New Onset Diabetes and Acute Pancreatitis- A Sequela of Long COVID?

Introduction: The association between worse COVID-19 outcomes and diabetes has been well-established in the literature. However, with more cases of new-onset diabetes and pancreatitis being reported with or after COVID-19 infection, it poses the question if there is a causal relationship between them. Case Description: 31 y/o female with COVID-19 infection 4-6 weeks ago with moderate symptoms (not requiring hospital admission or monoclonal ab), presented to ED with bandlike epigastric pain radiating to back, which is worsened with food, associated with nausea, vomiting, polyuria, and fatigue. Workup showed lipase 232, AST 180, ALT 256. Blood glucose was 281 and HbA1c was 12. CT A/P showed post cholecystectomy status, normal pancreas with mesenteric adenitis. MRCP showed hepatic steatosis with trace fluid around the pancreas s/o inflammation, and no evidence of choledocholithiasis or biliary dilatation. She denied alcohol use and autoimmune workup for pancreatitis was unremarkable. Islet cell antibodies were negative. The patient improved with fluid resuscitation and was discharged home on insulin with plans to transition to oral agents outpatient. Discussion(s): Long COVID is defined as a range of conditions or symptoms in patients recovering from COVID-19, lasting beyond 4 weeks after infection. A retrospective cohort study showed increased new-onset diabetes incidence in patients after COVID-19. This was redemonstrated in a systematic review and meta-analysis that showed a 14.4% increased proportion of new diagnoses of diabetes in patients hospitalized with COVID-19. Possible pathophysiology that have been attributed to this include undiagnosed pre-existing diabetes, hyperglycemia secondary to acute illness and stress from increased inflammatory markers during the cytokine storm, the effect of viral infections on the pancreas, and concurrent steroid use in patients with severe respiratory disease. The binding of SARS-CoV-2 to ACE2 receptors is thought to the other mechanism by which COVID can cause pancreatitis and hyperglycemia. Study showed increased lipase and amylase levels in patients with COVID and the increase in serum levels was proportional to the severity of the disease. Patients who died due to COVID-19 were also found to have degeneration of the islet cells. While, several studies have showed new onset diabetes and pancreatitis during an active COVID infections, we need larger cohort studies to comment on its true association or causation, especially in patients with long COVID symptoms. As more cases of new onset diabetes and pancreatitis with COVID-19 are being reported, there may be a need for more frequent blood sugar monitoring during the recovery phase of COVID-19.Copyright © 2023

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).

Recurrent intussusception with ileal perforation as a complication of Blue Rubber Bleb Nevus Syndrome in a pediatric patient

Blue rubber bleb nevus syndrome (BRBNS) is a rare congenital condition, characterized by multiple venous malformations that may involve any organ system, most commonly the skin or the gastrointestinal tract. These lesions are often responsible for chronic blood loss and secondary anemia, and in rare situations may cause severe complications such as intussusception, volvulus, and intestinal infarction. Intussusception as a complication of BRBNS, although a known complication of the disease, has rarely been reported, especially in the Philippines. In the Philippine Society for Orphan Disorders, only 2 cases of BRBNS are currently included in the organization, including the patient presented in the case report. The treatment of BRBNS that involves the gastrointestinal tract depends on the extent of intestinal involvement and severity of the disease. The treatment aims to preserve the GI tract as much as possible due to the high recurrence in the disease. In this case report, we present a 13 year-old male with BRBNS with previous history of intussusception, successfully managed conservatively;however, upon recurrence, underwent exploratory laparotomy wherein a subcentimeter perforation in the antimesenteric border of the proximal ileum was noted, together with a gangrenous intussuscipiens, and multiple mulberry-like formations on the antimesenteric border of the small bowels. Histopathological findings of the resected bowels showed multiple cavernous hemangiomas consistent with BRBNS. The postoperative course of the patient was unremarkable.Copyright © 2023 The Authors

