normalized with excellent graft function. One recipient experienced early portal vein thrombosis treated by interventional radiology with discharge on postoperative day 20. Conclusion(s): This report is the first to describe successful pediatric liver transplants from COVID+ donors. This data reinforces case reports in the adult transplant population of successful use of COVID + donor organs and further supports the judicious use of COVID+ donors for extrapulmonary pediatric organ transplant. The concern for donor-derived transmission must now be weighed against the realized benefit of successful, life-saving transplantation for end stage liver disease in the pediatric patient. (Figure Presented).

COVID-19: A CONFOUNDING MIMICKER OF HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS

SESSION TITLE: Challenging Cases of Hemophagocytic Lymphohistiocytosis SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Hemophagocytic lymphohistiocytosis (HLH) is a rare syndrome involving pathologic immune activation that is often fatal. The link between the cytokine storm related to COVID-19 and development of HLH has been reported since the onset of the pandemic, but little is known about clinical manifestations of HLH, thereby delaying treatment. CASE PRESENTATION: A 50 year-old male presented with a several day history of progressive weakness in the setting of missed dialysis session. Medical history was significant for ESRD on dialysis and diastolic heart failure (EF 35%). Initial vitals were unremarkable. Physical exam was notable for peripheral edema bilaterally. Laboratory studies were consistent with hyperkalemia, elevated ferritin (28,383) and elevated liver function tests. COVID-19 PCR was positive upon admission. Chest x-ray, CTA chest and a right upper quadrant ultrasound were unremarkable. He was admitted to the medical ICU for emergent dialysis. Soon after arrival to the ICU, he became lethargic and confused with increasing oxygen requirements and a subsequent a code blue was called. Cardiopulmonary resuscitation was immediately initiated, with a first rhythm consistent with ventricular fibrillation. He was shocked and placed on an amiodarone infusion with return of spontaneous circulation. TTE revealed a severely reduced EF <10%. Despite initiation of advanced COVID-19 therapies with Solu-Medrol and tocilizumab he remained ventilator dependent. Due to hemodynamic instability and persistent metabolic acidosis, he was transitioned to continuous renal replacement. Further blood work showed worsening inflammatory markers (ferritin 33,500, LDH 6981). Because of the significantly elevated ferritin, there were concerns for possible HLH. Triglycerides and IL-2 receptor were 395 mg/dL and 9300 pg/mL respectively. Total NK cells were decreased to 1.2%. He remained persistently unstable despite aggressive measures. He suffered a second cardiopulmonary arrest, which was unable to achieve return of spontaneous circulation and he ultimately passed away. DISCUSSION: HLH is characterized by uncontrolled activation and proliferation of benign macrophages in reticuloendothelial organs. This results in histiocytic hemophagocytosis, worsening peripheral blood cytopenia(s), cytokine storm, and cytokine mediated biochemical alteration ultimately culminating in multiorgan dysfunction and disseminated intravascular coagulation. Although a distinctive constellation of features has been described for HLH, diagnosis remains challenging as patients have diverse presentations associated with a variety of triggers. CONCLUSIONS: As HLH is a medical emergency with poor prognosis, prompt recognition and early treatment is crucial for improving clinical outcomes. We hope this case will create increased awareness and timely diagnosis of cytokine storm syndromes in patients with severe COVID-19 infection. Reference #1: Meazza Prina M, Martini F, Bracchi F, Di Mauro D, Fargnoli A, Motta M, Giussani C, Gobbin G, Taverna M, D'Alessio A. Hemophagocytic syndrome secondary to SARS-Cov-2 infection: a case report. BMC Infect Dis. 2021 Aug 13;21(1):811. doi: 10.1186/s12879-021-06532-7. PMID: 34388982;PMCID: PMC8361241. Reference #2: Schnaubelt, Sebastian MDa,*;Tihanyi, Daniel MDb;Strassl, Robert MDc;Schmidt, Ralf MDc;Anders, Sonja MDb;Laggner, Anton N. MDa;Agis, Hermine MDd;Domanovits, Hans MDa Hemophagocytic lymphohistiocytosis in COVID-19, Medicine: March 26, 2021 - Volume 100 - Issue 12 - p e25170 doi: 10.1097/MD.0000000000025170 DISCLOSURES: No relevant relationships by Garrett Fiscus No relevant relationships by Niala Moallem No relevant relationships by Resham Pawar

