Determining Extracellular Water Effects in Mild and Severe COVID-19 Pneumonia Clinical Course by using the Bioimpedance Method

Aim: Coronavirus disease-2019 (COVID-19) pneumonia is characterized by a clinical picture showing similar features in severe patients. Some studies evaluate the pathophysiology, prognosis, and treatment of COVID-19 pneumonia. Different laboratory tests have been used to assess the severity and prognosis of rigorously ill COVID-19 patients in addition to clinical and radiological findings. There is no precise indicator for predicting prognosis. We aimed to analyze disease severity by using extracellular water (ECW) measurements. Methods: Extracellular water values and cardiac parameters as cardiac output (CO), and stroke volume (SV) measurements of patients were performed using a non-invasive, easy-to-use, validated device non-invasive cardiac system (NICaS) within the first 2 h after admission. Hemodynamic parameters and ECW values were measured by connecting the NICaS device to make 12 measurements for 2 h at 5 min intervals during admission to service and intensive care patients. Results: Comparing the ward and intensive care groups, there was not any statistically significant difference found between demographic data and ECW, SV, and CO measurements. Conclusion: Although we could not find a statistically significant difference between our measurements, we believe that the NICaS device can play a significant role in the fluid treatment of COVID-19 patients. © 2023 by the Istanbul Haseki Training and Research Hospital.

Right heart catherisation - a virtual reality

Introduction: Right heart catheterisation (RHC) is the gold standard for assessing patients with pulmonary hypertension. Doctors require training in this procedure in a safe and friendly environment with minimal risk to patients. Due to the Covid pandemic, formal RHC teaching workshops were cancelled in our country, so we sought to develop a Virtual Reality Right Heart Catheterisation (VRRHC) training program to fulfil this area of need without the need for face to face contact. The aim was to improve training, competency and confidence in this technique with improved diagnostic skills and reduction of procedural errors. Method(s): We approached a health technology company to design a VRRHC training module based on our current RHC simulation workshops. Phase 1 required virtual insertion of RHC via the right internal jugular vein using micro-puncture, double Seldinger technique under ultrasound guidance, followed by insertion of the RHC to the right atrium, right ventricle and pulmonary artery with pulmonary artery occlusion using real time pressure tracings and fluoroscopy. Thermodilution cardiac outputs and chamber saturations were also performed. The proprietary platform technology was delivered via a laptop and VR headset. Clinicians perform the VRRHC with imaging, monitoring and haptic feedback with the collection of real time performance tracking allowing user data (e.g. failed steps and proficiency scores) to be captured and subsequently visualised in the learning management system. We collected analytics and data on user engagement, experience and retention, targeted learning outcomes and learning curve, reduction in operating costs, reduction in procedure times due to higher proficiency, early diagnosis of pulmonary hypertension, reduced complications, improved interpretation and diagnosis. Result(s): The program was launched in October 2021. Preliminary data shows a learning curve is associated with both using VR (10-15 minutes) and the RHC procedure itself. Initial time to completion of the RHC was 30-40 mins, reducing to 20-30 minutes with experience and 15 minutes in experts. Completion rates increase with experience from 40-50% to 100% and error rates reduce with frequency of completion. Conclusion(s): A Virtual Reality Right Heart Catheter training program is safe, feasible and non-invasive. Increased experience results in increased completion rates, reduced procedure time and reduced errors. Using this program will potentially have beneficial effects on doctor training, outcomes, patient safety and health economics with no risk to a real patient. VRRHC images VRRHC hardware and utilisation.

Management of Pediatric Pulmonary Hypertension Using Remote Pulmonary Artery Pressure Sensor Monitoring

Background Management of pediatric pulmonary hypertension (PH) may require manipulation of multiple receptor sites to maximize response to medical therapy. Assessment of response typically occurs through imaging, labs, physical exam and recurrent cardiac catheterization, with anesthetic exposure to assess pulmonary artery pressures (PAP) and vascular resistance (PVR). We aimed to assess feasibility, safety and utility of remote PAP monitoring in pediatric PH patients. Methods We reviewed 4 pediatric patients with significant PH, each of whom underwent cardiac catheterization with pulmonary vasoreactivity testing and placement of a CardioMEMS remote PAP monitoring device. Results Four patients (P1-4: ages 5, 6, 8 and 10 years old) underwent CardioMEMS insertion without procedural complication. P1, P2 and P3 presented with unrepaired VSD;ASD with partial anomalous pulmonary venous return;and ASD and PDA, respectively, while P4 had prior repair of atrioventricular canal. Three patients had Down syndrome. All had elevated PAP and PVR. Mean left lower PA branch size was 7 mm. Mean PAP prior to therapy was 70 mm Hg for P1, 82 for P2, 93 for P3 and 30 for P4. All 4 patients required initiation of triple therapy for treatment of PH, with improvement or normalization of PAP by CardioMEMS, which also included surgical or catheter based intervention for 3 patients. Post-repair of P2, he was unable to be separated from cardiopulmonary bypass and was placed on ECMO. Right ventricular cardiac output improved over 2 weeks, with improvement of PAP determined through serial CardioMEMS. He was successfully decannulated, utilizing CardioMEMS in the OR. Two patients also developed COVID respiratory infections at home with CardioMEMS assessments allowing for oxygen and medication titration. Conclusion Remote PAP monitoring is feasible and appears safe in pediatric patients with adequate PA size. It allows for manipulation of medical therapy with real time knowledge of impact on PAP and can augment management during weaning of mechanical cardiac support. It may also augment decision-making in management of PH patients with developmental disabilities in whom traditional assessments may be more challenging.Copyright © 2023 American College of Cardiology Foundation

