Extracorporeal membrane oxygenation instead of invasive ventilation in patients with COVID-19 acute respiratory distress syndrome (ARDS) and pneumomediastinum: A cohort trial

Objectives: In patients with severe respiratory failure, invasive ventilation may deteriorate the pneumomediastinum and hypoxia. This study aimed to compare the mortality and the complications of the patients with coronavirus disease 2019 (COVID-19) related severe ARDS treated with invasive ventilation or veno-venous ECMO (VV-ECMO) to avoid intubation. We hypothesized that VV-ECMO support without prior intubation is a feasible alternative strategy to invasive ventilation. Method(s): This retrospective study evaluated patients with COVID-19 related severe respiratory failure and radiological evidence of pneumomediastinum. The primary outcome was intensive care unit (ICU) survival at 90 days. Result(s): Out of 347 patients with COVID-19 disease treated in our unit, 22 patients developed spontaneous pneumomediastinum associated with deterioration of respiratory function. In 13 patients (59%), invasive ventilation was chosen as initial respiratory support;in 9 patients (41%), VV-ECMO was chosen as initial respiratory support. The median age of the patients in the invasive ventilation group was 62 years (IQR: 49-69) compared to 53 years (IQR: 46-62) in ECMO group (P=0.31). No statistically significant difference in SAPS II score between the groups was observed (39.7 (IQR: 33.2-45.3) vs. 28.9 (IQR:28.4-34.6), P=0.06). No elevated fluid balance within the first 4 days was observed in the ECMO group compared to the invasive ventilation group (162 mL (IQR: -366-2000) vs. 3905 mL (IQR: 2068-6192), P=0.07). VV-ECMO as the initial strategy for supporting patients with severe respiratory failure and pneumomediastinum, was associated with lower 90 days mortality (HR: 0.33 95%-CI: 0.11-0.97, P= 0.04) compared to patients treated with invasive ventilation (Figure). Conclusion(s): VV-ECMO can be an alternative strategy to invasive ventilation for treating patients with severe respiratory failure and spontaneous pneumomediastinum. (Figure Presented).

Correlation between serum levels of IL-6 and positive fluid balance in critical COVID-19

Introduction: IL-6 has been correlated as a prognostic biomarker for worsening sepsis and COVID-19 as well as positive fluid balance for duration of mechanical ventilation [1, 2]. Method(s): We performed a retrospective cohort study to analyze the correlation between high levels of serum IL-6 and positive fluid balances in the first 24 h of ICU arrival with mechanical ventilation days. We included adult patient records of critical COVID-19 during 2020 from the High Specialty Regional Hospital Bicentenario 2010, all patients were intubated, received treatment according to guidelines inforced in that time. We obtained mean and standard deviation for continuous variables and frequencies for categorical variables, calculated Kolmogorov-Smirnov for non-parametric test and Spearman correlation, OR for severe hypoxemia, RRT. Result(s): We analyzed 102 patient records, 72% were male, mean age 54.8 years (SD 19.4), tracheostomy was performed in 8.8% of cases, mean APACHE II 16.7 (SD 8.4), values of inflammatory markers were C-reactive protein 108 mg/dl (SD 95), IL-6 118 pg/ml (SD 240), mean paO2/FiO2 was 150 mmHg (SD 82), 93% were on vasopressors, fluid balance mean was 1542 ml (SD 839), severe hypoxemia was present on 62.7% (P/F below 150 mmHg), prono was used in 47.1%, with an overall mortality occurred in 69%. We found no correlation between serum IL-6 levels and positive fluid balance with mechanical ventilation days and outcomes (rs -0.11 p = 0.23, Fig. 1). Elevated serum IL-6 + positive fluid balance at 24 h ICU arrival was associated with severe hypoxemia (OR 2.82, CI 95% 1.14-6.97, x2 p = 0.022), OR for discharge was non-significant (0.48 CI 0.19-1.20 p = 0.11), RRT (1.09 CI 95% 0.27-4.37, p = 0.9). Conclusion(s): In our study no correlation was found between serum IL-6 levels, positive fluid balance and mechanical ventilation days, but there was a significant association with severe hypoxemia.

Fluid balance in critically ill children with lower respiratory tract viral infection: a cohort study.

BACKGROUND: Increasing evidence has associated positive fluid balance of critically ill patients with poor outcomes. The aim of this study was to explore the pattern of daily fluid balances and their association with outcomes in critically ill children with lower respiratory tract viral infection. METHODS: A retrospective single-center study was conducted, in children supported with high-flow nasal cannula, non-invasive ventilation, or invasive ventilation. Median (interquartile range) daily fluid balances, cumulative fluid overload (FO) and peak FO variation, indexed as the % of admission body weight, over the first week of Pediatric Intensive Care Unit admission, and their association with the duration of respiratory support were assessed. RESULTS: Overall, 94 patients with a median age of 6.9 (1.9-18) months, and a respiratory support duration of 4 (2-7) days, showed a median (interquartile range) daily fluid balance of 18 (4.5-19.5) ml/kg at day 1, which decreased up to day 3 to 5.9 (- 14 to 24.9) ml/kg and increased to 13 (- 11 to 29.9) ml/kg at day 7 (p = 0.001). Median cumulative FO% was 4.6 (- 0.8 to 11) and peak FO% was 5.7 (1.9-12.4). Daily fluid balances, once patients were stratified according to the respiratory support, were significantly lower in those requiring mechanical ventilation (p = 0.003). No correlation was found between all examined fluid balances and respiratory support duration or oxygen saturation, even after subgroup analysis of patients with invasive mechanical ventilation, or respiratory comorbidities, or bacterial coinfection, or of patients under 1 year old. CONCLUSIONS: In a cohort of children with bronchiolitis, fluid balance was not associated with duration of respiratory support or other parameters of pulmonary function.