Not all shortness of breath and throat pain is COVID

Case Report: A previously, healthy 18-year-old female presents to a Pediatric Emergency Medicine Department with shortness of breath, fever, and worsening throat and abdominal pain for 3 days. She had a sick contact, a teacher that tested positive for COVID-19 2 weeks prior to presentation. She denies runny/stuffy nose, cough, loss of taste/smell, or rashes/lesions. She denies any significant past medical history including allergies, as well as any history of smoking or any illicit drug use. Upon arrival to the ED, the patient was noted to be tachycardic, hypotensive and febrile. There were no desaturations. Initial physical examination revealed a generally uncomfortable female that was alert and oriented, with noted tenderness over the right anterior neck region, diffuse cervical lymphadenopathy, and painful neck range of motion. Her pharynx was noted to be erythematous without exudates or any unilateral tonsillar swelling. In the ED patient received IV fluid resuscitation and was started on norepinephrine drip, broad spectrum antibiotics. Initial lab workup revealed an anion gap metabolic acidosis, likely secondary to uremia or lactic acidosis from poor perfusion in setting of sepsis and hypovolemia. BUN and creatinine were elevated, likely due to an acute kidney injury (AKI) secondary to hypovolemia. The patient was also found to have an elevated LDH, fibrinogen, and mild elevation of AST. D-Dimer was elevated at 29 000. Covid PCR, Rapid Strep, and respiratory PCR panel were negative. Her chest X-ray (CXR) was negative and ECG showed sinus tachycardia. Given the patient's history of throat and neck pain with shortness of breath, in the setting of a septic picture, a CT scan of neck, chest, abdomen was ordered prior to transferring the patient to the PICU. CT scan of the chest revealed small patches of consolidation with ground glass opacities in the right lung apex, as well as an nearly occlusive, acute thrombosis of the anterior right facial vein. The patient's initial blood cultures grew gram negative bacilli which later were revealed to be Fusobacterium necrophorum. These findings are consistent with Lemierre's syndrome. The patient was treated in the PICU on vasopressors, heparin anticoagulation, and antibiotics for 6 days and discharged with a course of Augmentin. Lemierre's syndrome is an infectious thrombophlebitis of the internal jugular vein. First described by Andre Lemierre in 1936, it begins as a bacterial pharyngitis, generally developing into a peritonsillar abscess or other deep space neck infection with progressive erosion into the internal jugular vein. Diagnostic criteria for Lemierre's syndrome includes radiographically evidence of thrombophlebitis of the internal vein and positive blood cultures. CT and MRI can help make the diagnosis, but are not always required. Treatment is prompt intravenous antibiotics with beta-lactamase penicillins, metronidazole, clindamycin, and third generation cephalosporins. [Figure presented] Copyright © 2023 Southern Society for Clinical Investigation.

GATA2 deficiency presenting as fever and rash

Case Report: Our patient is an 8-year-old Caucasian female with a history of choanal atresia, first degree heart block, recurrent urinary tract infections, and recent COVID-19 infection, who initially presented with an episode of syncope and vomiting. By history, she had two weeks of daily fever and an intermittent nonspecific rash. She was diagnosed with a UTI 5 days prior to presentation but had not defervesced despite treatment. Shewas initially found to be in shock with tachycardia and poor perfusion and was treated with fluid resuscitation, antipyretics, and empiric antibiotics. Labs were significant for leukopenia, elevated inflammatory markers, lactic acidosis, coagulopathy, and mildly elevated troponin. Chest x-ray showed abnormal but non-specific widespread infiltrates. She was initially treated with IVIG and pulse steroids for a working diagnosis of MIS-C, however she did not improve and a more extensive infectious, oncologic, and rheumatologic work-up was performed. Her workup revealed a disseminated Mycobacterium abscessus infection. Bone marrow biopsy revealed myelodysplasia with monosomy 7. Her buccal swab testing revealed a heterozygous germline mutation in the GATA2 gene, a variant that is predicted to cause loss of normal protein function. She is presently on multidrug regimen for her mycobacterial infection. Her myelodysplasia evolved into an acute leukemia, and she is undergoing chemotherapy for that at this time. Discussion(s): GATA2 deficiency, first identified in 2011, is a rare immune disorder resulting in a wide variety of clinical presentations. It is caused by a germline mutation of the GATA2 gene that disrupts blood cell differentiation, resulting in decreased or absent monocytes, B cells, NK cells, and dendritic cells1. This case presented multiple challenges due to the broad range of differential diagnoses. This patient was ultimately diagnosed with myelodysplastic syndrome associated with monosomy 7 and GATA2 deficiency, confirmed by FISH testing. Due to the presentation and lab derangements this patient had, there was a delay in targeted treatment while managing her cytopenias and presumed pulmonary infection. GATA2 deficiency carries a high risk of progression from myelodysplastic syndrome to acute myelogenous leukemia. The best long-term treatment for GATA2 deficiency is hematopoietic stem cell transplant, which is the ultimate goal for our patient. Copyright © 2023 Southern Society for Clinical Investigation.