CT Transit Time And Its Correlation To Cardiac Output Derived From Mr

Introduction: Pulmonary transit time (PTT), the time taken for contrast to travel from the left to right ventricle, can be used as a surrogate marker for cardiac output. There have been previous studies evaluating the prognostic significance of Magnetic Resonance (MR) and Computed Tomography (CT) PTT in heart failure patients. This study used dynamic CT images to determine the PTT and study its correlation with left and right ventricular ejection fraction and left and right cardiac output in COVID patients, with a known range of cardiac outputs. Method(s): 123 COVID-19 patients were retrospectively studied. A single contrast bolus timing scan was acquired with a 320-detector CT (Acquilion ONE, Canon). A single 2 mm slice was placed axially where left and right ventricle and descending aorta were visualised. Contrast administration and scan acquisition began at the same with 20 ml of Omnipaque with 40 ml saline flush at 5 ml/s. One image was acquired every second and the total scan time was 26 seconds. A circular ROI was placed in the centre left and right ventricle, the signal intensity was plotted over time for each of these regions. Matlab software was used to extract the peak contrast time between the right and left ventricles. MR cardiac images were acquired on a 3 T Prisma, which determined MR PTT, left and right ejection fraction (LVEF, RVEF) and left and right ventricle cardiac output (LVCO, RVCO). These values were already computed from a previous study where this data was taken from. Correlations were studied using the Pearson correlation method using Minitab software. Result(s): There was correlation between MR PTT and LVEF and RVEF, r = - 0.433 p<0.05 and r=-0.358 p<0.05 respectively. A correlation was also seen with CT PTT and LVEF (figure 1) and RVEF, r=-0.-345 p<0.05 and r=-0.2 p=0.029 respectively. A correlation was seen for MR PTT and LVCO and RVCO, r=-0.322 p<0.05 and r=-0.295 p<0.05 but not for CT PTT and LVCO and RVCO, r=-0.1 p=0.297 and r=-0.04 p=0.668 respectively. Conclusion(s): A correlation was seen between MR PTT and CT PTT for both LVEF and RVEF, but this was not seen for CT PTT and LVCO and RVCO. Further work is required to understand the limitations of the CT PTT and why it fails to correlate with these parameters. Limitations may include dynamic CT temporal resolution or due to poor image quality due to motion from breathing. Compared to previous studies there is agreement between the MR PTT and MR cardiac parameters. At this stage there is an indication that CT PTT could be a potential tool to estimate LVEF and RVEF. [Formula presented]Copyright © 2023

Successful Use of Biventricular Assist Devices in Fulminant Myocarditis

Background Fulminant myocarditis can cause biventricular dysfunction with a mortality rate over 40%. We report a case with severe biventricular failure due to fulminant myocarditis that was successfully supported by left and right ventricular assist devices. Case A 65-year-old woman presented with chest pain, abdominal pain and diarrhea. She was hypotensive and labs revealed elevated troponin-T of 13.5 ng/mL and lactate of 4.3 mmol/L. She was positive for COVID by antigen testing. She was started on multiple vasopressor infusions and admitted to the intensive care unit. Echocardiogram revealed a severely reduced left ventricular ejection fraction of 15% and severe global hypokinesis. The following day, she developed a wide complex tachycardia that was refractory to amiodarone, lidocaine and multiple defibrillation attempts. She was transferred emergently to the cardiac cath lab where coronary angiography revealed an isolated 70% stenosis of the distal left circumflex artery. A Swan-Ganz catheter was placed that yielded a cardiac index by Fick of 1.2 L/min/m2, systemic vascular resistance of 1270 dynesseccm-5 and mixed venous oxygen saturation of 35%. Decision was made to emergently insert an Impella CP device. That evening, she developed complete heart block and transvenous pacing wire was inserted. Due to frequent suction alarms, decision was made to insert ProtekDuo device, which resulted in hemodynamic stabilization. A temporary coronary sinus pacing lead for atrial capture was inserted to improve atrioventricular synchrony. After several days of monitoring, repeat echocardiogram showed complete recovery of biventricular function and Impella CP and ProtekDuo devices were removed. Decision-making The decision of early implantation of ProtekDuo device was made to provide adequate blood flow to the left ventricular assist device for hemodynamic support. In addition, increased atrioventricular synchrony via insertion of temporary coronary sinus pacing wire improved cardiac output. Conclusion Fulminant myocarditis involving biventricular dysfunction can be supported by the use of simultaneous left and right ventricular assist devices.Copyright © 2023 American College of Cardiology Foundation

Acute Myocarditis: Secondary to Viral Infection or Pheochromocytoma?