Comparative Study of Serum Electrolytes in Covid-19 and Healthy Patients in Tertiary Care Center, Karimnagar

Introduction- Electrolyte balance of the body is maintained by renin angiotensin aldosterone system. Some previous studies suggested that COVID-19 is associated with gastrointestinal symptoms, such as diarrhea and vomiting. This may results in electrolyte disturbances in patients. Electrolytes in body like sodium (Na), potassium (K). Chloride (Cl) plays an important physiological role in maintaining acid base and water balance of cells of the body. Aims and objectives: Our study aimed to compare some electrolyte between covid 19 and non-covid patients retrospectively. Material(s) and Method(s): This retrospective study included total 57 males and 43 females in the age group of 28 to 65 years. The results were compared with 100 age and sex matched healthy controls. Estimation of serum electrolytes was done with the collected venous blood samples using the ion selective electrode technique in an electrolyte analyzer. Analysis was done using SPSS V 25 Software. Chi-square and t-test were used to see association and difference between two variable respectively. Result(s): We have found that covid 19 is associated with low levels of electrolytes like Na, K, Cl. Chloride levels in both the groups was not statistically significant. But Hyponatremia and Hypokalemia were observed in cases group with high statical Signficance. Conclusion(s): Study found that electrolytes deterioration in these patients play a critical role in patients management. Thus a monitoring of electrolyte is essential throughout their illness to manage covid patients to improve their quality of life.Copyright © 2020 Ubiquity Press. All rights reserved.

Fluid balance as an independent prognostic indicator of in-hospital mortality in heart failure patients with Covid19

Introduction: Fluid resuscitation confers protection against in-hospital mortality in heart failure (HF) patients with severe sepsis. SARS COV-2 infection leads to cytokine storm that is clinically similar to severe sepsis. We aim to evaluate if positive fluid balance is associated with in-hospital mortality in HF patients with Covid-19. Method(s): This single center retrospective cohort study was conducted in patients admitted in the ICU for Covid 19 from 10/2020 to 3/2021 in a community hospital in Newark. The primary outcome was survival to discharge. Clinical SAS 9.4 was used to obtain summary statistics, perform chi-squared test and multivariable logistic regression analysis. Result(s): We included 91 patients admitted in the ICU with covid 19, of which 33 were diagnosed with HF. Out of 33 people, majority were males. Most of the patients were hispanic. Diabetes and hypertension were the most common comorbidities. 60.61% of HF patients had multiple comorbidities. Odds of negative survival outcome in those with positive fluid balance after adjusting for HF as compared to those with negative fluid balance in patients of COVID 19 was 12.958 (P value= 0.0183). Conclusion(s): Positive fluid balance in HF patients admitted with Covid 19 may be associated with adverse outcomes. Larger, prospective studies are needed to investigate the correlation between covid 19 and fluid balance in HF patients.

Central diabetes insipidus following immunization with anti-COVID19 BNT162b2 Comirnaty vaccine

Introduction: The coronavirus disease 19 (COVID19) pandemic urged to develop new vaccines to reduce the morbidity and mortality associated with this disease. Recognition and report of potential adverse effects of these novel vaccines (especially the urgent and life-threatening ones) is therefore essential. Case Presentation: A 16-year-old boy presented to the Paediatric Emergency Department with polyuria (9 liters per day), polydipsia and concomitant weight loss (- 6 Kg) over the last four months. His past medical history was unremarkable. Onset of symptoms was referred to be few days after second dose of anti- COVID19 BNT162b2 Comirnaty vaccine. The patient was admitted to the Paediatric Department. The physical exam was normal, without neurological abnormalities. Auxological parameters were within normal limits (height -0.12 SDS, weight +0.35 SDS). Daily fluid balance monitoring confirmed polyuria and polydipsia (IN 6,250 L / OUT 7,100 L). Biochemistry laboratory analysis and urine culture were normal (Sodium levels 141 mEq/L). Serum osmolality was 297 mOsm/Kg H2O (normal values 285-305), whereas urine osmolality was 80 mOsm/Kg H2O (normal values 100-1100), suggesting diabetes insipidus. Hormonal tests showed no significant impairment of anterior pituitary function. Test with Desmopressin was performed and confirmed the diagnosis of central diabetes insipidus. Brain MRI revealed pituitary stalk enlargement (4 mm) with contrast enhancement, and loss of posterior pituitary bright spot on T1 weighted imaging. Even in absence of pituitary enlargement, those signs were consistent with neuroinfundibulohypophysitis. Immunoglobulin levels were normal. Low doses of oral Desmopressin were sufficient to control patient's symptoms, normalizing serum and urinary osmolality values and daily fluid balance at discharge. Brain MRI after 2 months showed stable thicken pituitary stalk and detectable small posterior pituitary. Due to persistence of polyuria and polydipsia, therapy with Desmopressin was adjusted by increasing dosage and number of daily administrations. Clinical and neuroradiological follow-up is still ongoing. Conclusion(s): Hypophysitis is a rare disorder characterized by lymphocytic, granulomatous, plasmacytic, or xanthomatous infiltration of the pituitary gland and stalk. Common manifestations are headache, hypopituitarism, and diabetes insipidus. To date, only time correlation between SARS-CoV-2 infection and development of hypophysitis and subsequent hypopituitarism has been reported. Further studies will be needed to deepen a possible causal link between anti-COVID19 vaccine and diabetes insipidus.