OUTCOME OF ADULT HEMATOPOIETIC TRANSPLANT RECIPIENTS AFTER ADMISSION TO INTENSIVE CARE UNIT (ICU): SINGLE CENTRE EXPERIENCE

Background: Intensive care unit (ICU) admission during hematopoietic stem cell transplant (HSCT) is associated with poor prognosis1,2. Published series report a range of ICU admission rates from 24-40% of transplant patients, most frequent reasons involving septic shock, respiratory failure and veno-occlusive disease3. In addition, patients undergoing HSCT are at a high risk of severe morbidity and mortality associated with COVID-194. Aims: The aim of this study was to analyze outcome of HSCT patients requiring ICU admission in our center. Methods: We retrospectively analysed outcome of 752 patients who underwent HSCT in our centre from January/2008 to June/2021. Data were collected from patients' clinical histories. Results: 103 (14%) patients required ICU admission (baseline and HSCT characteristics on table). Median time to ICU admission was 42 days (-2-1765). Seven of these patients were admitted to ICU on two occasions giving a total of 110 consecutive ICU admissions available for analysis. Main reason for ICU admission was respiratory distress (74;67%), mainly due to pneumonia (53%) including a 3% caused by COVID19, pulmonary edema (26%) and pulmonary haemorrhage (8%). Septic shock was second most common cause for ICU admission (26;24%) due to gram-negative bacilli (47%), fungal (15%) gram-positive bacteria (13%), virus (10%) and others/idiopathic (16%). Other less frequent causes were veno-occlusive disease (11;10%), hepatic failure/encephalopathy (8;7%), haemorrhagic complications (6;5%), cardiorespiratory arrest (2%), GVHD (2%), cardiogenic shock (2%). Of the 110 ICU admissions, 37 (34%) required hemofiltration, of which 30 (81%) died;and 77 (70%) required orotracheal intubation, of which 59 (77%) died. During the 110 ICU admissions, 67 patients (61%) died in the ICU;of these, 40 (37%) received unrelated donor HSCT, 36 (33%) sibling donor, 16 (15%) haploidentical and 17 (16%) autologous. Median ICU length of stay of these patients was 13 days (range 1-76). The cause of death was the same reason for ICU admission. Eighteen (16%) patients were discharged from ICU and died prior to Hospital discharge and 24 (22%) survived to Hospital discharge and were classified as post-discharge survivors. Of these 24 cases, 19 (79%) remain alive while the others (5;21%) succumbed to underlying disease or complications post-HSCT. Off note, both patients with COVID19 pneumonia (haploidentical and autologous HSCT respectively) were discharged from ICU and remain alive to date, without major complications. Summary/Conclusion: In our study 14% of transplant recipients required ICU admission, slightly lower than previous reports. Most common cause of admission was respiratory failure, consistent with reported. Mortality rate during ICU admission was 61%;higher death rate observed in allogeneic transplantation and those requiring aggressive ICU treatments such as mechanical ventilation or hemofiltration. Although patients with COVID19 pneumoniae who require ICU admission are usually associated with adverse outcome, in our series they responded successfully to intensive treatment. ICU admission following HSCT is associated with poor prognosis, but should not be considered futile. (Table Presented).