Background In a young healthy patient, acute cardiogenic shock with a dilated, thickened left ventricle is strongly suggestive of acute myocarditis. Case SM is a 33 year-old healthy man who presented with decompensated heart failure with severe hypervolemia. Notably, he was exposed to Hand-Foot-Mouth disease (HFMD) two weeks prior. B-type natriuretic peptide was elevated at 3,417 pg/mL (normal range < 50 pg/mL), and troponin was elevated. Echocardiogram revealed dilated, severe systolic dysfunction with thickened left ventricular walls. He progressed to cardiogenic shock and multi-organ failure. Right heart catheterization revealed significantly reduced cardiac output and index of 2.36 and 1.2, respectively. His course was complicated by left ventricular thrombus and subacute embolic stroke, acute renal failure and liver failure. He was treated with afterload reduction, inotropes, and diuresis. His shock resolved, and he improved with medical therapy for cardiomyopathy. Decision-making The clinical course is consistent with acute myocarditis leading to cardiogenic shock with multi-organ failure. A broad differential was considered, including viral etiologies, autoimmune diseases, vasculitis, and toxin-mediated myocarditis. Viral labs including COVID-19 and influenza, as well as HIV, and hepatitis B and C viruses were negative. Coxsackie B2 antibody was positive at 1:80, which is consistent with past or current infection. Rheumatology evaluation was unrevealing, and vasculitis was deemed unlikely given normal inflammatory markers. Urine drug screen was unrevealing. However, adrenergic myocarditis remained on the differential given an adrenal nodule noted on imaging. Plasma free metanephrines were significantly elevated, consistent with pheochromocytoma. Conclusion This is a case of acute myocarditis with two likely etiologies. The patient's presentation correlates temporally with exposure to HFMD, suggesting viral myocarditis. However, he had gross hypervolemia and diuresed 50 pounds, which suggests a more indolent course. We propose that he had adrenergic myocarditis and undetected cardiomyopathy which was exacerbated by a second insult, the Coxsackie virus.Copyright © 2023 American College of Cardiology Foundation

The post-anaesthetic care unit re-imagined: Whipps Cross Hospital's COVID-19 recovery initiative

The surgical demand upon the NHS was of concern prior to the COVID-19 pandemic, it has now worsened. The waiting list may rise from 6 to 14 million. One in five of these patients require admission and potential access to more than level 1 care [1]. The anaesthesia and perioperative medicine Getting It Right First Time (GIRFT) report made recommendations for the introduction of enhanced care to minimise cancellations due to lack of critical care beds, reduce the burden placed upon the intensive care unit (ICU) and help the future recovery of elective surgery. Enhanced care lies between level 1 and level 2/3 care. It facilitates closer observation, monitoring and interventions than is offered on a general ward. It is multidisciplinary, integrating the anaesthetic, surgical and enhanced recovery teams [2]. Whipps Cross Hospital introduced a post-anaesthetic care unit (PACU) in a green recovery in line with these recommendations. Methods We reviewed the records of all patients with PACU admissions between April 2021 to April 2022. We looked at engagement in pre-operative pathways, pre-operative interventions and postoperative enhanced care interventions, engagement by the multidisciplinary team (MDT), outcomes and escalations to intensive care. Results Fifty-four patients admitted to the PACU were identified. All were seen in the pre-operative assessment clinic, 51 were seen in the pre-operative planning clinic. Twenty-five received pre-operative optimisation. In the PACU, 44 received blood gas analysis, four received cardiac output monitoring, one received vasopressors and 29 received additional pain management. All patients were reviewed by the anaesthetic registrar and consultant, 98% by the surgical team and 78% by the enhanced recovery team within 24 h of admission to the PACU. Four were escalated to the ICU. Discussion Our analysis shows the successful application of the GIRFT report's recommendations, demonstrates the effectiveness of enhanced care and shows a successful reduction of the burden on ICU. High-risk patients were identified, optimised and received enhance cared. MDT engagement was high and only four patients were escalated to the ICU. We delivered our model in recovery, showing it is the mental approach that matters, not the physical location. This model also helps us deliver care tailored to each patient's unique risk profile. The GIRFT report estimates financial opportunities from the reduction of critical care bed days. We aim to do a local cost analysis. (Figure Presented).

Treatment Fluid Volume May Predict Stroke Volume Improvement

INTRODUCTION: Cardiac function is known to be negatively impacted by sepsis. Monitoring Cardiac Output (CO) and Stroke Volume (SV) trends over the course of treatment may provide insight into cardiac function and may be used to predict patient outcome. In the FRESH study, we have previously shown the impact of the volume of administered treatment fluid on fluid balance and patient outcome. The goal of this study was to explore the relationship between volume of fluid and stroke volume improvement in septic patients. METHOD(S): The Starling Registry study is an observational registry study evaluating trends in CO and SV over time as related to patient outcome (NCT04648293). Patients that exhibited an overall improvement in SV (first SV measurement compared to last SV measurement) were compared to those who did not exhibit improvement. RESULT(S): A total of 201 patients received hemodynamic monitoring during their stay at three different ICUs. 46% were female, and the average age was 63 years. 72% of the patients had sepsis, and 20% of patients were positive for COVID. When patients who improved their stroke volume over the course of treatment were compared to those who did not improve, results indicate that SV improved patients had received a total volume fluid of 1241 ml, while patients did not improve received 893 ml fluid, for a difference of 348 ml (p=0.018). CONCLUSION(S): Registry patients with minimal change in stroke volume appear to receive less fluid volume. FRESH and other studies have shown improved outcomes in restricting fluid in non-preload dependent (non-fluid responsive) state. Further research in the phenotype of nonresponsive patients may be helpful in identifying new methods to improve outcomes in this group.