Paediatric Multisystem Inflammatory Syndrome Temporally Associated with Covid-19 (Pimsts) on High Dependency Unit - the Echocardiographic Findings and Inotropic Support

BACKGROUND AND AIM: PIMS-TS is a multisystem inflammatory condition which has high morbidity requiring intensive care, most commonly due to the need for cardiovascular support. AIM: Review of patients managed on high dependency unit with PIMS-TS - who required inotropic support and their echocardiographic findings. METHOD(S): This is a retrospective analysis of the echocardiogram and inotropic support for all children admitted to HDU with a diagnosis of PIMS-TS, from October 2020-December 2021. RESULT(S): Thirty (10%) patients were admitted to HDU from the 300 patients diagnosed over the 15month period. Echocardiograms were performed on days 1, 3 and 7 to assess the coronaries and myocardial dysfunction. Echocardiogram was often performed when patients were already on inotropic support. Fifteen (50%) patients did not require any respiratory support. All patients required fluid resuscitation, between 20mls/kg to 70mls/kg. Ten (33%) out of thirty patients showed reduced fraction shortening on echocardiogram reflecting myocardial dysfunction. Patients with reduced myocardial function on echocardiogram required a median of 40mls/kg of resuscitation fluid, no difference when compared to other patients. Of those with myocardial dysfunction 50% patients required double inotropic agents rather than single agents. Two patients have coronary arteries ectasia - both patients only needed single agents. CONCLUSION(S): Patients with coronary ectasia or myocardial dysfunction did not require more support than patients with normal coronaries. Echocardiography findings provided reassurance when managing children requiring vasoactive therapy on HDU but ultimately clinician decision-making was a driver on management rather than echocardiographic findings.

Impact of Paediatric Multisystem Inflammatory Syndrome Temporally Associated with Covid-19 (Pims-Ts) on Critical Care

BACKGROUND AND AIM: Alder Hey is a tertiary children's hospital in North-West England with co-located Intensive Care and High Dependency units. PIMS-TS is a multisystem inflammatory condition which has led to an increased demand on critical care beds. AIM: review of all patients managed on Critical Care with PIMS-TS. METHOD(S): A daily PIMS-TS multidisciplinary meeting attended by paediatrics, infectious diseases, rheumatology, cardiology and critical care discussed all patients in the region. This is a retrospective analysis of all children admitted to HDU or PICU with a diagnosis of PIMS-TS, from October 2020-December 2021. RESULT(S): Thirty (10%) patients were admitted to HDU from the 300 patients discussed over the 15month period. 16 (53%) of patients were female. Mean age was 10 years (range 3-17). Median length of stay (LOS) on HDU was 2 days (range 1-8) with a median hospital LOS of 6 days (range 2-10). All patients admitted were monitored appropriately and had full echocardiography assessment. All but one patient admitted to HDU required cardiovascular support, twelve (40%) patients required a single agent and seventeen (57%) required double agents with a combination of adrenaline, noradrenaline and milrinone. Median fluid resuscitation was 40mls/kg (range 20-70mls/kg). Eight patients (27%) were escalated to PICU for either invasive ventilation (4) or higher vasopressor requirements than 0.2micrograms/kg/minute. There were no adverse events. CONCLUSION(S): Most children with PIMS-TS have low to moderate haemodynamic instability can be safely managed on HDU with appropriate monitoring and agreed limits to vasopressor therapy.

A Comparison of Pediatric Icu Presentation of Mis-C, Kawasaki Disease, Toxic Shock, and Septic Shock

