Report of the Association Between Multisystem Inflammatory Syndrome and Severe Myocarditis

Introduction: The people worldwide have been affected by severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) infection since its appearance in December, 2019. Kawasaki disease-like hyperinflammatory shock associated with SARS-CoV-2 infection in previously healthy children has been reported in the literature, which is now referred to as a multisystem inflammatory syndrome in children (MIS-C). Some aspects of MIS-C are similar to those of Kawasaki disease, toxic shock syndrome, secondary hemophagocytic syndrome, and macrophage activation syndrome. Case Presentation: This study reported an 11-year-old boy with MIS-C presented with periorbital and peripheral edema, abdominal pain, elevated liver enzymes, severe right pleural effusion, moderate ascites, and severe failure of right and left ventricles. Conclusion(s): Due to the increasing number of reported cases of critically ill patients afflicted with MIS-C and its life-threatening complications, it was recommended that further studies should be carried out in order to provide screening tests for myocardial dysfunction. Adopting a multidisciplinary approach was found inevitable.Copyright © 2023, Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

Post-Covid Myocarditis Simulating Acute Coronary Syndrome

Background: Acute myocarditis corresponds to an acute inflammation of the myocardium whose origin is most often viral. Several viruses can be incriminated to note the parvovirus B19, the virus herpes of the group 6 and to a lesser degree the virus of the hepatitis C (VHC) [18,19]. Since 2019 and with the discovery of SARS COV2 some cases of myocarditis associated with covid have been noted, this last association is rare and is present in only 5% of cases [8]. The diagnosis of myocarditis is sometimes difficult and can lead to confusion with acute coronary syndrome, especially in cases of ST-segment elevation on the EKG, hence the interest of magnetic resonance imaging, which has made it possible in recent years to reduce the rate of unnecessary coronary angiography, especially in the case of young subjects with no cardiovascular risk factors. in this context we report the case of a 33 year old patient with no cardiovascular risk factors and no medical or surgical antecedents who was admitted to the emergency department for the management of acute chest pain related to acute post-covid myocarditis, the patient was initially admitted to the cardiology intensive care unit where he was put in condition and under analgesic treatment and under therapeutic protocal of covid 19 and under anticoagulation based on low molecular weight heparin at preventive dose with a good clinical evolution he was transferred thereafter to the clinical cardiology then declared outgoing under treatment of covid 19 with an appointment of control in 1 month.

"working in the dark but expected to be an expert": Reflecting on critical care preparations for COVID-19

Introduction: Before spring 2020, many healthcare organisations did not possess detailed plans for the expansion and delivery of critical care during a pandemic. Furthermore, there was little directly-relevant individual or institutional experience to draw upon. Local, national and international guidance was drawn up rapidly and subject to frequent revision.1 Reflecting on these challenges, we designed a study to explore critical care and anaesthetic doctors' experiences of preparation for the provision of critical care services in the first wave of COVID-19. Objective(s): 1. To establish what factors facilitated and hindered the expansion and delivery of critical care services. 2. To identify important learning points for the provision of critical care during future pandemics. Method(s): We conducted semi-structured interviews with medical staff from the anaesthesia and critical care departments of our hospital, a tertiary centre with general and cardiothoracic intensive care units, including an ECMO service. We classified participants into two groups;1. Decision makers - individuals instrumental in shaping the critical care response, e.g., clinical directors and college tutors. 2. Staff members - clinicians working within the departments, including consultants and trainees. Thirteen interviews were conducted with 15 participants: eight decision makers and seven staff members. The interviews were recorded, transcribed and anonymised. We manually coded transcripts, and carried out an inductive thematic analysis.2 Results: Eight themes were generated from our analysis: * Problem solving with simulation: simulation exercises allowed experienced clinicians to troubleshoot practical issues and helped staff to prepare for unfamiliar tasks. * A sense of togetherness: staff reported that the "all hands-on deck" ethos was protective against fatigue, although this was short-lived. * Delayed and changing guidance: frequent guideline changes created confusion and anxiety. * Leading from the front: leaders with a clinical role were perceived more positively than those operating at a distance from the "shop-floor". * Coordination, collaboration and compromise: departments that accommodated each other's needs fostered productive inter-departmental relationships. * Insecure supply chains: staff took their own measures to ensure PPE availability, including acquisition of items outside NHS supply chains. * Constant communication: rapid methods of personal communication, e.g., WhatsApp were effective, although "WhatsApp fatigue" was endemic. * Balancing skill mix and fatigue: flux in workload required dynamic staff allocation. Underutilised staff groups created frustration and low morale in overworked colleagues. Conclusion(s): The threat to health and society from pandemic events is expected to increase over time.3 We should take this opportunity to gather experiences from those involved in the COVID-19 pandemic to guide future preparations. In early 2020, decision makes in local hospitals were operating with unclear guidance from external agencies. Our data, obtained in the summer of 2021 demonstrates that individual and departmental reflections had already resulted in processes being refined in later waves of COVID-19. Whilst the exact nature of future pandemics will vary, some elements of preparation will remain consistent. We recommend that plans for pandemic management should aim to reduce workload and target the most effective interventions, including by addressing the themes outlined above.