Stroke Volume Change May Predict Outcome in Patients with Lv/Rv Dysfunction

INTRODUCTION: Cardiac function is known to be negatively impacted by sepsis. Monitoring Cardiac Output (CO) and Stroke volume (SV) trends over the course of treatment may provide insight into cardiac function and may be used to predict patient outcome. In the FRESH study, we have previously shown that patients who improve CO and SV exhibit improved outcome such as decreased mortality and decreased need for ventilation. The goal of this study was to explore the relationship between the change in stroke volume and cardiac output in patients with LV and RV Dysfunction. METHOD(S): The Starling Registry study is an observational registry study evaluating trends in CO and SV over time as related to patient outcome (NCT04648293). Patients that exhibited an overall improvement in CO (first CO measurement compared to last CO measurement) were compared to those who did not exhibit improvement. RESULT(S): 71 patients with LV/RV dysfunction received hemodynamic monitoring during their stay across 4 units at 3 hospitals. 48% were female, and the average age was 68 years. 67% of the patients had sepsis, and 17% of patients were positive for COVID. Notably, in this population of LV/ RV dysfunction, patients with COVID (p=0.016), pneumonia (p=0.034) and those that required oxygen treatment (p=0.034) were less likely to improve Cardiac Output following fluid challenge. CONCLUSION(S): Patients with LV/RV dysfunction represent a vulnerable population. We have previously shown the benefits of trending cardiac output and stroke volume in this patient population (ATS, 2018). Trends observed in this population may help indicate which patients may be at risk for more negative outcome.

PATHOPHYSIOLOGY OF LACTIC ACIDOSIS IN PATIENTS WITH ASTHMA

SESSION TITLE: Challenges in Asthma SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Asthma is a chronic illness affecting 334 million people worldwide[1]. Asthma affects the respiratory gas exchange, which plays a significant role in acid-base balance. Acid-base disorders in asthma involve respiratory alkalosis, respiratory acidosis, and AG acidosis[2]. CASE PRESENTATION: A 37 years old Hispanic male with a PMH of intermittent asthma presents with progressive dyspnea for three days, worse with activity and decreases with rest. He reported no [cough, fever, rhinorrhea, chest pain]. No orthopnea. He is vaccinated for COVID ( 2 Pfizer doses), has no sickness exposure, and works as a driver. The patient is not a smoker. Physical Exam: Blood pressure 124/72 mmHg. Heart Rate 100 PPM. Temperature 97.1 F.Respiratory Rate 21BPM.SPO2 90% General appearance: acute distress with nasal flaring. Heart: Normal S1, S2. RRR. Lung: Poor air entry with diffuse wheeze bilaterally. He was placed on a 6 LPM NC. CBC and differential were unremarkable. He was started on methylprednisone, Ceftriaxone, and azithromycin. The patient was started on inhaled Salbutamol and Budesonide. Chest X-ray was unremarkable, Chemistry was unremarkable except for elevated Lactic acid 4.7, There was no concern for reduced tissue perfusion or hypoxia, with no evidence of an infectious process because both viral and bacterial causes for pneumonia were excluded, and antibiotics were stopped. A serial lactic acid level trend was 4.5/4.3/ 4.1/ 4 on the first day, while on the next day, it was 3.1/ 2.9/ 2.7/ 2.5/ 3.5, we stopped trending his lactic acid level. He improved and was discharged on an oral taper steroid and inhaled steroids with a B2 agonist. DISCUSSION: There are two types of Lactic acidosis in patients with asthma: 1- Type-A results from impaired oxygen delivery to tissues and reduced tissue perfusion in severe acute asthma may be accompanied by reduced cardiac output. 2- Type B where oxygen delivery is normal, but the cellular function is impaired due to increased norepinephrine in plasma, increasing metabolic rate and lactate production, drugs like beta-agonists increase glycogenolysis leading to an increased pyruvate concentration;pyruvate is converted to lactic acid. B2 agonist increases lipolysis and increases Acetyl CoA, this increase in Acetyl CoA inhibits the conversion of pyruvate to Acetyl CoA, increasing pyruvate which will be converted to lactic acid[2], Theophylline is a non-selective 5'-phosphodiesterase inhibitor and potentiates the activity of ß-adrenergic agents by increasing the intracellular concentration of cAMP, Glucocorticoids are also known to increase the ß-receptor's sensitivity to ß-adrenergic agonists. CONCLUSIONS: Providers are increasingly challenged by hyperlactatemia,it is not harmful but elevated Lactic acid levels and clearance rate is used for prognostication,hyperlactatemia might be misleading,and all possible causes of elevated lactic acid levels must be explored. Reference #1: 10.5334/aogh.2412 Reference #2: https://doi.org/10.3390/jcm8040563 Reference #3: Edwin B. Liem, Stephen C. Mnookin, Michael E. Mahla;Albuterol-induced Lactic Acidosis. Anesthesiology 2003;99:505–506 doi: https://doi.org/10.1097/00000542-200308000-00036 DISCLOSURES: No relevant relationships by Vasudev Malik Daliparty No relevant relationships by Abdallah Khashan No relevant relationships by Samer Talib No relevant relationships by MATTHEW YOTSUYA