The Effect of Fluid Balance on Proning and Successful Extubation in Intubated Covid-19 Patients

INTRODUCTION: Coronavirus disease 2019 (Covid-19) represents viral pneumonia from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In ARDS patients, positive fluid balance has been associated with prolonged mechanical ventilation, longer length of stay, and higher mortality. As a result, restrictive fluid strategies improved oxygenation and reduced duration of mechanical ventilation. Optimal fluid management strategy for invasively ventilated COVID-19 patients is lacking. The objective of this study is to evaluate the effect of fluid balance on need for proning and successful liberation of invasive mechanical ventilation (MV) in patients with COVID-19 ARDS. METHOD(S): All data were retrospectively collected from EHR of COVID-19 patients admitted to our ICU. COVID ARDS patients in our institution are managed based on ARDS management guidelines that include lung protective ventilation strategy, PEEP protocol, and prone positioning for persistent PaO2/FiO2 (P/F) ratio < 150. Fluid balance in ml was calculated on Day 1 (F1) and Day 7 (F7) of ICU admission. Groups were divided into those successfully liberated (L-group) and those unable to be liberated from MV (U-group). RESULT(S): A total of 57 patients intubated with COVID-19 ARDS were included, with 29 in the L-group and 28 in the U-group. Compared to U-group, L-group had similar age (64 +/- 13 vs 64 +/- 13, p = 1.0), number of comorbidities (2.3 +/- 2.2 vs 2.7 +/- 2.5, p = 0.5), P/F ratio on day 1 (D1, 144 +/- 110 vs 130 +/- 95, p = 0.6), D1 SOFA score (6.4 +/- 4.5 vs 5.9 +/- 4.3, p = 0.7), and F1 (434 +/- 1106 vs 413 +/- 1301, p = 0.9). F7 was significantly less for L-group than U-group (290 +/- 2500 vs 2000 +/- 4000, p = 0.05). [F7 - F1] was also significantly less for L-group compared to U-group (- 144 +/- 1400 vs 1600 +/- 2800, p = 0.004). There was less need for proning (38 % vs 72 %, p = 0.01), and lower mortality (24% vs 86 %, p < 0.001) in the L-group compared to the U-group. CONCLUSION(S): In a cohort of invasively ventilated patients with COVID-19 ARDS, a lower cumulative fluid balance was associated with less need for proning and more successful liberation of MV, indicating that restricted fluid management in these patients may be beneficial. These findings should be investigated in large multicenter prospective studies.

A Retrospective Analysis of Fluid Balance in Patients With AKI and Respiratory Failure due to COVID-19

Background: The optimal amount of hydration for patients with severe COVID-19 infection and AKI is unknown. This study aims to investigate the impact of fluid management strategy and outcomes in patients with AKI and respiratory failure due to COVID-19. Method(s): Data was gathered from a retrospective chart review of patients with hypoxia due to COVID-19 infection and stage 2 or greater AKI. Primary outcome was the difference in net fluid balance between patients who were successfully weaned to lower levels of oxygen support and discharged compared to those who died or remained ventilator dependent. Result(s): Of 58 cases, 41 died, 3 remained ventilator-dependent, and 14 were discharged without supplemental oxygen. The groups differed in net fluid balance (-10,065 cc vs +7,980 cc, p <0.001) and daily fluid balance (-367 vs. 515 cc/day, p <0.001) with a substantially lower mean fluid balance in patients who survived with minimal requirement for supplemental oxygen. Patients who maintained a positive fluid balance were significantly more likely to become ventilator dependent or die (OR: 40.7, 95% CI: 5.3 - 312.9). A fluid restrictive strategy did not reduce the likelihood of recovery from AKI or increase the need for renal replacement therapy. Conclusion(s): In our cohort, patients with COVID-19 and AKI who survived with minimal or no oxygen requirements tended to have negative fluid balance in contrast to those who died or remained ventilator-dependent. A fluid restrictive strategy with judicious volume removal using diuretics or dialysis may lead to improved outcomes in COVID-19 patients with AKI.