Successful Inter-Professional Team (IPT) collaboration in the care of peripartum women with COVID-19 on Extracorporeal Membrane Oxygenation (ECMO)

Objectives: To describe the IPT collaborative approach for peripartum women with COVID-19 on ECMO and report the intervention outcomes. Method(s): A retrospective electronic health record review was performed from January 2020 through January 2022. All peripartum women on ECMO with COVID19 admitted to the cardiothoracic intensive care unit (CTICU) were included. The IPT came together to coordinate peripartum care and delivery. An algorithm was created to outline the roles and workflow in the care of these patients. The outcomes evaluated included delivery method, timing, and location, maternal survival at discharge, maternal ICU length of stay (LOS), and neonatal survival Results: Thirteen Peropartum women were placed on ECMO (5 antepartum and 8 postpartum, ages 27-42). None had been vaccinated against COVID-19. All received femoral vessel cannulation (11 venovenous and 2 venoarterial). Four patients underwent Caesareansection delivery while on ECMO. Maternal survival to hospital discharge was 84.6%. All neonates survived with COVID-19 negative status. Conclusion(s): The collaborative IPT approach with a structured algorithm facilitated survival outcomes. This report adds to the limited literature on peripartum. ECMO and provides insights to consider in planning for the care of these patients.

Venovenous extracorporeal membrane oxygenation and late ductal stenting for infant with transposition of the great arteries, pulmonary stenosis and SARS, -CoV-2 pneumonia

Introduction: The SARS-CoV-2 pandemic has affected medical decision-making in all practice areas, including the pediatric cardiac intensive care unit (CICU), sometimes necessitating the use of innovative management strategies. Venovenous extracorporeal membrane oxygenation (VV-ECMO) and, particularly, late ductal stenting are infrequently applied interventions in the CICU. Here we present a critically ill infant with d-transposition of the great arteries (d-TGA), ventricular septal defect (VSD), pulmonary stenosis (PS), and patent ductus arteriosus (PDA), in which VV-ECMO and late ductal stenting were utilized successfully in the setting of active SARS-CoV-2 infection to treat worsening PS and pulmonary venous desaturation, thereby delaying surgical intervention and its associated risks during active infection. Case Description: A 3 month old male with d-TGA, VSD, and PS, initially managed with a balloon atrial septostomy at birth, was admitted to the CICU after presenting with respiratory distress and hypoxemia. He was found to be SARS-CoV-2 positive, requiring only nasal cannula initially. Admission echocardiogram demonstrated known d-TGA, VSD, severe pulmonary stenosis (peak gradient 95-110mmHg), unrestrictive atrial communication, and preserved systolic function. A tiny, hemodynamically insignificant PDA was also noted. While admitted, the patient exhibited intermittent, severe desaturations requiring escalating respiratory support. He was started on a prostaglandin infusion with aim to promote additional pulmonary blood flow through the PDA, thereby limiting the severity and frequency of desaturations. However, the patient ultimately became severely hypoxemic, despite multiple interventions to improve oxygenation. Echocardiogram at this time demonstrated preserved ventricular function, so the decision was made to escalate to VVECMO therapy. Following ECMO cannulation, the patient's hypoxemia quickly resolved, and he remained hemodynamically stable. Given the persistence of his PDA and the desire to avoid the risks of cardiac surgery in the setting of acute COVID infection, percutaneous intervention to augment pulmonary blood flow was attempted. Despite its diminutive size, his PDA was able to be successfully cannulated and stented the day after ECMO initiation. He was able to be quickly weaned from ECMO support and was decannulated the following day. He was subsequently extubated and ultimately discharged home with planning for definitive surgical intervention underway. Discussion(s): Here we present an interesting case of an infant with d-TGA, VSD, PS, and PDA in which VV-ECMO and PDA stenting were successfully applied to treat acute hypoxemia in the setting of SARS-CoV-2 infection and severe pulmonary stenosis. These therapies may be considered in appropriate patients for whom the risks of cardiac surgery are significant.

Tropheryma Whipplei Endocarditis: A Diagnosis In Hindsight

Description of case: We report a case of Tropheryma whipplei endocarditis, a rare cause of bloodculture-negative infective endocarditis (BCNIE). Due to its rarity and lack of availability of diagnostic tests in district hospitals, the diagnosis remains challenging. The objective of this case report is to increase physician awareness of this pathogen. A 61-year-old man presented to the Emergency Department with central chest pain at rest. A 12-lead ECG demonstrated ST- segment depression in V4-V6 leads, and his serial troponin levels were raised. He was commenced on treatment for acute coronary syndrome and transferred to the Coronary Care Unit. An echocardiogram showed a 15mm x 15mm vegetation in the aortic valve with mild aortic regurgitation. His initial microbiology workup, which included two sets of blood cultures (pre-antibiotics), MRSA screen & COVID-19 PCR, was negative. He was transferred to a cardiothoracic centre four days later. Pre-operative CT coronary angiogram showed severe three vessel coronary artery disease. He underwent triple coronary artery by-pass grafts and tissue aortic valve replacement. During early post-op recovery, he had fever episodes and an elevated C-reactive protein of 280 mg/L but normal white cell counts. He was treated with intravenous Tazocin for hospital-acquired pneumonia and discharged on doxycycline. Two weeks post-discharge, he had a positive 16S/18S PCR for Tropheryma whipplei on molecular analysis of the aortic valve. He was treated for Whipples endocarditis with a 4-week course of IV Ceftriaxone, followed by a 12-month course of oral Cotrimoxazole. The patient has reported doing well since the surgery. Discussion(s): Molecular assay with PCR of the heart valve is the mainstay of diagnosing Whipple's endocarditis. There have been 5 previously reported cases of Whipple's endocarditis in the United Kingdom in our knowledge. It is likely under-reported because of a reliance on tissue diagnosis. Preceding intestinal manifestations and arthralgia should raise its clinical suspicion for timely workup. Physician awareness of Whipple's Endocarditis is paramount in investigating for this pathogen.