INTRODUCTION: With the COVID19 pandemic there has been a rise of Multisystem Inflammatory Syndrome in Children (MIS-C) cases that have similar symptoms to Kawasaki Disease Shock Syndrome (KDSS), Toxic Shock Syndrome (TSS) and Septic Shock (SS). To differentiate between presenting clinical symptoms, laboratory values and vasoactive requirements would aide in the proper early diagnosis of these diseases. METHOD(S): This was a single center retrospective review of MIS-C, KDSS, TS, and SS patients admitted to the PICU. Mann-Whitney U testing compared each patient population to each other using admission laboratory values, VIS, fluid resuscitation, day of illness admitted, and physical exam findings. RESULT(S): SS and TS patients presented earlier to the ICU compared to MIS-C and KDSS (2 and 2 vs 4.5 and 5, p< 0.001). TS had the highest VIS compared to MIS-C (p=0.005), KDSS (p=0.009), and SS (p=0.008). MIS-C was found to utilize the least fluid resuscitation but only found to be different between MIS-C and TS (p< 0.001). MIS-C had the lowest ejection fraction compared to KDSS (p=0.02), TS (p< 0.001), and SS (p< 0.001). MIS-C patients presented with a highest CRP (24.8 mg/dL) but only found to be different from SS (p=0.01). MIS-C appeared to have a lower WBC (11.4 TH/ uL) compared to KDSS (13.3 TH/uL, p=0.004) and TSS (14.4 TH/uL, p=0.04). KDSS was found to have a greater platelet count (249 TH/uL) compared to MIS-C (128 TH/uL, p< 0.001), TSS (169 TH/uL, p=0.003), and SS (186 TH/uL, p=0.03). TSS had the largest presenting INR (1.50) compared to KDSS (1.25, p=0.009), SS (1.25 TH/uL, p =0.04) and MIS-C (1.13 TH/uL, p< 0.001). MIS-C had a lower sodium (132mmmol/L) compared to TSS (135mmol/L, p< 0.0001) and SS (138mmol/L, p< 0.0001). Patients with KDSS were found to have oral and extremity changes compared to MIS-C (p=0.02, p=0.002). KDSS likely had a cervical lymph node on presentation compared to TSS and SS (p=0.03, p=0.02). MIS-C and KDSS were more likely to have conjunctivitis compared to TSS and SS. CONCLUSION(S): MIS-C was found to have a lower WBC, lower sodium, lower ejection fraction, and required less fluid resuscitation. TSS had the highest VIS and had the highest INR. KDSS and MIS-C had more conjunctivitis and presentation than SS and TSS. KDSS had more oral and extremity changes compared to MIS-C.

Patient with Presumed Asthma Develops Flash Pulmonary Edema Secondary to Undiagnosed Cor Triatriatum

INTRODUCTION: A patient with presumed status asthmaticus, treated with beta-agonist and fluid resuscitation, developed flash pulmonary edema and respiratory failure in the setting of undiagnosed cor triatriatum. DESCRIPTION: A teen male with history of asthma developed dyspnea and chest pain at work. At a local emergency room (ER), he received albuterol, steroid, magnesium sulfate, and 2 liters (L) of fluid. Chest X-ray (CXR) and computed tomography of the chest were normal. He was transferred with a diagnosis of status asthmaticus. On exam in the pediatric ER, he had tachycardia, tachypnea and diffuse wheezing. He received albuterol 20mg/hour and 3L of fluid boluses over several hours. Despite improvement in wheezing, the patient had ongoing tachycardia and chest pain. He was placed on oxygen by high-flow nasal cannula. Repeat CXR exhibited new diffuse airspace opacities, and a focused cardiac ultrasound showed a hyperdynamic left ventricle (LV) with normal function. The patient began to expectorate pink frothy fluid, with hypoxemia, requiring intubation. Covid-19 PCR, Troponin-I and B-Type Natriuretic peptide were negative. An echocardiogram revealed a dilated left atrium (LA) with an echogenic membrane within the LA, separating the pulmonary venous chamber from the LA and restricting blood flow into the LV. The LV was small in size with normal function. The right heart was normal. These findings were consistent with diagnosis of cor triatriatum sinister, whereby the LA is divided into two compartments by a membrane that can variably obstruct flow into the LV. For this patient, treatment with beta-agonist caused tachycardia and decreased LV filling. Fluid resuscitation increased intravascular volume. This combination worsened obstruction of blood flow from the LA to the LV, leading to flash pulmonary edema, respiratory failure, and shock. In the ICU, the patient underwent diuresis, and the cor triatarium membrane was later surgically resected. DISCUSSION: Asthma is encountered commonly in children. Patients not responsive to treatment for respiratory distress should have alternative diagnoses considered. Multiple cognitive biases led to delayed recognition of cardiac etiology as the cause for this patient's respiratory failure, including anchoring bias with premature closure.