Assessing Fluid Management and Its Association With AKI in COVID-19 Patients

Background: Managing fluid balance in COVID-19 patients can be challenging, particularly if they develop acute kidney injury (AKI). We study the relationship between fluid net input and output (FNIO) in patients with confirmed COVID-19 infection with development of AKI, time to development of AKI, in-hospital length of stay (LOS), and in-hospital mortality. Method(s): This is a retrospective study of patients (n=403) with confirmed COVID-19. Data for FNIO was from day 1 through day 10 or until development of AKI were recorded, whichever occurred first. Available FNIO data was calculated as a mean due to information not available for all days. Covariates included demographics, comorbidities, treatment, and management variables. Result(s): Mean age was 58.1 (SD=16.5) years. There were 39.5% female and 53.1% Hispanic. Mean FNIO average was 612.2 (SD=747.4) mL. For the outcome variables, AKI occurred in 22.8%, in-hospital mortality occurred in 26.3%, mean days to AKI were 7.7 (SD=6.3), and mean LOS was 11.4 (SD=13.2) days. In the multivariate logistic regression analyses, increased FNIO mean was significantly associated with slightly increased odds for mortality (OR=1.001, 95% CI:1.00, 1.001, p=0.03) but was not significantly associated with AKI (p=0.82). In the multivariate linear regression analyses, increased FNIO mean was significantly associated with lesser days to AKI (B=-6.92*10-5, SE=<0.001, p=0.002) while FNIO mean was not significantly associated with LOS (p=0.75). Conclusion(s): Increased fluid balance was associated with AKI development and increased mortality. Physicians should exercise caution with administering fluid in patients with COVID-19 to prevent such adverse outcomes.

Clinical features and treatment of mixed cardiogenic and distributive shock in patients with multisystem inflammatory syndrome in children (MIS-C)

Background and Aim: Mixed shock in multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19 is con-sequence of acute heart failure, inflammation-induced vasodilation and potential volume loss. Method(s): Retrospective analysis included 25 patients (7 girls) with MIS-C-related combined shock, treated in period from April 2020 to December 2021. Result(s): Mean age of patients was 12.6 +/- 4.0 years. Admission was 6.1 +/- 1.6 days after symptoms onset. Systemic inflammatory response was manifested with neutrophilia (10.7 +/- 4.2 x109/), lymphopenia (1.1 +/- 0.7 x109/L), elevated CRP (220.9 +/- 86.1 mg/L), ferritin (684.5 +/- 549.5 mug/L) and D-dimer (1528 +/- 1254 ng/mL). One third of patients had acute kidney injury with glomerular filtration rate of 64 +/- 22 mL/min/1.73 m2 and urea level of 16.0 +/- 8.4 mmol/L. All patients had acute heart failure with ejection fraction 47.2% +/- 7.7% and fractional shortening 23.6% +/- 4.9%, 92% of patients had NTproBNP gt;1500 pg/mL and 58% had elevated troponin I (1.34 +/- 1.47 ng/mL). Z-scores for end-diastolic left ventricle, interventricular septum and pos-terior wall diameters were 0.7 +/- 1.1, 1.7 +/- 1.3 and 0.6 +/- 0.7 respectively. All patients had mild/moderate mitral regurgitation, and 60% had mild pericardial effusion. Inotropes, administered during first 3.7 +/- 1.6 days, were divided in three groups: 1) dop-amine (n = 14), 2) dobutamine + dopamine (n = 5), 3) milrinone +/- dopamine (n = 6). Additional treatment included diuretics and captopril. Total fluid balance (including insensible loss of 300 mL/m2/day) through days 1-7 was +860 mL/m2, +128 mL/m2,-108 mL/m2,-36 mL/m2,-306 mL/m2,-335 ml/m2,-298 ml/m2 (total-95 ml/m2). Methylprednisolone/intravenous immuno-globulin and low-molecular-weight heparin/acetylsalicylic acid were administered and fever persisted 1.2 days averagely. Oxygen supplementation was needed in 71% of patients. Transitory bradycardia was noticed and there was no difference in heart rate between treatment groups. Profound hypotension was revealed on admission and correction differed regarding treat-ment (p lt;0.05) (Figure 1). All patient survived with clinical improvement (one had mechanical ventilation, and one had stroke). Conclusion(s): Mixed shock is the most severe manifestation of MIS-C, and treatment of heart failure should be combined with cau-tious fluid resuscitation.

FLUID BALANCE AS AN INDEPENDENT PROGNOSTIC INDICATOR OF IN-HOSPITAL MORTALITY IN PATIENTS WITH HEART FAILURE AND COVID-19