UPDATE AND FOLLOW-UP OF NEWLY DIAGNOSED MULTIPLE MYELOMA (NDMM) WITH HIGH-RISK CYTOGENETIC (HRC)

Background: Despite therapeutic strategies improvement, there is still a subgroup of NDMM patients (pts) that pose a clinical challenge, whose represents a <20%, we refer to HRC. HRC Pts are associated with a poor prognosis and aggressive course, although, recent studies propose different clinical evolution according to the cytogenetic alteration (CA). IMWG identified a 4-year progression free survival (PFS) of 12% and OS of 35%. Aims: Describe our clinical experience and therapeutic management, also the clinical-biochemical alterations at diagnosis in a heterogeneous NDMM HRC's cohort. Evaluate survival curves according to HRC. Methods: Descriptive and retrospective analysis, using clinical and analytical NDMM HRC patient's data from 2009 to 2022 at Guadalajara University Hospital. 61/201 pts were selected in the MM treatment (tto) protocols. FISH results were not found in <30% NDMM, due to lack of metaphases or no request. Pts with t(4;14), t(14;16), gain 1q, t(14;20), plasmablastic leukemia and/or del(17p13) were classified as HRC. Survival data and Pearson (P) correlation were used. P value <0.05 was considered significant. Results: Total HRC NDMM 61 pts were analyzed. 21 of 61 pts (35%) were diagnosed with stage monoclonal gammopathy of undetermined significance (MGUS) prior to HRC NDMM, with a mean 4 years (y) (IR 2-10 y), greater % representation of MGUS were del17p (38), gain 1q (48), t (14;16) (4,5) and del17p + gain1q (9,5). Clinical characteristics data at diagnosis according to HRC are shown in Table 1. Pts receiving 1st line were 100% (61), 90,2% of the pts received bortezomib (V) - based induction, of them 29% (n=16) were treated with alkylating agents, 49,1% (n=27) received IMIDs and 18,2% (n=10) V with dexamethasone (d), plus two of these pts received regimens composed of 3xVCd + 3xVPd and the other dara-VRd. 25 pts (40,98%) were transplant eligible (TPH). 2nd line, 32 pts (52,5%), (n=3) VTD-PACE, (n=6) daratumumab (n=1 alone, 3 R, 1 V, 1 K), (n=1) Kdexa, (n=1) Pocydex and (n=9) V plus 3 IMIDs, 2 alkylating, 2 P or 2 alone and (n=12) IMIDs and alkylatings in combination. 5 pts (8,2) were TPH (1 alogenic). 3rd line, 16 pts (26,2), just 3 pts were TPH. 4th line, 7 pts (11,4), 1 pts were TPH. 5th line, 4 pts (6,5). 6th line, 2pts (3,3). In the last lines, the use of triplets with pomalidomide, karfilzomib or intensive chemotherapy prevail. After a median follow-up of 3 y (IR 1,6-6,2) from diagnosis, pts had relapsed at least one time (60,6%) and more than 3 times (11,5%), and 25 had died (40,9%), 16 of them due to infections (14 bacteremia, 2 COVID), 5 cardiorespiratory arrest and 3 due to progression. (Image 1) represents PFS y OS for only 5 CA, as data were no representative in other CA. Correlation between ISS and ISS-R data were only able to execute in HRC gain1q, due to lack of sample in other CA. We found a P coefficient of 0.568399 or 56.83% (p- <0.00578, CI 95%). Summary/Conclusion: Our case series continues with a longer survival curve compared to those commented in other studies. As cytogenetic abnormalities (t(4;14), t(14;16), t(14;20) and gain1q), similar % of representation are described as Kumar. Nat Rev Clin Oncol. 2018, except for del(17p), 23% vs 10%. From the second line, the probability of receiving a new line, the duration of tto and the interval without tto decreased with each line of tto. As treatment lines progress, therapeutic combinations are more heterogeneous and less concordant. A further longer follow-up and higher HRC NDMM pts's recruitment will be necessary to clarify the response to tto regimens based on individual cytogenetic groups.

