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

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

CRRT impact on outcomes of patients treated with ECMO and fluid overload: a case report

Background: ECMO is an extracorporeal circulation used as a short-term life-saving support in patients with refractory cardiac and respiratory failure. Fluid overload (FO) in patient with this support, sometimes due to the onset of AKI, is associated with an increased morbidity and mortality rate and with prolonged duration of mechanical ventilation and ECMO. It also alters the volume of distribution of most drugs and can even mask the presence of AKI. Mantaining a negative fluid balance is an essential goal to improve gas exchanges in patients with respiratory failure who have undergone ECMO support. So, fluid overload removal has a significant prognostic value. Diuretic therapy, at the maximal dosage, can be insufficient to reach a negative water balance and it can also lead to metabolic disorders. Initiating RRT may help to obtain this goal. Method(s): A 32-years-old man, without any comorbidity, was admitted to the intensive care unite (ICU) with severe acute respiratory distress syndrome (ARDS) due to SARS Cov-2 infection and refractory hypoxemia. After intubation and mechanical ventilation, he was treated with VV-ECMO. In order to maintain a negative fluid balance, diuretic therapy at maximum dosage was started. Despite this therapy, the patient continued to show fluid overload clinical and its radiological signs, with a little improvement in gas exchanges. For that reason and in order to avoid metabolic alterations due to the diuretic therapy, it was decided to start CVVHF treatment. Thus, the patient was submitted to 3 sessions of CVVHF with a total ultrafiltration of 12 liters. He never lost spontaneous diuresis (his hourly dieresis was about of 150 ml). Diuretic therapy was restarted at the end of the CRRT sessions. Result(s): There was an improvement in patient's gas exchanges already during the first treatment which led to the stop of ECMO after 14 days. FGF (fresh gas flow) had been progressively decreased to the oxygenator. At the same time, lung ventilation has been increased to maintain an adequate CO2 clearance. The patient remained stable at a FGF of 0 L/min for a period of 24 hours;thus only mechanical ventilation was kept. A negative fluid balance has led to a significant patient's clinical conditions improvement to permit VV-ECMO weaning. Conclusion(s): Fluid overload removal is an essential goal to improve gas exchanges and, consequently, outcomes in patients treated with ECMO and its duration can both improve. This goal requires continuous renal replacement therapy (CRRT) because of patient's hemodynamic instability. However, the approach combining CRRT and ECMO is facilitated by several ways to link the different circuits without the necessity of positioning a bilumen CVC and, also, by using the same anticoagulation regimen.

Use of Outpatient Intravenous Diuretic Therapy Among Patients With Heart Failure in the United States

Introduction: Select centers have published local experiences with outpatient (OP) intravenous (IV) diuretic clinics to treat worsening heart failure (HF) and prevent hospitalization. Little is known regarding widespread use of this care strategy in contemporary US practice, including the potential impact of the COVID-19 pandemic. Method(s): Inpatient (IP) and OP claims from Optum (April 2018-March 2021) were utilized to identify instances where patients with HF with reduced ejection fraction (HFrEF) received >=1 administration of IV diuretic. Episodes of care were categorized into hierarchical mutually exclusive groups defined by intensity of care setting, including IP hospitalization, critical care (without IP hospitalization), emergency department (without IP hospitalization), observation unit, nursing facility, and outpatient clinic. Analyses were stratified across pre-pandemic (4/2018-3/2019, 4/2019-3/2020) and COVID-19 pandemic periods (4/2020-3/2021). Result(s): Among 302,397 patients with HFrEF, 56,213 (19%) patients received IV diuretic therapy during the study period, accounting for 94,865 total IV diuretic episodes. Of patients receiving IV diuretics, 44% were female and 20% were Black. Among 85,827 (90%) IV diuretic episodes with available data on location of care, 14% were outpatient clinic visits, 60% were IP hospitalizations, and 21% were ED visits. Critical care, observation unit, and nursing facility locations each constituted ~1-2% of IV diuretic episodes. The proportion of outpatient IV diuretic visits and the overall distribution of IV diuretic episodes was similar over time, spanning the pre-pandemic and COVID-19 pandemic periods (Figure). Conclusion(s): In this cohort of US patients with HFrEF, approximately 1 in 7 care episodes involving IV diuretic therapy occurred in outpatient clinic. The relative proportion of outpatient IV diuretic visits did not meaningfully change during the first year of the COVID-19 pandemic. (Figure Presented).