Hemoperfusion in a COVID-19 Patient With Severe Burn Injuries

Introduction: Severe burn injury can cause effects in cellular mechanisms known as systemic inflammatory response syndrome. Survival rate is decreased in patients with severe burns with the added insult of this inflammatory response. Optimizing management for these patients can include utilization of hemoperfusion to decrease inflammatory reposnse and mortality rate. The use of hemoperfusion is not usually included in the initial treatment but few studies showed promising benefits. Case Description: A 29-year old male who works in smelting industry, had a flame burn injury. Upon arrival in the ER, COVID-19 RT PCR oral and nasopharyngeal swab turned out to be positive, and he was transferred to a COVID critical care unit. Altogether there was ~67% TBSA affected. Fluid resuscitation was started with saline alternating with Lactated Ringer's solution. Surgeries were done sequentially. There was a high inflammatory state on the 2nd hospital day as shown by high-grade fever with a temperature of 38-39oC and elevated CRP of 48 and Procalcitonin at 22.51 ng/mL. Hemoperfusion was done for three consecutive days from 2nd to 4th hospital day using HA330 cartridge. Urine output and biochemical markers eventually improved (Fig. 1). Discussion(s): Hemoperfusion is indicated to remove cytokines in patients with sepsis and systemic inflammatory response syndrome. There were several studies with conflicting evidence for the use of hemoperfusion and other forms of extracorporeal therapies in an inflammatory state. Hemoperfusion done in this case involves the use of a standard hemodialysis machine done for 3 consecutive days using the HA330 cartridge for 3 hours each session. The return of levels to baseline or normal procalcitonin plasma concentrations have a high negative predictive value to rule out severe systemic inflammation. The indication for hemoperfusion in severe burn injury patients with severe inflammatory response syndrome still remains experimental. There is no current recommendation for the use of hemoperfusion specifically on burn patients, and further clinical trials were recommended. (Figure Presented).

Impact of Paediatric Multisystem Inflammatory Syndrome Temporally Associated with Covid-19 (Pims-Ts) on Critical Care - an Hdu Experience

Aims Background Alder Hey is a tertiary children's hospital in North-West England with co-located Intensive Care and High Dependency units, covering North West England, North Wales and Isle of Man. PIMS-TS is a new multisystem inflammatory condition which has led to an increased demand on critical care beds. Some children presenting with PIMS-TS need haemodynamic support in the form of inotropes, which would traditionally need an PICU bed. Aim Review of all patients managed on Critical Care with PIMS-TS. Methods All patients in the region were discussed in a PIMSTS multidisciplinary meeting attended by Paediatrics, Infectious Diseases, Rheumatology, Cardiology and Critical Care daily. Patients across the region needing haemodynamic support or cardiology evaluation were highlighted as, in need of either HDU or PICU bed and transferred by the North West & Wales Paediatric Transport Service (NWTS). This is a retrospective analysis of all children admitted to HDU or PICU with a diagnosis of PIMS-TS, from October 2020-December 2021. Results Thirty (10%) patients were admitted to HDU from the 300 patients discussed over the 15month period. 16 (53%) of patients were female. Mean age was 10 years (range 3-17). Median length of stay (LOS) on HDU was 2 days (range 1-8) with a median hospital LOS of 6 days (range 2- 10). All patients admitted were monitored appropriately and had full echocardiography assessment. Twenty nine (97%) patients admitted to HDU required inotropic support, twelve (40%) patients required a single agent and seventeen (57%) required double agents with a combination of adrenaline, noradrenaline and milrinone. Median fluid resuscitation was 40mls/kg (range 20-70mls/ kg). Eight patients (27%) were escalated to PICU for either invasive ventilation (4) or higher inotropic requirements of 0.2micrograms/kg/minute. There were no adverse events. Conclusion Most children with PIMS-TS have low to moderate haemodynamic instability that can be safely managed on HDU with appropriate monitoring and agreed limits to vasopressor therapy. Our experience in managing with these patients successfully and safely in a high dependency setting has helped in the use of a critical care bed efficiently, thus reducing dependency on the availability of a PICU bed.

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.