Multisystem Inflammatory Syndrome in Indian Children Associated with SARS-CoV-2 Infection: A Case Series ABS0026)

Introduction: The coronavirus disease 2019 pandemic has affected all the countries and age groups alike. However, during the initial part of a pandemic, COVID-19 affected children with a milder form of the disease and had better clinical outcomes than adults.1 Subsequently, a rising number of previously well children with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) induced hyperinflammatory states resembling macrophage activation syndrome, toxic shock syndrome, and Kawasaki disease were reported.2 Here, we describe four children with COVID-19-associated MIS-C presenting to a tertiary care center between May 17 and June 17, 2021. They had distinct clinical features, but similar laboratory and radiological findings. However, none of them were positive for SARS-CoV-2 nucleic acid on real-time polymerase chain reaction but all of them had elevated immunoglobulin G titers against SARS-CoV-2. Case description: Four previously well children, aged 13-14 years, including equal number of males and females, presented to us with complaints of fever with rash, abdominal pain for 5-6 days. None of the patients had comorbidities, except patient 2, who was a known case of type 1 diabetes mellitus and was receiving huminsulin. At presentation, patients 1 and 4 had hypovolemic shock and dyspnea. There was mild global hypokinesia with mild tricuspid and mitral regurgitation in patient 3 and biventricular dysfunction (ejection fraction: 54%) with mild pericardial effusion in patient 4. Laboratory investigations revealed negative for malaria, dengue, scrub typhus, and leptospira in all the patients. Neutrophilia and lymphocytosis were observed in every patient. All, except patient 2, had thrombocytopenia. The international normalization ratio was raised in patients 1 and 2. All patients had negative RT-PCR for SARS-CoV-2. While, the levels of COVID-19 IgG antibody, C-reactive protein, D-dimer, lactate dehydrogenase, erythrocyte sedimentation rate. They were managed in the medicine intensive care unit (MICU). The shock and hypoxia was managed with fluids and inotropes and 6-8 L O2 through bag-mask-ventilation (BMV). Additionally, in all the patients, MIS-C was suspected and intravenous immunoglobulin (IVIG, 2 mg/kg), intravenous methylprednisolone, low molecular weight heparin, broad spectrum antibiotics, fluid therapy, and supportive care was initiated. One of them developed cardiorespiratory arrest. Resuscitation was done but the patient could not be revived back. While other patients responded well over the next 48-72 hours with a gradual decrease in titers of inflammatory markers. Steroids were slowly tapered off and patients were discharged. Conclusion: The findings of our series suggest that COVID-19 can trigger a hyperinflammatory state resulting in shock and pulmonary involvement, in some of the patients. The patients presented with distinct clinical features, with some mimicking atypical KD, the underlying mechanism for which still remain unclear. The physicians should be suspicious of MIS-C in children presenting with fever, rash, and gastrointestinal symptoms.

A Randomized-controlled Simulation based Pilot Trial of Patient Barrier Devices on Resuscitation Quality for Patients Under Investigation for COVID-19