Atrio-Ventricular Conduction Abnormalities in Multisystem Inflammatory Syndrome in Children

Purpose of study Since mid-April 2020 in Europe and North America, clusters of pediatric cases with a newly described severe systemic inflammatory response with shock have appeared. Patients had persistent fevers >38.5 C, hypotension, features of myocardial dysfunction, coagulopathy, gastrointestinal symptoms, rash, and elevated inflammatory markers without other causes of infection. The World Health Organization, Centers for Disease Control, and Royal College of Paediatrics associated these symptoms with SARS-CoV-2 as multisystem inflammatory syndrome in children (MIS-C). Cardiac manifestations include coronary artery aneurysms, left ventricular systolic dysfunction evidenced by elevation of troponin-T (TnT) and pro-B-type naturietic peptide (proBNP), and electrocardiogram (ECG) abnormalities. We report the clinical course of three children with MIS-C while focusing on the unique atrioventricular (AV) conduction abnormalities. Case #1:19-year-old previously healthy Hispanic male presented with abdominal pain, fever, and non-bloody diarrhea for three days. He was febrile and hypotensive (80/47 mmHg) requiring fluid resuscitation. Symptoms, lab findings, and a positive COVID-19 antibody test were consistent with MIS-C. Methylprednisolone, intravenous immunoglobulin (IVIG), and enoxaparin were started. He required epinephrine for shock and high flow nasal cannula for respiratory distress. Initial echocardiogram demonstrated a left ventricular ejection fraction (LVEF) of 40% with normal appearing coronaries. Troponin and proBNP were 0.41 ng/mL and proBNP 15,301 pg/mL respectively. ECG showed an incomplete right bundle branch block. He eventually became bradycardic to the 30s-50s and cardiac tracing revealed a complete AV block (figure 1a). Isoproterenol, a B1 receptor agonist, supported the severe bradycardia until the patient progressed to a type 2 second degree AV block (figure 1b). A second dose of IVIG was administered improving the rhythm to a type 1 second degree AV block. An IL-6 inhibitor, tocilizumab was given as the rhythm would not improve, and the patient soon converted to a first-degree AV block. Cardiac magnetic resonance imaging showed septal predominant left ventricular hypertrophy and subepicardial enhancement along the basal inferior/anteroseptal walls typical for myocarditis. Case #2: 9-year-old previously healthy Hispanic male presented after three days of daily fevers, headaches, myalgias, diffuse abdominal pain, and ageusia. He was febrile, tachycardic, and hypotensive (68/39 mmHg). Hypotension of 50s/20s mmHg required 3 normal saline boluses of 20 ml/kg and initiation of an epinephrine drip. Severe hypoxia required endotracheal intubation. After the MIS-C diagnosis was made, he was treated with IVIG, mehtylprednisolone, enoxaparin, aspirin, and ceftriaxone. Due to elevated inflammatory markers by day 4 and patient's illness severity, a 7-day course of anakinra was initiated. Initial echocardiogram showed mild tricuspid and mitral regurgitation with a LVEF of 35-40%. Despite anti-inflammatory therapy, troponin and proBNP were 0.33 ng/mL and BNP of 25,335 pg/mL. A second echocardiogram confirmed poor function so milrinone was started. Only, after two doses of anakinra, LVEF soon normalized. Despite that, he progressively became bradycardic to the 50's. QTc was prolonged to 545 ms and worsened to a max of 592 ms. The aforementioned therapies were continued, and the bradycardia and QTc improved to 405 ms. Patient #3: 9-year-old African American male presented with four days of right sided abdominal pain, constipation, and non-bilious non-bloody emesis. He had a negative COVID test and unremarkable ultrasound of the appendix days prior. His history, elevated inflammatory markers, and positive COVID- 19 antibody were indicative of MIS-C. He was started on the appropriate medication regimen. Initial ECG showed sinus rhythm with normal intervals and echocardiogram was unremarkable. Repeat imaging by day three showed a decreased LVEF of 50%. ECG had since changed to a right bundle branch block. Anakinra as started and steroid dosing was increased. By day 5, he became bradycardic to the 50s and progressed to a junctional cardiac rhythm. Cardiac function normalized by day 7, and anakinra was subsequently stopped. Thereafter, heart rates ranged from 38-48 bpm requiring transfer to the pediatric cardiac intensive care unit for better monitoring and potential isoproterenol infusion. He remained well perfused, with continued medical management, heart rates improved. Methods used Retrospective Chart Review. Summary of results Non-specific T-wave, ST segment changes, and premature atrial or ventricular beats are the most often noted ECG anomalies. All patients initially had normal ECGs but developed bradycardia followed by either PR prolongation or QTc elongation. Two had mild LVEF dysfunction prior to developing third degree heart block and/or a junctional escape rhythm;one had moderate LVEF dysfunction that normalized before developing a prolonged QTc. Inflammatory and cardiac markers along with coagulation factors were the highest early in disease course, peak BNP occurred at approximately hospital day 3-4, and patient's typically had their lowest LVEF at day 5-6. Initial ECGs were benign with PR intervals below 200 milliseconds (ms). Collectively the length of time from initial symptom presentation till when ECG abnormalities began tended to be at day 8-9. Patients similarly developed increased QTc intervals later in the hospitalization. When comparing with the CRP and BNP trends, it appeared that the ECG changes (including PR and QTc elongation) occurred after the initial hyperinflammatory response. Conclusions Although the mechanism for COVID-19 induced heart block continues to be studied, it is suspected to be secondary to inflammation and edema of the conduction tissue. Insufficiency of the coronary arterial supply to the AV node and rest of the conduction system also seems to play a role. Although our patients had normal ECG findings, two developed bundle branch blocks prior to more complex rhythms near the peak of inflammatory marker values. Based on the premise that MIS-C is a hyperinflammatory response likely affecting conduction tissue, our group was treated with different regimens of IVIG, steroids, anakinra, and/or tocilizumab. Anakinra, being an IL-1 inhibitor, has been reported to dampen inflammation in viral myocarditis and tocilizumab has improved LVEF in rheumatoid arthritis patients. Based on our small case series, patient's with MISC can have AV nodal conduction abnormalities. The usual cocktail of IVIG and steroids helps;however, when there are more serious cases of cardiac inflammation, adjuvant immunosuppresants like anakinra and toculizumab can be beneficial. (Figure Presented).