Defer Thy Diuresis

With the spread of the novel coronavirus disease 2019 (COVID-19) pandemic, an alarming number of patients now present with acute respiratory distress syndrome (ARDS). Conservative fluid management with diuresis in the ARDS patients improves lung function and decreases ventilator-dependent days. Several cardiac manifestations have been reported in COVID-19 patients including rhythm disorders, myocarditis, Takotsubo cardiomyopathy and myocardial infarction. A 65-year-old Asian female with a history of hypertension presented to the emergency department with cough, worsening dyspnea and palpitations of one-week duration. Investigations at admission were significant for a positive COVID-19 polymerase chain reaction test with an electrocardiogram (EKG) (Figure 1 Panel-A) revealing inferior ST-elevations. Troponin-T was elevated to 1162 ng/L with bedside echocardiogram revealing inferior hypokinesis. Due to concerns for acute ST-elevation myocardial infarction (STEMI), the patient underwent cardiac catheterization with no obvious coronary artery occlusion. A ventriculogram revealed apical ballooning and the patient was treated for COVID-19 induced Takotsubo cardiomyopathy. The patient developed worsening respiratory distress on hospitalization day 3 requiring oxygen supplementation with a high-flow nasal cannula. Conservative fluid regimen and diuretic therapy were being administered when the patient developed ventricular fibrillation and suffered a cardiac arrest. After successful resuscitation, a repeat EKG (Figure 1 Panel-B) demonstrated new anterior and inferior ST-elevations. The patient required increasing vasopressor support, and a repeat cardiac catheterization to rule out coronary artery thromboembolism induced STEMI was negative. A right heart catheterization revealed elevated SVR with decreased cardiac index. The patient clinically deteriorated despite negative fluid balance with recurrent malignant arrhythmias. A bedside echocardiogram performed revealed persistent apical hypokinesis and systolic anterior motion of anterior mitral leaflet (Figure 1 Panel-C) with flow acceleration at left ventricular outflow tract (LVOT) (Figure 1 Panel-D). Due to concerns of cardiogenic shock secondary to Takotsubo cardiomyopathy with dynamic LVOT obstruction physiology, the patient was treated with liberal intravenous fluid resuscitation and successfully weaned from vasopressor therapy. Although she was successfully extubated 2 days later, the patient, unfortunately, passed away later from a thromboembolic stroke. Severe COVID-19 infections are associated with catecholamine surge which may precipitate Takotsubo cardiomyopathy in the susceptible patient population. Female patients with Takotsubo cardiomyopathy are at increased risk of developing dynamic LVOT obstruction. In these patients, management of shock and ARDS can be challenging as the use of inotropic agents may result in hemodynamic instability. Our patient was successfully hemodynamically stabilized using fluid resuscitation once the inotropic support was withdrawn after identifying dynamic LVOT obstruction.