Background: The COVID-19 pandemic had placed constraints on cardiopulmonary resuscitation (CPR), including early intubation, minimizing bag-valve mask ventilation1, and using protective equipment and barriers during resuscitation. Patient barrier devices have been introduced in emergency departments and operating rooms, consisting of plastic drapes over the patient9, or the use of an acrylic box.2 Both of these adjuncts reduce aerosolization of oropharyngeal particles from the patient, and can facilitate video-based intubation.2,3 However, it is unknown whether these devices help or hinder the ultimate resuscitation quality in cardiopulmonary arrest patients. Our specific question addresses the effect of a patient barrier device and COVID-19 resuscitation recommendations on resuscitation quality. We hypothesize that a simple patient barrier consisting of a plastic drape reduces healthcare worker (HCW) contamination without affecting resuscitation quality. Methods: This was a single-center randomized controlled pilot trial, in which in-hospital teams of 4 to 6 HCWs were randomized to either use a plastic drape (intervention) or no plastic drape (control) for a simulated adolescent cardiopulmonary arrest. The manikin was modified to emanate simulated viral particles (GloGerm®, Moab, UT) from the trachea detectable using ultraviolet light. Teams managed a cardiopulmonary arrest until intubation, using Personal Protective Equipment (PPE) and PALS/ACLS algorithms. Data were captured via arbitrated video review. Resuscitation data included time-to-bagging, time-to-intubation, and chest compression quality metrics - depth, rate, and lean. Contamination data were collected visually, marking the number of PPE equipment with visible fluorescence. Mean NASA-TLX and NOTECHS scores measured workload and team performance. Descriptive and univariate statistics were used to determine differences between intervention and control teams. Results: Fifteen simulations were conducted from 2020 to 2021;one was excluded from analysis as a performance outlier, leaving 7 intervention vs. 7 control teams. Scenarios lasted an average of 10.4+/- 3 minutes. Time-to-bagging, time-to-intubation, and intubation duration were not different between groups (72.1+/-22.4 vs 56.7+/-30.9 sec, 536+/-289 vs 544+/-127 sec, 78.9+/-73.0 vs 95.7+/-113 sec, p>0.3), and CPR quality for mean depth, rate, and lean were also not different (36.1+/-11.6 vs 30.9+/-13.2 cm, 108+/-13 vs 112+/-8/min, 8.7+/-5.2 vs 4.5+/-4.3 cm, p>0.14). Contamination rates were lower for the intubating physician (2.3+/-0.5 vs 4.1+/-0.9 surfaces, p<0.001) and for all participants (2.8+/-0.7 vs 3.7+/-0.9 surfaces, p=0.05) when using a barrier. No other contamination rate changes were observed. Participants noted no differences in team performance (22.4+/-1.6 vs 20.8+/-1.8, p=0.5) but a slight trend towards higher workload with the plastic barrier (+9.5+/-7.7 vs -0.1+/-11.5, p=0.09). Conclusion: The use of a plastic drape as a patient barrier appears to reduce simulated virus contamination for HCWs, particularly for the intubation physician during a simulated cardiopulmonary arrest without affecting resuscitation performance. Perceived workload increases with the drape, and further studies are needed to substantiate these findings in larger samples and in different settings.

Clinical and Social Determinants of Change in Code Status among Patients Hospitalized with Covid-19

Background: Patients hospitalized with COVID-19 who develop cardiopulmonary arrest often have poor prognosis, prompting discussions with families about goals of care. The relationship between clinical and social determinants of code status change is poorly understood. Methods: This retrospective study included adult COVID-19 positive patients admitted to the intensive care unit with cardiac arrest in a multihospital center over the first 9 months of the pandemic (3/1/2020-12/1/2020). Data on medical and social factors was collected and adjudicated. Results: We identified 208 patients over the study timeline. The mean age was 63.7 ± 14.5 years and 54.3% (n=113) were male. The majority of patients with cardiopulmonary arrest had pulseless electrical activity (PEA) as their initial rhythm (91.3%, n=190). Code status was changed in 56.3% (n=117) of patients. The majority of COVID-19 patients with cardiac arrest were Hispanic (53.4%, n=111), followed by African American (27.9%, n=58), and White patients (13.5%, n=28). Race/ethnicity did not affect the rate of code status change. COVID-19 patients who had a code status change were statistically more likely to have a lower salary ($54,838 vs $62,374), have a history of stroke/transient ischemic attack (15.4 vs 4.4%, 18:4), or heart failure (28.2 vs 15.6%, 33:14), all with P<0.05. Patients with code status change had shorter courses of cardiopulmonary resuscitation (11.9 vs 16.9 minutes, P<0.05). Both groups had similar levels of aggressive care received including continuous renal replacement therapy, vasopressor and broad-spectrum antibiotics requirements. Insurance status, ethnicity, religion, and education did not lead to statistically significant changes in code status in COVID patients. Conclusion: Patients hospitalized with cardiopulmonary arrest and positive for COVID-19 are more likely to have a change in code status. This code status change is affected by cardiovascular comorbidities such as stroke and heart failure, along with lower income but not by insurance status, ethnicity, religion, and educational level.