A CASE OF TRACHEOBRONCHIAL AMYLOIDOSIS PRESENTING AS SYNCOPE

SESSION TITLE: Systemic Diseases with Deceptive Pulmonary Manifestations SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: Amyloidosis of the respiratory tract is rare. We present a case of tracheobronchial amyloid presenting as multifactorial cough with syncope. CASE PRESENTATION: The patient is a 65-year-old man with history of hypertension, hyperlipidemia, and allergic rhinitis who presented to the ED after a syncopal event. Two weeks prior, he had a new-onset myalgias and severe persistent cough, not resolving with over-the-counter medications. During a coughing paroxysm, he experienced a brief loss of consciousness. On arrival, his vital signs and physical exam were within normal limits except for Mallampati II, BM of 38.8 kg/m2. Basic laboratory testing was also unremarkable except for troponin T of 251 nl/dL and NT-ProBNP of 1181 pg/mL. NP swab for Sars-CoV-19 (PCR), Influenza A and B were not detected. CT of the chest revealed an area of circumferential mural soft tissue thickening in the left lower lobe bronchi. Cardiac MRI showed an area of subepicardial delayed enhancement, suggestive of myocardial inflammation or edema. Flexible bronchoscopy confirmed that the left lower lobe bronchus and proximal subsegmental bronchi had an infiltrative process with a friable, erythematous irregular mucosal surface. Forceps biopsy sampling and staining with Congo red, sulfate Alcian blue and Trichome stain were positive for amyloid deposits. Immunostain revealed predominantly CD3 positive T-Cells. Mass spectometry showed AL (lamda)-type amyloid deposition. GMS and AFB stains were negative. Telemetry showed 2-3 second pauses, correlated with episodes of cough. DISCUSSION: Amyloidosis is a disorder caused by misfolding of proteins and fibril accumulation in the extracellular space. It can present as a diffuse or localized process to one organ system. Several patterns of lung involvement have been described: nodular pulmonary, diffuse alveolar-septal, cystic, pleural, and tracheobronchial amyloidosis. Tracheobronchial amyloidosis is usually limited and not associated with systemic disease or hematologic malignancy. It can be asymptomatic, or can present with cough, dyspnea or signs of obstruction, including postobstructive pneumonia. Congo Red stained samples reveal green birefringence under polarized light microscopy. Further analysis of proteins usually reveals localized immunoglobulin light chains (AL). Cough syncope is due to increased intrathoracic pressure, decreased venous return and cardiac output, stimulation of baroreceptors, decreased chronotropic response, arterial hypotension and decreased cerebral perfusion. Our patient presented with multifactorial cough (possible viral infection, upper airway cough syndrome, amyloidosis) causing sinus pauses and syncope, on underlying myocarditis. CONCLUSIONS: Amyloid infiltration of the respiratory system is rare, but it should be considered in the differential diagnosis of airway disorders, nodular or cystic lung diseases, and pleural processes. Reference #1: Milani P, Basset M, Russo F, et al. The lung in amyloidosis. Eur Respir Rev 2017;26: 170046 [https://doi.org/10.1183/16000617.0046-2017]. Reference #2: Utz JP, Swensen SJ, Gertz MA. Pulmonary amyloidosis. The Mayo Clinic experience from 1980 to 1993. Ann Intern Med. 1996 Feb 15;124(4):407-13. doi: 10.7326/0003-4819-124-4-199602150-00004 Reference #3: Dicpinigaitis PV, Lim L, Farmakidis C. Cough syncope. Respir Med. 2014 Feb;108(2):244-51. doi: 10.1016/j.rmed.2013.10.020. Epub 2013 Nov 5. PMID: 24238768. DISCLOSURES: No relevant relationships by Amarilys Alarcon-Calderon No relevant relationships by Ashokakumar Patel