A UNIQUE CASE OF SEVERE PULMONARY NOCARDIOSIS PRESENTING WITH ARDS AND CARDIOGENIC SHOCK

SESSION TITLE: Shock and Sepsis in the ICU Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Nocardiosis is a rare bacterial infection, which frequently affects immunocompromised patients. It can present as an acute, subacute, or chronic pulmonary infection with non-specific symptoms, such as fever, cough, dyspnea, weight loss, and hemoptysis. CASE PRESENTATION: A 34-year-old female with a history of chronic granulomatous disease and hidradenitis suppurativa on adalimumab presented to the ED with fever, shortness of breath, and productive cough of 2 days. Her vitals were T 101F, BP 66/48, HR 148, RR 42, and SPO2 94% on room air. On exam, she was cachectic, with bilateral crackles and rales in the right lung base. Extremities were cold, with trace pitting edema was present on bilateral lower extremities. COVID-19 PCR was negative. Despite fluid resuscitation, she remained hypotensive and was started on norepinephrine. Blood cultures were collected, and broad-spectrum antibiotics and an antifungal agent were initiated. Chest CT demonstrated bilateral multifocal consolidation with surrounding ground-glass opacities and complete consolidation of the right lower lobe. Due to worsening respiratory distress and tachypnea, and lack of improvement with non-invasive ventilation, she was intubated, placed on mechanical ventilation, and admitted to the Medical ICU. On hospital day 1, due to the patient's immunosuppression, unresolving shock, and radiographic findings, a bronchoscopy with bronchoalveolar lavage (BAL) was performed. On hospital day 2, a transthoracic echocardiogram showed LV ejection fraction of 20-25% with severe global hypokinesis of the LV. ACS workup had been unremarkable, with mildly elevated troponin and no ischemic changes on EKG. She was initiated on cardiac inotropes. On hospital day 3, BAL culture revealed Nocardia cyriacigeorgica. TMP-SMX and ceftriaxone were started for severe pulmonary nocardiosis. On hospital day 11, she was liberated from mechanical ventilation, and by hospital day 14, she was weaned off all pressors and inotropes. Approximately 4 weeks after admission, repeat TTE showed recovery of LV ejection fraction (55-60%) and she was discharged with a prolonged course of TMP-SMX and IV ceftriaxone, with duration to be determined at outpatient infectious disease follow-up. DISCUSSION: We discuss a unique case of severe pulmonary nocardiosis, presenting with ARDS and cardiogenic shock. To the best of our knowledge, this is the first case of a patient with pulmonary nocardiosis presenting with stress cardiomyopathy reported in the literature. While the pathophysiology is not well understood, theorized mechanisms include catecholamine excess, coronary artery spasm, microvascular dysfunction. CONCLUSIONS: This case highlights the need for a broad differential diagnosis in patients presenting with ARDS and cardiogenic shock and illustrates the value of clinical bronchoscopy in patients with unique presenting features. Reference #1: Lerner PI. Nocardiosis. Clin Infect Dis. 1996 Jun;22(6):891-903;quiz 904-5. doi: 10.1093/clinids/22.6.891. PMID: 8783685. Reference #2: Wittstein IS, Thiemann DR, Lima JA, Baughman KL, Schulman SP, Gerstenblith G, Wu KC, Rade JJ, Bivalacqua TJ, Champion HC. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med. 2005 Feb 10;352(6):539-48. doi: 10.1056/NEJMoa043046. PMID: 15703419. Reference #3: Park JH, Kang SJ, Song JK, Kim HK, Lim CM, Kang DH, Koh Y. Left ventricular apical ballooning due to severe physical stress in patients admitted to the medical ICU. Chest. 2005 Jul;128(1):296-302. doi: 10.1378/chest.128.1.296. PMID: 16002949. DISCLOSURES: no disclosure on file for D. Clark Files;No relevant relationships by Nisha Patel No relevant relationships by Meehir Shah

SAFETY OF 30-ML/KG IV FLUID ADMINISTRATION PER SEP-1 TO ADULT PATIENTS IN THE ED MEETING CRITERIA FOR SEPTIC SHOCK BEFORE KNOWN COVID-19 STATUS