Impact of early readmission to the cardiac ICUon in-hospital mortality and hospital length of stay in 30,942 cardiac patients

Background: The need for cardiac intensive care unit (ICU) beds remains high in order to monitor and treat emergency patients with severe cardiovascular diseases, particularly during the COVID-19 pandemic. Therefore, timely discharge strategies from the cardiac ICU to peripheral wards are crucial to meet the increasing demand for cardiac ICU beds. Early patient transfer from ICU to the peripheral ward may result in worsening of the patient's clinical condition and outcome with readmission to the ICU, while late transfer may require prolonged expert care and generate unwanted costs. Purpose(s): To investigate whether unplanned readmission of cardiac patients to the cardiac ICU within 72 hours after the index ICU stay is associated with increased mortality risk (primary outcome) and prolonged total hospital length of stay (LOS) (secondary outcome), as well as to identify predictors of ICU readmission in cardiac patients. Method(s): Adult patients who were admitted to the cardiac ICU due to a primary cardiac admission diagnosis at a tertiary care center between 2003 and 2021 were included. Outcomes were analysed with multivariable regression models adjusted for 26 a priori defined variables on patient demographics, underlying comorbidity levels, ICU procedures and administered ICU drugs. Result(s): 30,942 cardiac patients were included, out of whom 1,499 patients (4.84%) were readmitted to the cardiac ICU within 72 hours. 1,023 (68.2%) of readmitted patients were male. Compared to non-readmitted patients, readmitted patients were older, had more underlying comorbidities (Charlson Index), had more severe disease courses (SOFA score, TISS, APACHE II score and SAPS), as well as required more frequently vasopressor therapy, renal replacement therapy and coronary angiographies (Table 1). Readmission to the cardiac ICU was associated with higher in-hospital mortality risk (Odds Ratio 7.52, 95% Confidence Interval (CI) 4.15-12.27, P<0.001) and prolonged hospital LOS (Incidence Rate Ratio 1.56, 95% CI 1.15-1.58, P<0.001). Patients who were readmitted to the ICU had been discharged 18% earlier during the index ICU stay compared to non-readmitted patients (P<0.001). Of note, readmitted and nonreadmitted patients had similar vital parameters at time of ICU discharge after their index ICU stay. During the index ICU stay, non-readmitted patients were prescribed more beta blockers (65.3% vs. 45.8%), ACE inhibitors (37.0% vs. 27.2%) and blood transfusions (10.7% vs. 7.7%). Conclusion(s): Early readmission to the cardiac ICU was associated with increased in-hospital mortality and prolonged hospitalisation. Readmitted patients had been discharged earlier from their index ICU stay and required more comprehensive critical care. ICU discharge strategies should optimally be based on objective patient assessments to facilitate patient safety and shorten hospital length of stay. Artificial intelligence-based algorithms may support clinicians with safe ICU discharge. (Table Presented).

Takostubo syndrome during the COVID-19 pandemic: A single center experience

Background: Takotsubo syndrome (TTS) is a major psychosomatic cardiovascular disease. It has been suggested that in the current pandemic of coronavirus disease 2019 (COVID-19), the psychological, mental and physical consequences of the restrictive measures taken to combat the pandemic, is likely to make individuals more vulnerable to TTS. Purpose(s): In our study, we investigated whether TTS incidence has increased during the COVID-19 era in a major tertiary hospital in Athens. Method(s): The study population included 316 consecutive patients admitted to the Coronary Care Unit (CCU) of our hospital throughout the 16 months (March 2020-June 2021) pandemic COVID-19 with the initial diagnosis of acute coronary syndrome (ACS). For comparison 342 patients with ACS admitted to CCU during the 16 months period preceding the COVID- 19 pandemic (November 2018-February 2020) were analyzed. All ACS patients underwent coronary angiography within 48 hours of admission. A prerequisite for admission to CCU of all ACS patients during the pandemic period was a negative reverse transcription-polymerase chain reaction test for COVID-19. Result(s): The vast majority (95%) of TTS patients were women and the mean age was 71.1+/-15.4 years. There was a significant increase in the incidence of TTS during the 16 months COVID-19 period (6.3%, i.e., 20 TSS among 316 ACS patients) compared with the corresponding incidence of TTS 16 months prior the pandemic (2.6%, i.e., 9 TTS among 342 ACS patients) [Figure 1]. The incidence rate ratio comparing the TTS cases of COVID-19 pandemic period to the pre-pandemic period was 2.22 (95% CI: 0.97-5.54, p=0.021). Conclusion(s): COVID-19 pandemic was associated with a significant increase in the incidence of TTSprobably due to the additional psychological burden imposed by the pandemic. (Figure Presented).