COHORT STUDY IN PATIENTS WITH HYPERTENSIVE CRISIS: CHARACTERISTICS AND FOLLOW-UP AFTER 30 DAYS

Objective: Characterize patients with hypertensive crisis and evaluate occurrences 30 days after the hypertensive event. Design and method: Cohort study was performed with 583 patients treated between August 2020 and July 2021, from an Emergency Unit in a Hospital specializes in cardiology in São Paulo, Brazil. Inclusion criteria: 18 years old, systolic pressure > 180 mmHg and/or diastolic pressure > 120 mmHg, have telephone contact. A consulting on the electronic medical record was made to identify the elegible patients, whom after were included on the REDCap platform, and 30 days of the hypertensive event, an interview by telephone was made to investigate cardiovascular events. Results: The sample characteristics were: women (53%), 66.24(13.89) years, white ethnicity (78.7%), married (50.5%), high school (27.9%), retired people (77.5%), average [(mean(SD)] monthly income R$2384.6 (R$3438). The mean(SD) systolic/diastolic blood pressure, respectively, in emergency department was 189.74(17.46)/99.28(19.89) mmHg. Hypertensive emergencies were 63.8%, urgencies 27.4% and 8.7% were not possible to classify. The prevalent symptoms in the emergency department were: chest pain (41.2%), dyspnea (34.3%), nausea (11.7%), dizziness (10,4%), radiating pain (10.1%). The most used treatments were: anticoagulant (35.1%), diuretic (28.1%), analgesic (25.3%), ACE inhibitor (23.8.7%). Regarding the performance of tests: 85.6% underwent laboratory tests, 71% electrocardiogram, 36.3% echocardiogram and 30.5% computed tomography. After being treated at the emergency department, 60.1% of patients were discharged, 35.8% hospitalized, 3.8% transferred to other hospitals and 0,3% died. Regarding comorbidities, 97.7% had hypertension, 68.7% high cholesterol, 48.4% diabetes, 34.1% acute myocardial infarction, 25.1% heart failure, 19.6% kidney disease and 12% stroke. Regarding outcomes 30 days after the hypertensive event, 1.4% had some type of stroke, being 85.7% ischemic and 14.3% hemorrhagic, 2.3% had acute infarction of the myocardium, and 2% cardiorespiratory arrest. Also, 14.5% returned to a health service for high blood pressure, and 23.1% for others reasons like angina, bradycardia, aortic aneurysm, covid-19, acute pulmonary edema, epigastric pain, dyspnea. Besides we identify that 4.7% died within 30 days. Conclusions: The findings indicate the need for tertiary systematization, through outpatient follow-up programs for people with hypertensive crisis in emergencies units.

Improving Knowledge and Confidence in the Resuscitation of the Peripartum Patient Through Simulation

Rationale Per the CDC, Since the COVID-19 pandemic, at least 25,000 pregnant women have been hospitalized in the USA, with almost 4% requiring ICU admission. Care of the critically ill pregnant patient is distinct and complex due to changes in physiology, cardiovascular demands, and changes in immune system function. Though cardiac arrest in a pregnant patient is fortunately rare, a poor outcome can be devastating. Existing literature suggests that providers have knowledge deficits regarding recommended resuscitation practices of parturients (Cohen). Additionally, in simulated scenarios, teams exhibit significant deficiencies when scored on Advanced Cardiac Life Support (ACLS) metrics when responding to a simulated pregnant patient in cardiopulmonary arrest (Lipman). We developed a high fidelity simulation in accordance with the 2020 American Heart Association (AHA) ACLS guidelines, with the hope that deliberate practice would improve response to future resuscitation efforts (Panchal). Methods Between October and December 2021, we recruited eighty-six Internal Medicine residents at a large university hospital program to complete knowledge (multiple choice) and confidence (Likert scale) assessment before and after participation in a maternal arrest simulation. For the knowledge assessment component, we utilized questions relating to the resuscitation of a pregnant patient previously published in the anesthesia literature (Cohen). Questions were derived from high yield practices highlighted in the 2020 AHA guidelines for ACLS in the peripartum patient. Data were compared using a two-tailed t-test with unequal variance. Results Regarding clinical knowledge, participants showed significant improvement in correct patient positioning (+34.5%, P = 0.00), epinephrine dosing (+10.53%, P = 0.01), and timing of perimortem delivery (+22.5%, P = 0.00). Participants also had significantly improved confidence in approaching peripartum scenarios (+53%, P = 0.00) and general ACLS scenarios (+63%, P = 0.00). Conclusions Following participation in our simulation, residents demonstrated increased confidence and increased medical knowledge related to the resuscitation algorithm utilized when caring for pregnant patients. In the future, we plan to survey residents to determine if this knowledge and confidence persists or decays over time. (Table Presented).