USE OF POINT-OF-CARE ULTRASONOGRAPHY (POCUS) TO PREVENT DILTIAZEM-INDUCED CARDIOGENIC SHOCK

SESSION TITLE: Using Imaging for Diagnosis Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Point of care ultrasonography (POCUS) uses an ultrasound technique that helps physicians augment physical examination findings and guide clinical decision-making at the bedside. We present a case that became a watershed moment for internal medicine residents at Abington Jefferson Hospital to use POCUS for every patient with atrial flutter/fibrillation with RVR prior to initiating diltiazem drip. CASE PRESENTATION: A 73-year-old male presented to the emergency department with complaints of palpitations. He was tachycardic with a heart rate in the 150s, and his rhythm was irregular. His basic labs were normal;an electrocardiogram investigation showed that he was experiencing an atrial flutter with 2:1 and 3:1 blocks. Chest X-ray was clear. He was given IV metoprolol 10 mg twice without achieving rate control and then started on a diltiazem drip, which initially improved his heart rate to 70s with rhythm changing to atrial flutter with 4:1 block. However, he started to become hypoxic, requiring intubation and then hemodynamically unstable, requiring initiation of pressors. Postintubation CXR indicated bilateral diffuse pulmonary edema and vascular congestion. Subsequently, he had Pulseless electrical activity (PEA) arrest. Return of spontaneous circulation (ROSC) was achieved after 3 minutes of chest compression and one round of epinephrine injection. Transthoracic echocardiogram showed an ejection fraction of 10%. He had a right heart catheterization which showed a CI of 1.7 and elevated PCWP and RVP. He was started on milrinone for ionotropic support and needed norepinephrine, vasopressin and phenylephrine to sustain his blood pressure. DISCUSSION: Atrial flutter and fibrillation are routinely seen arrhythmias in hospital settings. Patients with irregular rhythm who are in rapid ventricular rate and normotensive are often given IV metoprolol few times and then started on a diltiazem drip if RVR continues. Diltiazem not only decreases heart rate (negative chronotropic) but also decreases ventricular squeeze (negative ionotropic). It is contraindicated in patients with reduced ejection fraction. Patients’ ejection fraction values are not always known, especially if they have never had a transthoracic echocardiogram in the past or prior records are not available. POCUS helps physicians and residents to access and estimate LV function quickly and augments clinical decision making at the bedside. CONCLUSIONS: Internal Medicine Residents at Abington Hospital have made it a part of their protocol to always perform bedside ultrasonography in patients with atrial flutter/fibrillation with rapid ventricular rate before initiating diltiazem drip to prevent further avoidable cardiogenic shocks. Reference #1: Fey H, Jost M, Geise AT, Bertsch T, Christ M. Kardiogener Schock nach bradykardisierender Therapie bei tachykardem Vorhofflimmern : Fallvorstellung einer 89-jährigen Patientin [Cardiogenic shock after drug therapy for atrial fibrillation with tachycardia : Case report of an 89-year-old woman]. Med Klin Intensivmed Notfmed. 2016 Jun;111(5):458-62. German. doi: 10.1007/s00063-015-0089-9. Epub 2015 Oct 6. PMID: 26440099. Reference #2: Bitar ZI, Shamsah M, Bamasood OM, Maadarani OS, Alfoudri H. Point-of-Care Ultrasound for COVID-19 Pneumonia Patients in the ICU. J Cardiovasc Imaging. 2021 Jan;29(1):60-68. doi: 10.4250/jcvi.2020.0138. PMID: 33511802;PMCID: PMC7847790. Reference #3: Murray A, Hutchison H, Popil M, Krebs W. The Use of Point-of-Care Ultrasound to Accurately Measure Cardiac Output in Flight. Air Med J. 2020 May-Jun;39(3):218-220. doi: 10.1016/j.amj.2019.12.008. Epub 2020 Jan 14. PMID: 32540116. DISCLOSURES: No relevant relationships by Fnu Aisha No relevant relationships by Lucy Checchio No relevant relationships by Ans Dastgir No relevant relationships by Shravya Ginnaram No relevant relationships by Syeda Hassan No relevant relationships by Chaitra Janga No relev nt relationships by Rameesha Mehreen No relevant relationships by Rahat Ahmed Memon No relevant relationships by Binod Poudel No relevant relationships by Shreeja Shah

FLUID RESPONSIVENESS AND PATIENT OUTCOMES

SESSION TITLE: Sepsis: Beyond 30cc/kg and Antibiotics SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Cardiac function is known to be negatively impacted by sepsis. Stroke volume (SV) change in response to Passive Leg Raise (PLR) is an effective method to predict fluid responsiveness (FR) or cardiac response to preload expansion. We have previously shown that short-term sepsis resuscitation phenotypes based responses to passive leg raise (PLR) can identify discrete patient sub-groups. The goal of this study was to identify resuscitation phenotypes and explore the relationship between the cardiac physiology and patient outcome. METHODS: The Starling Registry study is an observational registry study evaluating trends in cardiac output (CO) and SV over time as related to patient outcome (NCT04648293). Patients were classified as FR if SV increased ≥ 10% when measured with non-invasive bioreactance (Starling Monitor, Baxter Healthcare). Patients were characterized Non FR if SV increased <10%. Patients were grouped into 6 different sextets based on the percentage of FR PLRs within each group. RESULTS: 222 critical care patients received hemodynamic monitoring during their ICU stay across two different hospitals. 46 % were female, and the average age was 64 years. 65% of the patients had sepsis, and 20% of patients were positive for COVID. There were an equal percentage of septic patient in whose who were not FR (68%) and patients who were 100% FR (65%, p=0.334). Patients who were not FR received significantly less resuscitation fluid (609 ml) compared to patients who were 100% FR (1094 ml, p<0.0001). Patients who were 100% FR exhibited a decreased incidence of mortality (20.2%) compared to patient with 0% incidence FR (35.5%, p= 0.028). CONCLUSIONS: Short-term sepsis resuscitation phenotypes based responses to PLR identify discrete patient sub-groups. We have previously shown patients who improve CO in response to the resuscitation exhibited improved outcome. The ability to respond to the addition of IV fluid by increasing CO and SV may improve perfusion and lead to decreased adverse events. As there were an equal number of septic patients in both groups, a 0% incidence of FR may reflect a reduced EF or cardiac dysfunction instead of peripheral leakage. The results provided by a real time dynamic assessment may predict patient outcome and demonstrate physiology based on fluid responsiveness. CLINICAL IMPLICATIONS: Monitoring cardiac function closely is a high priority to prevent clinically relevant changes in patient outcome. DISCLOSURES: Employee relationship with Cheetah Medical Please note: >$100000 by Douglas Hansell, value=Salary Stock Holder relationship with Baxter Please note: 13 years Added 03/29/2022 by Kai Harenski, value=Stocks No relevant relationships by Muhammad Ali Javed Speaker/Speaker's Bureau relationship with Cheetah Medical Inc Please note: $1001 - $5000 by Heath Latham, value=Consulting fee Removed 03/28/2022 by Heath Latham Speaker/Speaker's Bureau relationship with Baxter Please note: 1/2021 - 3-2022 Added 03/28/2022 by Heath Latham, value=Consulting fee Employee relationship with Baxter Healthcare Please note: 15 months by Jennifer Sahatjian, value=Salary