Impact of COVID 19 on bacterial respiratory isolates (2018-2021) from a UK tertiary cardio-thoracic ICU

Aim: To study the impact of COVID-19 admissions during 1st and 2nd surges on bacteriology of ICU respiratory isolates. Method(s): Retrospective time trend analysis of bacterial respiratory isolates from a single centre, tertiary cardiothoracic ICU (CT-ICU) from patients admitted from Jan 2018- June 2021. We compared pre-COVID-19 (January 2018- March 2020) and COVID-19 periods (April 2020- June 2021) and surge periods (surge 1: March 2020- June 2020, surge 2: January- March 2021) to similar time frames in previous years. Chi-square test used to compare proportions. Result(s): 4974 respiratory isolates (Sputum-4230, BAL-563, ET secretions-181) included. During surge 2, culture positivity and gram-negative rates tripled from baseline (20% to 75%;p<0.05). Comparing the pre- pandemic to pandemic period, rates of Klebsiella sp, Acinetobacter sp and Stenotrophomonas sp increased from 12% to 21.3%, 2.4% to 6.2% and 10.5% to 14.3% respectively, while Pseudomonas sp dropped from 30.7% to 23.1% (all p<0.05). MDR Pseudomonas increased significantly from 38.9% to 47.9% (p<0.05), with a non-significant increase in MRSA (5.2% to 9.3%;p=0.34) and MDR enterobacterales (22.6% to 23%;p=0.48). Conclusion(s): This is the first report from a UK CTICU showing a marked epidemiological shift in the bacteriology of respiratory isolates in terms of organism profile, increase in culture positivity and MDR Pseudomonas rates during the pandemic. Analyzing trends on longevity of the findings will help guide changes to infection control and antibiotic policies. This emphasizes the importance of unit specific ecology in choosing appropriate timely antimicrobial therapy and therefore improving patient outcome.

Evaluation of Time From Pre-Hospital Symptom Onset to Angiography on Coronary Artery Occlusion Status and Outcomes in Patients Presenting With NSTE-ACS

Introduction: Current guidelines for invasive coronary angiography (ICA) in patients presenting with NSTE-ACS outline two treatment pathways: early (within 24 hours [hrs]);or late (>24 hrs). Time of hospital admission is used as the start time, however, we hypothesize that pre-hospital time of symptom onset may be a more optimal starting time. This study was designed to test optimal symptom onset-to-angiography time (OAT) and its association with the presence of coronary occlusion and adverse outcomes. Method(s): Secondary data analysis in NSTE-ACS patients (pre-COVID-19) who underwent ICA. We tested the optimal cutoff point of OAT in classifying coronary occlusion using Youden-index analysis. We tested the association of OAT and in-hospital complication (i.e., myocardial infarction [MI] after admission, unplanned transfer to the cardiac intensive care unit, pulmonary edema, cardiogenic shock, dysrhythmia with intervention) and hospital length of stay [LOS]) using regression models. Result(s): In 163 patients: 124 (76%) had an occluded artery;37 (23%) had an in-hospital complication. Overall, the mean OAT was 26+/-22 hrs (24+/-22 vs. 31+/-21, with and without occluded artery, respectively), and the median LOS was 55 hrs. The Youden-index optimum OAT cutoff point was 13.4 hrs. In the two logistic models, the adjusted OAT was associated with the presence of coronary occlusion (Figure A). OAT, as a continuous variable, was associated with LOS (beta=0.64, 95% CI 0.08-1.21, p=0.025), no other in-hospital complications were significant (Figure B) Conclusion(s): In patients presenting with NSTE-ACS, OAT at both 13.4 and <24 hrs is a significant predictor of the presence of coronary artery occlusion. Every hour of delayed OAT was associated with a prolonged hospital LOS 0.64 hrs (38 min). Symptom onset appears to be an important starting point in determining optimal timing of ICA in patients with NSTE-ACS, but requires further study with a large sample of patients.