Two Neonates With Cyanotic Heart Disease and COVID-19

We herein describe 2 neonates with cyanotic-type congenital heart disease and COVID-19. The first case was a boy at 37 weeks of gestational age (GA) who had cyanosis (SpO2 <90%) on the second day of the birth. He was transferred to the neonatal intensive care unit (NICU) for COVID-19 patients for infection treatment following a positive COVID-19 PCR test. Finally, he had a cardiopulmonary arrest, and cardiopulmonary resuscitation failed. The second case was a boy at 38 weeks of GA. His fetal echocardiography showed a hypoplastic right ventricle with decreased contractility, an atretic tricuspid valve, a hypoplastic pulmonary valve, and a small echogenic focus in the left ventricle. He was then diagnosed with COVID-19 and treated with Kaletra. Follow-up echocardiography showed a functioning shunt, a relieved pericardial effusion, and a normal ejection fraction. He was discharged a week later in good general condition.

If Your Heart Were to Stop: Characterization and Comparison of Code Status Orders in Adult Patients Admitted with COVID-19.

Aim: Our aim is to characterize code status documentation for patients hospitalized with novel coronavirus 2019 (COVID-19) during the first peak of the pandemic, when prognosis, resource availability, and provider safety were uncertain. Methods: This retrospective cohort study was performed at a single tertiary academic medical center. Adult patients admitted between March 1, 2020 and October 31, 2020 who tested positive for COVID-19 were included. Demographic and hospital outcome data were collected. Code status orders during this admission and prior admissions were trended. Data were analyzed with multivariable analysis to identify predictors of code status choice. Results: A total of 720 patients were included. The majority (70%) were full code and 12% were in do-not-attempt resuscitation (DNAR) status on admission; by discharge, 20% were DNAR. Age (p < 0.001), time in the intensive care unit (ICU) (p < 0.001), and having Medicaid (p = 0.04) compared to private insurance were predictors of DNAR. Fourteen percent had no code status order. Older age (p < 0.001), time in the ICU (p = 0.01), and admission to a teaching service (p < 0.001) were associated with having an order. Of patients with a prior admission (n = 227), 33.5% previously had no code status order and 44.5% had a different code status for their COVID-19 admission. Of those with a change, most transitioned to less aggressive resuscitation preferences. Conclusions: Most patients hospitalized with COVID-19 in our study elected to be full code. Almost half of patients with prepandemic admissions had a different code status during their COVID-19 admission, with a trend toward less aggressive resuscitation preference.

REassessment Campaign On VEterinary Resuscitation: Has the time come for horses?

9 Hoehne, S.N., Hopper, K. and Epstein, S.E. (2019) Prospective evaluation of cardiopulmonary resuscitation performed in dogs and cats according to the RECOVER guidelines. Keywords: horse;cardiopulmonary arrest;CPR;international guidelines;RECOVER EN horse cardiopulmonary arrest CPR international guidelines RECOVER 117 119 3 02/09/22 20220301 NES 220301 It is disconcerting that equine anaesthetic-related fatalities for elective procedures are nearly 10- to 20-fold more frequent than their small animal counterparts, and between 100- and 1000-fold more likely than human anaesthesia-associated fatalities (Brodbelt I et al i . 2008;Li I et al i . 2009;Dugdale I et al i . 2016;Laurenza I et al i . 2019). The RECOVER guidelines, published in the summer of 2012, aimed to systematically review the body of literature on CPR from a veterinary standpoint and to generate practical consensus guidelines to be used in dogs and cats. Horse, CPR, RECOVER, cardiopulmonary arrest, international guidelines. [Extracted from the article] Copyright of Equine Veterinary Education is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)