Just a flue with heart failure

In January 2022 we treated two young patients (26y & 37y) that were admitted to hospital because of fever and flu-like symptoms (Respiratory symptoms resp. abdominal symptoms). Due to a septic condition with significantly elevated inflammatory blood values (CRP 389mg/L, resp. 270mg/L) and pneumonic infiltrate, they were hospitalised and an antibiotic therapy was initiated. Shortly after admission, they became increasingly hemodynamic instable and were transferred to the intensive care unit with a catecholamine and oxygen dependency, severely decreased ejection fraction (20% resp. 40%), pericardial and pleural effusions and highly elevated cardiac markers (Trop-T: 2406ng/L, resp. 1874ng/L / NT-proBNP: 17805pg/mL, resp. 14976pg/mL). All blood cultures, Ag-tests, immune serologies were negative, but the patients were suffering from a cardiogenic shock with SIRS. Only a COVID-infection (mild symptoms resp. asymptomatic, PCR tested in 12/2021) three to four weeks past was remarkable in their health history. They received one resp. no vaccination before infection. Therefore the heart failure was interpreted as a myocarditis and the symptom complex as Multisystem Inflammatory Syndrome in Adults (MIS-A). The following days, they were treated with high-dose steroids (500mg resp. 250mg) at first, to which they responded well combined with catecholamines and inotrops. After a continued improving heart and infection blood work a slowly tapering regimen of the steroid therapy (down to 1mg/kg KG) and an IVIG therapy (2g/kg KG) for five days was initiated. The echocardiographic monitoring showed a positive development with a regression of the pericardial effusion and a normal cardiac output. With an improving general condition, the patients were discharged to either cardiac rehabilitation or home. A cardio MRT showed typical findings of a peri-/myocarditis with epicardial late-gadolinum enhancement (LGE) and in one patient additionally with myocardial LGE and edema. The intention of this case series is to report on the rare but potentially lethal MIS-A, especially in a younger age group, predominant male after COVID-infection. Prompt recognition of MIS-A with immunomodulatory treatment is necessary to limit the hyperinflammatory response. In the reported cases, it was especially remarkable that the patients underwent a mild initial infection and after a latency of several weeks a rapidly progressive reaction of immune disorder occurred.

Virtual Reality Training in Right Heart Catheterisation

Introduction: Right heart catheterisation is the gold standard for assessing patients with pulmonary hypertension. Doctors require training in this procedure in a safe and friendly environment with minimal risk to patients. During the COVID-19 pandemic, we sought to develop a Virtual Reality Right Heart Catheterisation (VRRHC) training program to fulfil this area of need without face-to-face contact. The aim was to improve procedure competency, aid diagnosis and reduce medical error. Method: We approached a health technology company to design a VRRHC training module based on our current RHC simulation workshops. Phase 1 required virtual insertion of RHC via right internal jugular vein using a micro-puncture, double-Seldinger technique under ultrasound guidance, followed by insertion of the RHC to the right atrium, right ventricle, pulmonary artery, pulmonary artery occlusion position using real time pressure tracings and fluoroscopy. Thermodilution cardiac outputs were performed and measured. Using real-time performance tracking and haptic feedback, we collected analytics and data on user engagement, experience, retention, learning outcomes and curve, improved interpretation and diagnosis and reduction in operating costs, procedure times and complications. Results: The program was launched in October 2021. Preliminary data shows a short learning curve for VR itself (10-15 minutes) and RHC (initial 30-40 minutes reducing to 20-30minutes and <15 minutes in experts). Completion rates increase with experience from 40-50% to 100%. Error rate also reduces with frequency of completion. Conclusion: Virtual Reality Right Heart Catheter training is feasible with a short learning curve and results in improved competence and error rate with frequency of use.