To Cool or Not to Cool for Brugada Syndrome

Brugada syndrome (BrS) is an autosomal dominant genetic disorder, characterized by abnormal findings on the electrocardiogram (ECG) in conjunction with an increased risk of ventricular tachycardia (VT) and sudden cardiac death. Triggers of the ECG pattern and VT in BrS include fevers, drugs, and electrolyte abnormalities. This case reports a unique treatment approach of targeted temperature management (TTM) to treat persistent fevers and VT secondary to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in a patient with BrS. We report the case of a 23 year old male with history of BrS with an intracardiac defibrillator (ICD) who presented to the hospital with chest pain and a runny nose. Vital signs upon admission were notable for temperature of 38.2 C, heart rate of 155 beats/minute and blood pressure of 134/110 mmHG. Laboratory values on admission revealed a normal complete blood count, a normal basic metabolic panel, an elevated c-reactive protein (CRP) of 19.1, and PCR confirmed SARS-CoV-2 infection, with a cycle threshold value of 16.4. ECG revealed a type 2 Brugada pattern. Interrogation of his ICD revealed 28 device shocks on the morning of admission, with each episode beginning with a premature ventricular contraction inciting polymorphic VT. His transthoracic echocardiogram (TTE) discovered a newly reduced ejection fraction of 25% with global hypokinesis. Persistent VT prompted intubation and sedation with propofol. Repeat SARS-CoV-2 inflammatory markers revealed a rising CRP of 244. Therapies included acetaminophen around the clock and remdesivir and dexamethasone to target COVID-19. During the first two days in the cardiac intensive care unit (CICU), fevers persisted with Brugada pattern on ECG. Given the potential for recurrent VT, targeted TTM was initiated using the Arctic Sun external cooling device to maintain normothermia to 37 C. After 5 days of no VT, fever curve, Brugada pattern, and inflammatory markers improved. TTM was discontinued, COVID-19 therapies were completed, and he was extubated. His cardiac function normalized on repeat TTE and he was discharged home. We report a unique case of TTM use in a patient with BrS with VT secondary to infection with COVID-19, as a way to decrease fevers and prevent further triggering of VT.

Interdisciplinary Assessment of Quality of Dying and Death in a Pediatric Cardiac Intensive Care Unit during the Covid-19 Pandemic

BACKGROUND AND AIM: Cardiac Intensive Care Unit (CICU) interdisciplinary staff play an integral role supporting children and families at end-of-life (EOL). We examined staff's perceptions of quality of dying and death (QODD) before and during the COVID-19 pandemic. METHOD(S): We performed a cross-sectional survey of staff involved in all CICU deaths 6.30.2019-7.1.2021. Staff completed demographic questions, the pediatric-QODD instrument (standardized to 100), rated quality of the moment of death and the 7 days prior (0-terrible, 10-ideal). Intense EOL care included mechanical support, open chest, or cardio-pulmonary resuscitation. RESULT(S): 713 surveys were completed (72% response rate) for 60 deaths, including 455 (64%) during the pandemic, 246 (35%) from nurses, 208 (29%) medical providers, and 259 (36%) allied-health staff. Clinical experience varied (42% <=5years). 33 patients (55%) were receiving intense care. Median scores were 93 for QODD [IQR 84, 97], 9 for moment of death (IQR 7, 10), and 5 (IQR 2, 7) for the 7 days prior. QODD scores were 3 points lower for nursing and allied health compared to medical providers (p<0.001) and for staff with <5years of clinical experience compared to >15years (p=0.002)(figure). Intense care was associated with lower scores for moment of death and 7 days prior (both, p=0.001). Responses pre-COVID-19 and during the pandemic were similar (figure). CONCLUSION(S): Overall CICU staff positively perceived QODD with lower scores for quality of the 7 days prior to death. Perceptions varied by staff characteristics and medical intensity with no influence from the pandemic. Our data guide strategies to meaningfully improve staff wellbeing and EOL experiences. (Figure Presented).

Improving Picu Patient Safety by Implementing a Robust Supply Chain Management Process

INTRODUCTION: With recent gaps in the timely availability of critical pieces of intensive care-specific equipment, clinical care has been affected by the COVID-19 pandemic. Presently complex systems are in place for the essential supplies unique to the pediatric intensive care unit (PICU), such as endotracheal tube sizes, central line supplies, etc. A robust multidisciplinary process can ensure an adequate and timely supply of critically important ICU equipment. This quality improvement initiative's goal was to establish a supply chain management (SCM) process map to reduce elements of inefficiency and acquire resources that would enhance patient safety. METHOD(S): Our goal was to redesign the process that ensures an adequate supply of critical equipment in the PICU, ensures adequate communication during supply chain breakdowns, and minimizes waste by six months. We provided education to increase the patient safety event report (PSER) entries for missing supplies (process metric). We developed an SCM process map (PM) through collaboration with nursing, physicians, and central supply and identified key PM steps. Adherence >50% to the three key steps in the event of missing supplies (process metric) and a decline in days with missing critical supplies was the outcome metric (75% by 6 months). RESULT(S): In our 12-bed pediatric and cardiac intensive care unit, PSERs with missing critical supplies were measured over six months. 21 PSERs were reported compared to 9 over the preceding 2-year period. The three key steps identified in the PM were the Central Issues (CI) specialist sent a daily email to the group (nurse manager (NM), physician, CI Manager, Special order manager) regarding missing supplies. The 2nd step was the expected arrival time (ETA) provided by the special-order manager to the NM within 24 hours for back-ordered items. The 3rd step was a replacement item is expeditiously ordered if the ETA for the item is not acceptable to the PICU team. The three measures adhered to 79% of the time, and the number of days with missing critical supplies decreased to 9 in 6 months. CONCLUSION(S): Implementation of SCM strategies in healthcare has been slow despite the essential need. SCM PM increases productivity in critical care by enhancing safety, shortening product/service cycles, and can lower inventory costs.