SESSION TITLE: Outcomes Across COVID-19 SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Fluid resuscitation confers protection against in-hospital mortality in heart failure (HF) patients with severe sepsis. SARS COV-2 infection can lead to a cytokine storm that is clinically similar to severe sepsis. Little is known about fluid balance in patients with HF admitted for covid 19. We aim to evaluate whether positive fluid balance is associated with in-hospital mortality in HF patients admitted for Covid-19. METHODS: This single center retrospective cohort study was conducted in patients admitted in the ICU for confirmed Covid 19 from 10/2020 to 3/2021 in a community hospital in Newark. The primary outcome was survival to discharge. Clinical SAS 9.4 was used to obtain summary statistics, perform chi-squared test and multivariable logistic regression analysis. RESULTS: We included 91 patients admitted in the ICU with covid 19. Out of these 33 patients were diagnosed with heart failure. Out of 33 people with HF 23 (69.70%) were male, 10 (30.3%) were females. Of the 33, 17(56.67%) were latino, 5(16.67%) were caucasian and 6(20%) were african-american. Mean age of population with and without Heart Failure was 70.78 yrs(?12.52) and 58.57 yrs(?13.37) respectively. Amongst them 18(54.55%) had DM, 27(81.82%) had HTN, 5 (15.15%) had chronic respiratory disease and 7(21.21%) had CKD. Amongst those with Heart Failure, 20(60.61%) had multiple comorbidities. The odds for negative survival are shown in table 1. Odds of negative survival outcome in those with positive fluid balance after adjusting for heart failure as compared to those with negative fluid balance in patients of COVID 19 was 12.958 (P value= 0.0183). CONCLUSIONS: Positive fluid balance in HF patients admitted with Covid 19 may be associated with adverse outcomes. Larger, prospective studies are needed to investigate the correlation between covid 19 and fluid balance in HF patients. CLINICAL IMPLICATIONS: This study creates awareness on the need of caution while fluid resuscitation in heart failure patients with Covid-19 as a positive fluid balance might be associated with unfavorable outcomes DISCLOSURES: No relevant relationships by Ruhma Ali no disclosure on file for Joaquim Correia;No relevant relationships by Neev Mehta No relevant relationships by Aditya Patel No relevant relationships by jihad slim, value=Honoraria Removed 03/25/2022 by jihad slim No relevant relationships by jihad slim, value=Honoraria Removed 03/25/2022 by jihad slim No relevant relationships by jihad slim, value=Honoraria Removed 03/25/2022 by jihad slim No relevant relationships by jihad slim, value=Honoraria Removed 03/25/2022 by jihad slim No relevant relationships by jihad slim, value=Honoraria Removed 03/25/2022 by jihad slim

BETA BLOCKER AND CALCIUM CHANNEL BLOCKER OVERDOSE COMPLICATED BY COVID-19 PNEUMONIA AND RENAL FAILURE IN A PATIENT WITH SEVERE OBESITY

SESSION TITLE: A Look Into Poisoning and Drug Overdoses SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: We present a case of a 64-year-old woman with severe obesity (BMI 53) who presented with shock after beta-blocker (BB) and calcium channel-blocker (CCB) overdose. CASE PRESENTATION: The patient presented after an intentional suicide attempt, taking multiple antihypertensive medications, including tablets of nifedipine 90mg, carvedilol 25mg, and losartan 100mg. She had also been experiencing shortness of breath and lower extremity pain for several days. Upon arrival, she was lethargic and minimally responsive, and was found to be in shock with a heart rate 63. She was intubated for airway protection and started on multiple vasopressors including norepinephrine, phenylephrine, vasopressin, dopamine and epinephrine for circulatory support. She was also found to be positive for SARS-CoV-2. She was given activated charcoal, received gastric lavage, and whole bowel irrigation. She received a bolus of regular insulin at 1U/kg, and subsequently started on a high-dose insulin infusion titrated to 11U/kg/h along with dextrose infusion and calcium gluconate. By day four of admission, vasopressor requirements had been reduced to only norepinephrine and the insulin infusion had been successfully discontinued. However, her hospital course was further complicated MRSA and Pseudomonas pneumonia, and renal failure requiring hemodialysis. She continued to develop refractory shock, and remained over 50 liters net positive. Her condition progressively deteriorated and her gross volume overload was difficult to manage, and ultimately expired on day ten of admission. DISCUSSION: The management of CCB and BB overdose has been studied, with hyperinsulinemic euglycemic therapy (HIET)1,2 as our choice. Our patient's decline was likely secondary to the high volumes of dextrose infusion required after HIET. With underlying renal failure, insulin clearance proved to be a significant challenge. Such severe obesity with a weight-based regimen resulted in over 1500U insulin/hr at any given point with our patient. Renal clearance is governed by a proportion of t/V, where t denotes length of a dialysis session and V the volume of fluid in the patient's body.3 Patients with significant volume would require extensive dialysis sessions and fluid balances would be challenging. Continuous renal replacement therapy (CRRT) was attempted later in her hospital course. However, the patient was not able to tolerate it as she had progressed to multiorgan failure. CONCLUSIONS: HIET has shown to be a successful management strategy for CCB and BB overdose. However, weight-based dosing can prove to be a challenge in patients with severe obesity. CRRT should be considered early in severely obese patients that undergo HIET, given the rapid accumulation of fluid secondary to the large-volume insulin and dextrose infusions. Further investigations should look into identifying maximal safe dosages of HIET, especially in severely obese patients. Reference #1: Cole JB, Arens AM, Laes JR, Klein LR, Bangh SA, Olives TD. High dose insulin for beta-blocker and calcium channel-blocker poisoning. Am J Emerg Med. 2018 Oct;36(10):1817-1824. doi: 10.1016/j.ajem.2018.02.004 Reference #2: Krenz JR, Kaakeh Y. An Overview of Hyperinsulinemic-Euglycemic Therapy in Calcium Channel Blocker and β-blocker Overdose. Pharmacotherapy. 2018 Nov;38(11):1130-1142. doi: 10.1002/phar.2177 Reference #3: Turgut F, Abdel-Rahman E, M: Challenges Associated with Managing End-Stage Renal Disease in Extremely Morbid Obese Patients: Case Series and Literature Review. Nephron 2017;137:172-177. doi: 10.1159/000479118 DISCLOSURES: No relevant relationships by Alejandro Garcia No relevant relationships by Vishad Sheth no disclosure on file for Andre Sotelo;

Fluid balance neutralization secured by hemodynamic monitoring versus protocolized standard of care in critically ill patients requiring continuous renal replacement therapy: study protocol of the GO NEUTRAL randomized controlled trial.