SESSION TITLE: Outcomes Across COVID-19 SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: ED clinicians play a critical role in the early detection and management of septic shock. Intravenous fluid (IVF) resuscitation is a central component of the recommended treatment for septic shock (SEP-1), but experts have expressed concerns that excessive fluid administration to patients with COVID-19 could lead to poor clinical outcomes due to the development of ARDS like lung physiology. COVID-19 status is often unknown in the first several hours after ED arrival and withholding adequate IVF resuscitation to patients with septic shock is known to be harmful. Our objective was to evaluate whether adult ED patients meeting criteria for septic shock (≥2 SIRS + initial lactate ≥4 or Mean Arterial Pressure (MAP) <65) who receive 30ml/kg of IV fluids in the ED have poor clinical outcomes, if they are later found to have COVID-19, compared to adult ED patients with non-COVID-19 septic shock. METHODS: In this retrospective cohort study we analyzed EHR of adult patients who visited any of 3 EDs within a single academic health system in Rhode Island. We included patients who had a discharge diagnosis of septic shock and presented to the ED between February 15 -September 30, 2020. The exposure was the receipt of 30ml/kg of IVF and outcomes were intensive care unit (ICU) admission, ventilator receipt, and inpatient mortality. We used multivariate logistic regression and adjusted for fluid volume, age, receipt of antibiotics, and Charlson Comorbidity Index. RESULTS: Of 278 patients with septic shock, 39 (14%) were COVID positive. 15 (38%) COVID positive patients received 30ml/kg IVF per SEP-1 bundle compared to 163 (68%) of COVID negative patients. The overall inpatient mortality rate of COVID positive septic shock patients (n=25, 64%) was three times higher as compared to COVID negative septic shock patients (n=51, 21%). Receipt of 30ml/kg IVF in the ED did not increase the odds of ICU admission [AOR 0.46 (0.07-3.26), p = 0.43], receipt of ventilator [AOR 0.40 (0.07-2.28), p=0.30], or inpatient mortality [AOR 0.15 (0.020-1.10), p=0.06] in patients who were COVID positive. However, in COVID negative patients, receipt of 30ml/kg IVF in the ED significantly reduced the odds of ICU admission [AOR 0.50 (0.27-0.93), p=0.029], receipt of ventilator [AOR 0.41 (0.22-0.74), p=0.003] and inpatient mortality [AOR 0.44 (0.22-0.87), p=0.018]. CONCLUSIONS: Optimal and timely fluid resuscitation per the SEP-1 bundle reduces the odds of unfavorable clinical outcomes in patients with septic shock who test negative for COVID-19, while causing no increased odds of harm to patients with COVID-19 and septic shock. Replication of our work in a post-vaccination cohort and during waves with different variants is advisable as the clinical outcomes may vary. CLINICAL IMPLICATIONS: Early fluid resuscitation in patients diagnosed with septic shock in the ED appears to be a safe strategy even in patients that are later diagnosed with COVID-19. DISCLOSURES: No relevant relationships by Natalie Davoodi No relevant relationships by Elizabeth Goldberg No relevant relationships by Richa Nahar

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

Tension Pneumomediastinum in COVID-19 ARDS Patient Managed with Percutaneous Ultrasound-guided Catheter Insertion: A Case Report

Introduction: Tension pneumomediastinum is a condition in which there is a trapping of air in the mediastinum with a resultant increase in the pressure causing compression of the great vessels which leads to decreased venous return and cardiovascular collapse. It is a rare and severe form of pulmonary barotrauma in ICU ventilated patients which can lead to refractory hypotension and death if not addressed at the right time. Case description: A 42-year-old man with no known comorbidities referred to our centre in view of severe COVID ARDS with refractory hypoxemia. Endotracheally intubated and put on ventilatory support. Developed shock not responding to fluid resuscitation and was started on IV vasopressor infusion. CT chest revealed tension pneumomediastinum. The patient continued to worsen clinically with hypotension and hypoxia despite low PEEP and high FiO2 ventilation. So bedside USG-guided pigtail catheter was inserted into the anterior mediastinum using a modified Seldinger technique following which there was a rapid clinical improvement. Conclusion: Tension pneumomediastinum is a rare and life-threatening cause of refractory hypotension and hypoxia in mechanically ventilated ARDS patients and bedside ultrasound-guided intervention is a feasible and quick therapeutic option. Highlights: A review of the literature showed very few case reports of tension pneumomediastinum in mechanical ventilated ARDS patients. Because ultrasound of the chest gives air artefacts and poor visualization in patients with pneumomediastinum and subcutaneous emphysema, CT-guided drainage catheters insertion is the standard of care. But in a very sick ICU patient, bedside ultrasound-guided catheter insertion could be a safe and immediate measure to save a patient's life. To our knowledge, this is the first case report of an adult ARDS patient with tension pneumomediastinum managed with bedside ultrasound-guided catheter insertion.

Fluid Management 100% Non-invasive for COVID Patient in ICU by Sterling Stroke Volume Guided Resuscitation ABS0007)