Bedside Nurse Staffing on Patient Outcomes and Throughput in a Pediatric Cardiac Intensive Care Unit

INTRODUCTION: Healthcare throughput is the progression of patients from admission to discharge, limited by bed occupancy and hospital capacity. This study examines Heart Center throughput, cascading effects of limited beds, transfer delays, and nursing assignments on outcomes utilizing elective surgery cancellation during the initial COVID-19 pandemic wave. METHOD(S): Nursing assignments, patient data, and transfers were collected. Elective surgery cancellation was March-May 2020. Heart Center occupancy (Stepdown Unit and Cardiac Intensive Care Unit), transfer delays, and patient outcomes were analyzed controlling for patient factors, surgical risk, staffing, and time effects. Setting(s): Retrospective single-center study Patients: Heart Center admissions January 1, 2018 - December 31, 2020. RESULT(S): There were 2,589 patients, median age 5 months (6 days-4 years), 1,543 (60%) surgical, 1,046 (40%) medical. Mortality was 3.9% (n=101), median stay 5 days (3- 11 days), median 1:1 nursing assignments 40% (33%-48%), median occupancy 54% (43%-65%) for Stepdown Unit and 81% (74%-85%) for Cardiac Intensive Care Unit. Every 10% increase in Stepdown Unit occupancy had a 0.5-day increase in Cardiac Intensive Care Unit stay (p=0.044), 2.1% increase 2-day readmission (p=0.023), and 2.6% mortality increase (p< 0.001). Every 10% increase in Cardiac Intensive Care Unit occupancy had 3.4% increase in surgical delay (p=0.016) and 6.5% increase in transfer delay (p=0.020). Elective surgery cancellation reduced high occupancy days (23% to 10%, p< 0.001), increased 1:1 nursing (34% to 55%, p< 0.001), decreased transfer delays (19% to 4%, p=0.008), and decreased mortality (3.7% to 1.5%, p=0.044). CONCLUSION(S): Cancelation of elective surgery was associated with increased 1:1 nursing assignments and decreased mortality. Increased Cardiac Stepdown Unit occupancy resulted in longer Cardiac Intensive Care Unit stay, and increased Cardiac Intensive Care Unit occupancy increased transfer and surgical delays. Additional studies are need to understand the interaction of staffing and outcomes.

Prognostic Markers of Geriatric Patients in the Icu with Respiratory Failure Secondary to Covid-19

INTRODUCTION: SARS-CoV-2 (COVID-19) has continued to be a public health emergency, affecting almost 450 million people worldwide, with a disproportionate significant disease burden in the elderly community. Our objective is to provide population specific prognostic markers upon description of demographic factors, clinical characteristics, diagnostic variables, treatment characteristics and outcome variables in critically ill geriatric patients with acute hypoxic respiratory failure due to COVID-19 infection. METHOD(S): This is a retrospective chart review of 165 patients admitted to a single institution's medical and cardiovascular intensive care unit between the dates of March 01, 2020 and December 31, 2020. Inclusion criteria was patients age greater than or equal to 65 years, documented positive COVID-19 polymerase chain reaction test result and a diagnosis of acute hypoxic respiratory failure. Our primary end point evaluated the rate of mortality in relation to multiple variables during intensive care unit admission. RESULT(S): Of 165 patients, 45 patients were excluded. Of the remaining 120 patients, 41 were females and 79 were males. Four independent risk factors are significantly associated with higher odds of mortality for the concerned population: presence of solid tumor (AOR: 0.002, 95% CI: < 0.001, 0.31), maximum value of PaCO2 (AOR: 1.094, 95% CI: 1.029, 1.163), Charlson comorbidity index (AOR: 2.962, 95% CI: 1.59, 5.52), and use of diuretics (AOR: 0.015, 95% CI: < 0.001, 0.49). CONCLUSION(S): It was to our surprise that the mortality rate among those intubated was not statistically significant. However, it has been shown in prior research, which is in alignment with our results, that mechanical ventilation does not necessarily result in increased mortality. Certain factors were found to be poor prognostic markers during intensive care unit admission, which may predict a higher rate of mortality in those patient populations.

Staphylococcus Aureus Infection Risk in Intensive Care Unit Patients during the Covid-19 Pandemic

INTRODUCTION: Although Staphylococcus aureus is known to be a poor prognostic factor in coronavirus disease of 2019 (SARS-CoV-2 or COVID-19), it is unclear if COVID-19 increases the risk of S. aureus infections. The purpose of this study is to give healthcare providers a better understanding of the pharmacological risk factors that may predispose patients to a S. aureus co-infection in COVID-19 positive patients. METHOD(S): This retrospective chart review included adult patients treated at a Spectrum Health medical or cardiothoracic ICU between October 2020 and November 2021. To be included in the exposure arm of the analysis, patients had to have a positive culture for S. aureus. A chi-square analysis was utilized for the primary outcome while a logistic regression was used to uncover possible risk factors for S. aureus in COVID-19 patients. Overall, S. aureus infections were compared between patients with and without COVID-19 with a secondary analysis that was done for patients who had been treated with tocilizumab or dexamethasone. RESULT(S): A total of 406 patients were included;96 patients were positive for S. aureus, and 310 patients remained negative throughout their admission. COVID-19 patients were more likely to acquire a S. aureus infection than their COVID-19 negative counterparts (p < 0.0001). Neither tocilizumab nor dexamethasone use were statistically significant in increasing risk of S. aureus co-infection. CONCLUSION(S): COVID-19 patients are more likely to acquire S. aureus infections than their COVID-19 negative counterparts. Dexamethasone and tocilizumab use were not associated with increased incidence of S. aureus infections in COVID-19 patients.