BACKGROUND: Fluid overload is associated with worse outcome in critically ill patients requiring continuous renal replacement therapy (CRRT). Net ultrafiltration (UFNET) allows precise control of the fluid removal but is frequently ceased due to hemodynamic instability episodes. However, approximately 50% of the hemodynamic instability episodes in ICU patients treated with CRRT are not associated with preload dependence (i.e., are not related to a decrease in cardiac preload), suggesting that volume removal is not responsible for these episodes of hemodynamic impairment. The use of advanced hemodynamic monitoring, comprising continuous cardiac output monitoring to repeatedly assess preload dependency, could allow securing UFNET to allow fluid balance control and prevent fluid overload. METHODS: The GO NEUTRAL trial is a multicenter, open-labeled, randomized, controlled, superiority trial with parallel groups and balanced randomization with a 1:1 ratio. The trial will enroll adult patients with acute circulatory failure treated with vasopressors and severe acute kidney injury requiring CRRT who already have been equipped with a continuous cardiac output monitoring device. After informed consent, patients will be randomized into two groups. The control group will receive protocolized fluid removal with an UFNET rate set to 0-25 ml h-1 between inclusion and H72 of inclusion. The intervention group will be treated with an UFNET rate set on the CRRT of at least 100 ml h-1 between inclusion and H72 of inclusion if hemodynamically tolerated based on a protocolized hemodynamic protocol aiming to adjust UFNET based on cardiac output, arterial lactate concentration, and preload dependence assessment by postural maneuvers, performed regularly during nursing rounds, and in case of a hemodynamic instability episode. The primary outcome of the study will be the cumulative fluid balance between inclusion and H72 of inclusion. Randomization will be generated using random block sizes and stratified based on fluid overload status at inclusion. The main outcome will be analyzed in the modified intention-to-treat population, defined as all alive patients at H72 of inclusion, based on their initial allocation group. DISCUSSION: We present in the present protocol all study procedures in regard to the achievement of the GO NEUTRAL trial, to prevent biased analysis of trial outcomes and improve the transparency of the trial result report. Enrollment of patients in the GO NEUTRAL trial has started on June 31, 2021, and is ongoing. TRIAL REGISTRATION: ClinicalTrials.gov NCT04801784. Registered on March 12, 2021, before the start of inclusion.

Enteral feed delivery in patients with COVID-19 admitted to a Nightingale intensive care unit (ICU)

Introduction: Optimal calorie delivery is around 80% of predicted energy requirements.1 Underfeeding critical care patients may cause harm in some long stay patients.2 ESPEN guidelines state if oral intake is not possible, enteral nutrition should commence within 48 hours. Calorie delivery can be increased to 80-100% after day three of admission to ICU.3 The Nightingale ICU was situated on an acute ward which was modified to function as an ICU. This was to facilitate increased admissions of COVID-19. The Nightingale dietetic team were redeployed from acute and community settings in from within the trust, with various levels of ICU experience. The team provided seven day dietetic cover based on a rota, including bank holidays. Objectives: The aim of this audit was to evaluate enteral feed delivery and the number of days taken to reach target rate of feed compared to the regimen set by the dietitian, in patients with COVID-19 admitted to Nightingale ICU. Methods: At each review, dietitians calculated enteral feed delivery over the preceding 24 hours as a percentage of the target regimen, from the input recorded on the fluid balance chart. The number of days to reach enteral feed delivery targets were calculated relative to dietetic plans. All patients who required enteral nutrition from 15/10/ 2020 until 11/03/2021 were eligible for inclusion. Days where enteral feed was not required, target rate of enteral feed was not yet due to be achieved, parenteral nutrition was required, or following ICU discharge and end of life care were excluded. Days where enteral nutrition delivery information was unavailable were also excluded from the analysis. No imputation was used to estimate missing data. Results: The data consisted of a total of 116 patients. Following exclusions, the total number of patients included in the analysis was 107. Mean age was 63.6 ± 9.4 years.Mean body mass index (BMI) was 32.7 ± 7.4kg/m2. Number of enteral feed days per patient was 11. Patients with COVID-19 admitted to Nightingale ICU received a median of 84% of their enteral feeding regimen. The feeding regimen set by the dietitian aimed to achieve target rate of feed by 3.1 days. The data analysis showed the mean number of days until the target was achieved was 3.5 days. Conclusion: Results are based on a homogenous COVID-19 ICU cohort. Dietetic staffing levels were increased, and seven-day working was provided in response to the COVID-19 pandemic compared to a standard ICU. Quantifying common reasons for feed interruptions could be explored further. Despite suboptimal COVID-19 Nightingale ICU conditions, enteral feed delivery and time taken to reach target rate of feed was in keeping with ESPEN guidelines.