RENAL RECOVERY AFTER ACUTE KIDNEY INJURY ASSOCIATED TO COVID REQUIRING CRRT DURING ICU HOSPITALIZATION

BACKGROUND AND AIMS: Renal recovery (RR) after AKI is a determinant outcome of future comorbidity and mortality in critical care patients. Related predictive factors remain uncertain. METHOD: We retrospectively analyzed patients admitted to ICU between January 2020 and February 2021 from our critical nephrology database. We analyzed adult patients with diagnosis of AKI (KDIGO criteria) treated with renal replacement therapy (RRT) during ICU hospitalization. We excluded patients with dialysis support previous to the admission. The main outcomes we evaluated were (1) RR (successful suspension of RRT without hyperkalemia, increase in serum creatinine (SCr), hypervolemia or acidemia after 1 week without RRT, with urine volume > 500 mL/d without diuretic treatment or > 2000 mL/d with diuretics). (2) Mortality during hospitalization. RESULTS: We found 1442 patients were admitted to ICU, 418 presented AKI (29.8%), of them, 178 patients (64% male) required RRT (AKI-RRTd) in ICU during follow-up, with mean age of 66 year old (52.8% >65 year). Main comorbidity and demographic data are in Table 1. Mean time in ICU was 19 days (RIC 11-35). The most frequent admission cause was non-surgical pathologies (93%), 53% of admitted patients had COVID-19 as main diagnosis (95 patients). There was need of vasoactive support in 73.6%, ventilatory support (82.6) and 67.2% of patients had fluid overload. The indication of dialysis was determined by a nephrologist: mainly oliguria, acidosis, hyperkalemia, fluid overload and increase SCr. Mean SCR at admission was 2.5 mg/dL. There were missing data in 48% of basal SCr (known SCr between 1 and 12 months prior to admission). Total mortality in AKI-RRTd was 70.8% (126 patients). In COVID patients, was 77.9% (74 patients). We found renal recovery in 63.4% of total survivors (33/52 patients). When analyzing COVID, there were 21 survivors, and we found renal recovery in 80.9% of patients. Patients who did not achieved renal recovery had longer ICU stay (median: 20 days, RIC: 4-26) and inhospitalization (median: 41 days, RIC: 29-58). Those patients were older, and had higher morbidity (diabetes), higher SCr at ICU admission and lower urine output. Their fluid balance was higher at 48 h after CRRT initiation (OR 3.05, 95% CI 1.39-6.65, P <.01). In COVID population without renal recovery, there were more urgent dialysis onset (OR 8.33, 95% confidence interval (95% CI) 1.04-66.2;P = .04), age > 65 year (OR 6.48, 95% CI 1.94-21.6;P < .01), positive fluid balance at 48 h after RRT (OR 3.25;95% CI 1.09-9.69;P = .03). The risk factors for mortality, were age > 65 year (OR 4.14, 95% CI 2.05- 8.35;P < .01), mechanical ventilation (OR 3.28, 95% CI 1.48-7.30;P < .01), haemodynamic support (OR 4.37, 95% CI 2.14-8.92;P < .01). Otherwise, lower SCr at admission (OR 0.82, 95% CI 0.71-0.93;P < .01) and at instauration of RRT (OR 0.75, 95% CI 0.065-0.88;P < .01) were associated to lower mortality. In COVID patients, fluid overload at RRT initiation (OR 10.83, 95% CI 1.37-85.36;P = .02), age > 65 year old (OR 8.85, 95% CI 2.68-29.1;P < .01) and FiO2 > 50% at RRT start (OR 2.77, 95% CI 1.02-7.50;P = .04) were associated to higher mortality. CONCLUSION: In ICU patients with AKI-RRT dependence, negative fluid balance at 48 h after RRT onset and in COVID patients, age < 65 year old, negative fluid balance at 48 h after RRT onset and non-urgent onset of RRT were related with renal recovery. (Table Presented).

A rare case of cardiomyopaty: a case report

A 46-years old Egyptian man was admitted to our department because of the onset of worsening dyspnea. In his clinical history were present: hypothyroidism, obesity, hyperuricemia, hypertension and recent Sars-Cov2 infection. Bilateral pleuric effusion was suspected during physical examination and confirmed by chest CT. Blood data showed mild macrocytic anemia, increased levels of creatinine, transaminases, pro-BNP (3574 pg/ml cut-off 0-125) and D-dimer. Multiple molecular swabs for research of Sars-Cov2 were negative. ECG showed sinus rhythm and non specific atypia of repolarization. An eco-fast was performed at bedside and revelead left ventricular dilatation and severe systolic disfunction due to diffuse hypokinesia (EF 30%). Diuretic therapy was set up with improvement of the clinical status. In order to exclude ischaemic genesis of the cardiopathy a coronary angiography was performed without evidence of obstructive lesions. An echocardiogram was repeated and it showed a parietal ipertrabeculation of the left ventricle. This aspect was suggestive of non-compact myocardium, a rare disease due to the arrest of the myocardial maturation process during fetal development, leading to the persistence of embryonic structures in the heart muscle. Genetic inheritance arises in 30-50% of patients and are involved genes that generally seem to encode sarcomeric or cytoskeletal proteins.Cardiac MRI is planned in order to have further confirmation of our diagnostic hypothesis. In the meantime wearable defibrillator was prescribed for the prevention of sudden death.