Aim and objective: Non-invasive fluid management in COVID shock patient in ICU. Materials and methods: Our hospital use sterling stroke volume-guided fluid management for COVID shock patients. In the University of Kansas health system evaluated 200 cases for stroke volume (sv) guided fluid resuscitation this study showed ICU length of stay reduced by 2.89 days, risk of mechanical ventilation reduced by 51%, initiation of acute dialysis therapy reduced by 13.2%, this system saves an estimated $14498 per treated patient this system use Bioreactance technology to measure sv in shock patient in two sensor place above the heart and two below the heart and continue measurement of sv done in 48 seconds. Validation studies over 500 patient published clinical studies result are same all major technologies (Swan Ganz, pulse contour, Doppler, fick) and over 100 peer-reviewed publications are there. This technique is 100% non-invasive accurate flexible-this sterling system use PLR or bolus test for sv management we are using in emergency for our Rapid Response Team in MICU OT for perioperative fluid management and all surgical ICU. Results: 1 ICU length of stay reduced by 2.89 days 2 risk of mechanical ventilation reduced by 51% 3 initiations of acute dialysis therapy reduced by 13.5% 4 save an estimated $14498 per treated patient. Conclusion: Sterling monitoring platforms use unique, patented Bioreactance technology to take measures continuously and precisely, and they require only four easy to place sensor pads. The sensors can be- anywhere on the chest two above the heart and two below the heart to create a box around the heart we advise sterling stroke volume guided fluid management in emergency medical ICU surgical ICU and perioperative and RRT for accurate fast and 100% non-invasive technique for COVID patient.

2021: Perioperative and critical care year in review for the cardiothoracic surgery team.

For yet another year, our lives have been dominated by a pandemic. This year in review, we feature an expert panel opinion regarding extracorporeal support in the context of COVID-19, challenging previously held standards. We also feature survey results assessing the impact of the pandemic on cardiac surgical volume. Furthermore, we focus on a single center experience that evaluated the use of pulmonary artery catheters and the comparison of transfusion strategies in the Restrictive and Liberal Transfusion Strategies in Patients With Acute Myocardial Infarction (REALITY) trial. Additionally, we address the impact of acute kidney injury on cardiac surgery and highlight the controversy regarding the choice of fluid resuscitation. We close with an evaluation of dysphagia in cardiac surgery and the impact of prehabilitation to optimize surgical outcomes.

IDIOPATHIC ISOLATED RIGHT VENTRICULAR DYSFUNCTION IN THE SETTING OF RECENT COVID-19 INFECTION: A CASE REPORT

CASE: We describe a case of isolated acute right ventricular (RV) strain not attributable to pulmonary embolism (PE) or Acute Respiratory Distress Syndrome (ARDS) in the setting of recent COVID-19 infection. A 77-year-old male with medical history notable for type 2 diabetes, obesity, chronic kidney disease, obstructive sleep apnea, and chronic hypoxemic respiratory insufficiency with a last known left ventricular ejection fraction (LVEF) of 77% on admission with preserved RV function, and recent COVID-19 infection was admitted for septic shock secondary to a post-viral MRSA pneumonia 12 days after diagnosis with COVID-19. On day 5 of admission, after completion of antibiotic therapy and resolved shock, the patient developed relative hypotension and an oliguric acute kidney injury with creatinine of 1.9 (previously 1.0) and urine microscopy findings consistent with acute tubular necrosis. EKG at the time showed new incomplete right bundle branch block. On day 8 of admission, relative hypotension continued with an uptrend in creatinine to 4.8 despite adequate fluid resuscitation. EKG showed new complete right bundle branch block with high-sensitivity troponin peaking at 550 (previously 15). A transthoracic echocardiogram showed enlarged RV and isolated severe hypokinesis of the RV mid-free wall consistent with “McConnel's sign” and acute right heart strain, with poorly visualized left ventricle, but without regional wall motion abnormalities. CTA Chest evaluating through the segmental arteries ruled out acute PE. Acute coronary syndrome was ruled out with traditional and right-sided EKG. Oxygen requirements remained unchanged throughout the course of his admission. The patient was transferred to the ICU for undifferentiated shock requiring triple pressor therapy and eventually died from acute renal failure and volume overload. IMPACT/DISCUSSION: While RV strain secondary to ARDS and PE has been implicated in COVID-19 and found to be an independent predictor of mortality, there is limited literature describing isolated RV dysfunction in their absence. Increasing reports showing cardiac microthrombi in autopsies of COVID-19 patients suggest alternate etiologies of RV injury and suggest potential utility of empiric therapeutic anticoagulation in all patients presenting with COVID-19. Alternatively, direct viral injury isolated to the RV may be unique in COVID19. Additionally, “McConnell's sign” combined with enlarged RV is traditionally considered a specific marker of PE, with reported specificity of 94% in the original report. However, there are increasing reports shedding doubt on the specificity of this finding. CONCLUSION: This case demonstrates the need to consider alternate etiologies for RV dysfunction in COVID-19, including microthrombi and direct viral injury. Additionally, this case adds to the growing literature demonstrating the limitation of “McConnell's sign,” even in patients with high suspicion for PE.