Focused Ultrasound in Critical Care Outreach for acutely ill and deteriorating patients on the wards

Introduction: Focused Ultrasound in Intensive Care (FUSIC) refers to the use of ultrasound by a trained bedside clinician to guide patient management in real-time. Ultrasound is widely applied in practice and there is growing consensus that it is an essential tool for managing acutely ill patients in the intensive care unit (ICU). The Critical Care Outreach Team uses FUSIC as an additional assessment tool to guide management and decision-making plan for deteriorating patients on the wards. Objectives: To investigate whether how often information gained fromFUSICimaging had an impact on patient care and management decisions in a critical care outreach setting. Methods: A single-centre observational study at an academic tertiary referral institution. We included all patients reviewed by critical care outreach who were assessed by ultrasound during a 12-month period. Routine procedures for teaching purposes were not included. Results: Forty-six patients were assessed and supported by a combined focused lung and heart ultrasound performed at the patient bedside on the wards. In 46 patients FUSIC was instrumental in the differential diagnostic workup and in guiding the clinical management. In 32 (70%) patients FUSIC aided fluid therapy or diuresis (in case of pulmonary oedema) and helped targeting fluid balance. In three patients though to have consolidation on chest x-ray we were able to identify significant pleural effusions without needing an additional CT scan. In four patients with hypotension, an additional CT-PA was warranted due to dilated right ventricle (RV) with abnormal septal motion and decreased left ventricle (LV) size ratio (i.e. sign of right heart strain) as highly suspicious of pulmonary embolus. In two young patients with Coronavirus disease 2019 (COVID-19), using FUSIC we identified severe LV dysfunction which was subsequentially diagnosed as myocarditis and Angiotensin-converting enzyme (ACE) inhibitors therapy was commenced within 24 hours. Further diagnosis included cardiac tamponade (n = 2) requiring pericardiocentesis and pneumothorax (n =1). In all cases, the use of ultrasound helped in promptly referring patients to the specialist team (i.e. respiratory or cardiology) and to the ICU consultant. Conclusions: In our critical care outreach practice, FUSIC is considered an indispensable tool for safe and accurate management of acutely ill and deteriorating patients on the wards.

Critical care dietetic outcomes during the first wave of the COVID-19 pandemic

The COVID-19 pandemic led to a surge in patients being admitted to the Intensive Care Unit (ICU) and increased dietetic input was required for their daily nutritional management. Non-ICU dietitians were upskilled to meet this increased demand – resulting in an increase to 5 band 6 dietitians and 1 band 7 dietitian overseen by the band 8a clinical lead. The service also changed from a 5-day to a 7-day service. The aim of this service evaluation was to analyse changes in nutritional outcomes during the COVID-19 pandemic, and how changes to the dietetic service impacted upon dietetic outcomes. Outcomes included energy and protein provision, feed type used and prokinetic use. Data was collected for all ICU patients under dietetic care with a confirmed COVID-19 diagnosis for the period of 22/03/2020 to 04/06/2020 (75 days). Total patient cohort equalled 66. Patients were reviewed daily until the patient was discharged from ICU or the patient passed away. All data was then retrospectively analysed using descriptive statistics, and an independent t-test was used to compare COVID-19 feed delivery to previous feed deliverydata. Ethical approval was not required for this service evaluation. Of the 66 patients, 62 required enteral nutrition (EN). Feeding was commenced within 48 hours of ICU admission in 92% of patients. Average percentage feed delivery was 82.4% for energy and protein. This total does not include additional protein supplementation;therefore, the overall protein delivery was higher, with 36% of patients being prescribed 1 to 2 20g protein supplements per day. A total of 60% of patients were initially started on a fluid restricted feed for fluid balance or due to being proned. A total of 50% of patients continued with a fluid restricted feed, with 44% of patients receiving a standard protocol feed (1kcal/ml high-protein feed) and 6% receiving a peptide or renal feed. Prokinetics were required in 35% of patients. A total of 3% of patients (n=2) required parenteral nutrition due to persistent high gastric residual volumes despite prokinetics. Of the 66 patients, 46 (70%) were discharged alive from ICU. Of these, 70% were receiving total or supplementary EN at the time of discharge from the ICU. A number of barriers to maintaining high standards of patient outcomes arose at the onset of the COVID-19 pandemic. These included disruptions to normal MDT working, challenges in undertaking face-to-face assessments and reviews, and an increased caseload and footfall - thereby increasing the demand for ICU trained dietitians. Despite these barriers, this service evaluation demonstrates that percentage feed delivery remained relatively stable when compared to the pre-COVID 2020 audit (n = 35) - 82.4% vs. 85% respectively. An independent-samples t-test was conducted to compare feed delivery in pre-COVID and COVID-19 samples. There was no significant difference in the scores for pre-COVID (M = 85%, SD = 13.4) and COVID (M = 82.4%, SD = 16.8) samples;t(180) = -0.81, p =.42. This is despite 36% of patients requiring proning during COVID vs. 0% pre-COVID, and increased gastrointestinal intolerance evidenced by 35% of patients requiring prokinetics vs. 29% pre-COVID. These factors eliminated the ability to utilise ‘catch-up’ feeding, which significantly improves feed delivery in normal circumstances. This suggests that changes in dietetic provision of service, including delivering a 7-day service, thereby allowing more prompt management of nutritional issues and improved access to dietetic expertise, facilitated the maintenance of the pre-existing high standards of nutritional care. Achieving this degree of feed delivery necessitated the use of a variety of different feeds – to manage tolerance, fluid volume, electrolyte imbalances and ensure nutritional adequacy. Adapting feeding regimens to best meet the patients need is a key role of the dietitian, and in the absence of dietetic input it is unlikely these feeding strategies would have been utilised. The COVID-19 pandemic presented new challenges and obstacles to eve y aspect of the healthcare sector;necessitating fast adaptations, novel methods of working and reinforcing the importance of multidisciplinary teams to guide patient care in the absence of evidence-based guidelines. This service evaluation demonstrates that forward-planning and the expansion of services in alignment with demand can assure that patient care need not be compromised, despite the unprecedented challenges and barriers presented by the COVID-19 pandemic.