A More Unique Than Rare Myopericarditis - a Case Report

A 33yo man, ex-convict, with a history of IV substance abuse, without previous cardiological history, was admitted at our emergency department in the clinical context of an acute pericarditis, intermittent fever in the last 10 days and non-itchy maculo-papular erythema of palms and thorax. EKG documented a diffuse ST-segment elevation, chest X-rays revealed a bilateral pleural effusion and echocardiography documented a normal biventricular morphology and function, normal valvular function, and a circumferential pericardial effusion (14mm). The patient was admitted at our Cardiology Unit after a negative PCR SARS-CoV-2 test. Blood chemistry showed elevated WBC count with an important neutrophilia (24.000/mm3;90% neutrophils), elevated TnI-HS (236 ng/L;n.v. <18 ng/L), elevated C-reactive protein (340 mg/L;n.v. < 5mg/L). A classic anti-inflammatory therapy was set up with indomethacin + colchicine with little clinical benefit. Blood cultures, bacterial serology (i.e., Tubercolosis, T.gondii, Syphilis, Leptospirosis) and viral serology (i.e., HIV, HCV, HBV, EBV, HSV) resulted negative. However, an empirical antibiotic coverage was set up: sequentially with Piperacillin/Tazobactam, Vancomycin, Linezolid and Ceftriaxone. None of the antibiotics improved patient's clinical status. On the contrary, the patient developed an allergic reaction to Vancomycin and Linezolid. All autoantibodies tested resulted negative. After 10 days of hospitalization, the patient's clinical status continued to deteriorate. The intermittent fever (max 41degreeC) was not responsive to any treatment. The evanescent skin rash had spread to the whole body and was concomitant with the fever peaks. The indexes of inflammation were rising (C-reactive protein 400 mg/ L) and so were the WBC count (36.000/mm3). The patient lost weight (-8kg), developed hand and feet arthralgia, diffuse myalgia, painful retronucal lymph nodes, pharyngodynia and abdominal pain. An abdominal echography and CT were performed with evidence of mild abdominal effusion and splenomegaly. Hepatic cytolysis indices began to rise (AST 100 U/L;ALT 150 U/L;LDH 385 U/L). At that point, on the basis of Yamaguchi's Criteria, we suspected our patient could be affected by Adult-onset Still's disease (AOSD) with an initial stage of hemophagocytic lymphohistiocytosis (HLH). Prednisone (IV 2 mg/kg/die) was administered for 72h with an incomplete clinical and biochemical response (C-reactive Protein 180 mg/L). Subsequently, Anakinra (SC 100 mg/die) was administered with a complete clinical response in less than 72h. AOSD is very uncommon. The annual incidence is 0.16/100.000 with an equal distribution between sexes. HLH have been observed in 15% of patients, meanwhile myopericarditis is a rare complication. Although rare, it is fair to know and consider AOSD in the complicated and tricky diagnostic process of myopericarditis. A noteworthy point of this case report is the extreme efficacy of Anakinra in contexts of systemic inflammation and myopericarditis. A point still to be clarified concerns the duration of the treatment and the down-titration of Anakinra in these complicated contexts..

Total Artificial Heart Implantation as a Bridgeto- Candidacy to Heart Transplantation in a young patient with AL cardiac amyloidosis

A 42-year-old woman was referred to our Cardiac Intensive Care Unit for possible acute coronary syndrome (acute heart failure and elevated serum cardiac troponin levels). Urgent coronary angiogram was unremarkable. Transthoracic echocardiography revealed severe concentric biventricular hypertrophy, systolic dysfunction (LVEF 26%, FAC 20%), and restrictive physiology (E/E' 27). LV strain analysis showed an apical sparing pattern with severely reduced GLS (-6%) and raised the suspicion of cardiac amyloidosis (CA). The endomyocardial biopsy established the diagnosis of lightchains CA. The patient's prognosis was very poor at the diagnosis, with a median survival of 4 months based on Mayo Clinic's revised staging system. Combination chemotherapy with CyBorD scheme (Cyclofosfamide/Bortezomib/Dexamethasone) was promptly started, but prematurely stopped because of the development of rapidly progressive biventricular failure. Therefore, the patient received a total artificial heart (TAH) as a bridge-to-candidacy to orthotopic heart transplantation (OHT). The CyBorD therapy was then restarted, and complete haematological remission was achieved six months later. Therefore, the patient underwent effective monoclonal antibody therapy for nosocomial SARS-CoV-2 infection. Subsequently, the patient was placed on the urgent transplant list because of the bacterial device's driveline infection. Two months later, she underwent OHT. The patients died three days for multiple reasons: difficult TAH explant with prolonge extracorporeal circulation time, the necessity of central V-A ECMO, graft failure.

Jordanian nurses' attitudes toward using electronic health records during COVID-19 pandemic.

Electronic health records (EHRs) have proven their effectiveness during the coronavirus disease (COVID-19) pandemic. However, successful implementation of EHRs requires assessing nurses' attitudes as they are considered the first line in providing direct care for patients. This study assessed Jordanian nurses' attitudes and examined factors that affect nurses' attitudes toward using EHRs. A cross-sectional, correlational design was used. A convenient sample of 130 nurses was recruited from three major public hospitals in Jordan. All Participants completed the Nurses' attitudes Towards Computerization (NATC) Questionnaire. The overall nurses' attitude was positive; the mean was 61.85 (SD = 10.97). Findings revealed no significant relationship between nurses' attitudes toward using EHRs and nurses' age, gender, education level, previous computer skills experience, years of work experience, and years of dealing with EHRs. However, the work unit was found to have a significant correlation with nurses' attitudes toward using EHRs. Therefore, nurse administrators should arrange for the conduct of educational workshops and continuous training programs considering the needs of the nurses.