A multi-disciplinary e-learning starter course - would you like some salt with that?

Introduction: Peripartum hyponatraemia is a potentially serious condition with implications for both mother and baby [1,2]. Pregnant women are more at risk of developing hyponatraemia due to a lower baseline sodium, impaired ability to excrete water, the antidiuretic effect of oxytocin and excessive fluid intake during labour. We found that peripartum hyponatraemia was often poorly managed and there was no trust guidance for diagnosis and management. Hence, we designed a new departmental protocol based on the GAIN guidelines [2]. Due to the impact of COVID 19 on traditional teaching methods,we upskilled staff by designing a tailored e-learning package using articulate software and re-assessed the team’s knowledge of the condition. Methods: After trust approval and advice from the hospital’s audit department, a local survey was sent out to members of the obstetric multi-disciplinary team before and after the introduction of a departmental peripartum hyponatraemia guideline together with its associated e-learning package. Results: We received a total of 74 responses. Initially, we identified a large proportion of the team were not confident in managing hyponatraemia. After implementation of our e-learning package, we demonstrated an increase in staff confidence (Figure). The initial survey showed much uncertainty surrounding the indications for fluid balance monitoring, prescription of intravenous fluids and management of hyponatraemia. However, results from the post e-learning survey showed improved knowledge in all these areas. Discussion: Our survey suggests that many members of the obstetric multi-disciplinary team were unfamiliar and not confident in managing peripartum hyponatraemia. However, a tailored e-learning programme is an extremely useful adjunct in highlighting new guidance, upskilling members of the team and changing the attitudes of the multidisciplinary team to unfamiliar medical conditions. (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.

OUTCOMES OF REMOTE PATIENT MONITORING AMONG PERITONEAL DIALYSIS POPULATION IN THE COVID-19 ERA

BACKGROUND AND AIMS: Automated peritoneal dialysis (APD) is a growing PD modality but as with other home dialysis methods, the lack of monitoring of patients' adherence to prescriptions is a limitation with potential negative impact on clinical outcome parameters. Remote patient monitoring (RPM-PD) allowing the clinical team to have access to dialysis data and adjust the treatment may overcome this limitation. As a result of the coronavirus disease 2019 (COVID-19) pandemic, the importance of RPM programs has raised to allow the physicians ensure optimal care of PD patients. In addition, to avoid the increased risk of complications or technique failure, the present study sought to determine clinical outcomes associated with RPM use in patients on APD therapy. METHOD: We performed a systematic review in PubMed, MEDLINE, Embase and Cochrane databases to select studies that met the inclusion criteria. The search terms used were: peritoneal dialysis, remote monitoring, sharesource, outcomes, peritonitis, hospitalization, technique failure and adherence. These search terms were individually used and then combined in different databases. References within the chosen studies were reviewed. We followed the recommendations of Cochrane collaboration and the Quality of Reporting of Meta-analyses guidelines. STATA package-15 was used. We combined all study-specific estimates using inverse-variant weighted averages of logarithmic relative risk in random effects model. Confidence interval including the value of 1 was used evident for statistically significant estimate. Heterogeneity was evaluated using the Higgins I2 statistic. Heterogeneity was estimated when the level of P-value was < 0.1. Results of the random effects model were spread out on the forest plot graph. RESULTS: Twenty-two studies were included in our meta-analysis. In qualitative analysis: five studies showed that RPM in APD patients had lower hospitalization rates compared to traditional PD. Five studies showed better adherence in the RPM-PD group. Five studies showed better outcomes among RPM-APD patients in terms of symptom control, management of fluid balance, blood pressure control, dialysis prescription and electrolyte management. Five studies showed that RPM-APD had better outcomes in terms of patient independence, quality of life, patient and caregiver satisfaction. Five studies showed better cost-effectiveness in RPM-PD compared to traditional PD. Four studies showed better cost-effectiveness in RMP-PD. Three studies showed lower technique failure rates in RPM-PD compared to traditional PD. Three studies showed lower mortality rates in RPM-PD compared to traditional PD. Three studies showed better quality of life and patient satisfaction in RPM-PD. In quantitative analysis, RPM-PD patients had lower rates of technique failure (log relative risk = -0.32, 95% CI: -0.59 to -0.04), lower hospitalization rates (SMD = -0.84, 95% CI: -1.24 to -0.45), lower mortality rates (log RR = -0.26, 95% CI: -0.44 to -0.08) in comparison to traditional PD. CONCLUSION: RPM-PD has better outcomes in terms of cost-effectiveness, patient adherence, hospital admissions, rate of peritonitis, technique failure, mortality rates, symptom control, quality of life, patient and caregiver satisfaction.

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).