CLINICAL FEATURES AND CHARACTERISTIC OF CHOLANGIOPATHY AFTER SEVERE COVID-19

Introduction Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 virus (SARS-CoV-2), can commonly lead to abnormal liver tests, mostly transaminase elevation. Recently, a novel entity of cholangiopathy was discovered in patients who recovered from critical COVID-19 infection. However, understanding of this disease is limited due to its rarity. Methods We reviewed Pubmed, Embase, and Web of Science Core Collection databases from inception to Nov 30th, 2021, to identify studies reporting cholangiopathy after severe COVID-19 infection. “SARS-CoV-2” or “COVID-19” with “cholangiopathy” were used as keywords to search. Our study is to summarize the clinical features and characteristics of cholangiopathy after severe COVID-19 illness. Results Literature review identified 15 articles including 33 patients for reviews. Most studies were performed in the United States. The mean age of participants from all studies is 52.17 ± 13.98 years old. Among the 33 included patients, the majority are male (29, 88%) and the common medical histories include hypertension (n=11), obesity (n=8), and diabetes mellitus (n=8). The length of stay (LOS) during hospitalization was prolonged with a mean of 80.23 ± 33.14 days. All patients were intubated and put on mechanical ventilation during medical intensive care stay with 12 patients having a history of endotracheal cardiac output monitoring. The mean peak of serum alkaline phosphatase, aspartate aminotransferase, alanine transaminase and total bilirubin were 2106.96 (U/l) ± 784.04, 1456.09 (U/l) ± 2325.10, 983.57 (U/l) ± 1244.44 and 14.04 (mg/dl) ± 8.41, respectively. Cholangiopathy after severe COVID illness mimics secondary sclerosing cholangitis on magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography studies with ductal beading but the presence of unique severe cholangiocyte injury and intrahepatic microangiopathy is suggestive of direct hepatic injury due to COVID-19. In terms of outcome, 7 patients were documented as deceased. Eight patients underwent liver transplantation (Table 1). Discussion Cholangiopathy is a late complication of severe COVID-19 after prolonged ICU stay with potential for long-term liver morbidity and liver failure needing liver transplantation. Further studies are warranted to understand pathogenesis, natural history, therapeutic interventions, and prognostic indicators. (Table Presented)

CONTINUOUS REMOTE PATIENT MONITORING SHOWS EARLY CARDIOVASCULAR CHANGES IN COVID-19 PATIENTS

Objective: COVID-19 exerts deleterious cardiopulmonary effects, leading to a worse prognosis in the most affected. This study aimed to analyze the trajectories of key vitals amongst hospitalized COVID-19 patients using a chest-patch wearable medical-grade monitor providing continuous remote patient monitoring of numerous vital signs. Design and method: This retrospective multicenter observational cohort study was conducted in five COVID-19 isolation units. 492 COVID-19 patients were included in the final analysis. Physiological parameters were measured every 15 minutes. Results: More than 3 million measurements were collected including heart rate, systolic and diastolic blood pressure, cardiac output, cardiac index, systemic vascular resistance, respiratory rate, blood oxygen saturation, and body temperature. Cardiovascular deterioration appeared early after admission and in parallel with changes in the respiratory parameters, showing a significant difference in trajectories within sub-populations at high risk. Conclusions: Early detection of cardiovascular deterioration of COVID-19 patients is achievable when using frequent remote patient monitoring.

Different modalities to assess right ventricular function in post-COVID taking ST-elevation as a gold standard and arrhythmias in post-COVID

The COVID-19 caused by novel single-stranded RNA enveloped severe acute respiratory syndrome coronavirus-2 (SARS CoV-2) first appeared in Wuhan, China. A lot of focus has been given to pulmonary complications. According to several case reports, cardiovascular associated clinical manifestations include myocarditis, arrhythmias, veno-thromboembolic events, acute coronary syndrome (ACS), and pericarditis. Different modalities in diagnosis like 2D, doppler can help in the early diagnosis of right ventricular function. This study evaluates the cardiac changes in recovered COVID-19 positive patients by 2D echocardiogram and other modalities. In this prospective observational study, 139 participants recently recovered from COVID-19 illness were identified and recruited after obtaining the Informed concerned form (ICF). The patients once enrolled were subjected to 2D echo and ECG as part of routine clinical practice. Out of 139 patients, 89 (64.03%) were males, and the rest were females. Based on the severity scale, 13 (9.35%) participants had suffered a severe form of COVID-19 infection. Right ventricular functional assessment, right ventricular global strain (RVGLS) was abnormal in 72 (51.80%) participants. Arrhythmias were reported in 31 (22.30%) participants;among them, 30 participants had sinus bradycardia. Our study demonstrates the association between COVID-19 and cardiac changes/ incidence of cardiovascular complications in recovered COVID-19 patients. This study provides first-hand evidence of the incidence of abnormal LVGLS and RVGLS in COVID-19 recovered patients. In addition, there was a higher incidence of arrythmias.

Cardiac output change predicts patient outcome

Introduction: Cardiac function is known to be negatively impacted by sepsis. Monitoring Cardiac Output (CO) trends over the course of treatment may provide insight into cardiac function and may be used to predict patient outcome. The goal of this study was to explore the relationship between the change in stroke volume and outcome in critically ill patients. Methods: The Starling Registry study is an observational registry study evaluating trends in CO and SV (Stroke Volume) over time as related to patient outcome (NCT04648293). Patients that exhibited an overall improvement in CO (first CO measurement compared to last CO measurement) were compared to those who did not exhibit improvement. Results: A total of 229 critical care patients received hemodynamic monitoring during their ICU stay across three different hospitals. 48% were female, and the average age was 64 years. 64% of the patients had sepsis, and 17% of patients were positive for COVID. Notably, patients who exhibited an overall improvement in CO exhibited a decrease need for mechanical ventilation (4.8% vs 15%, p = 0.041) and a trend toward a decrease in mortality (16.4%) compared to those who did not improve (28.0%, p = 0.080) (Fig. 1). Conclusions: We have previously shown that patients who show an improvement in CO in response to the resuscitation exhibited improved outcome. Trending cardiac output over a 1-3 day monitoring period revealed additional usefulness in predicting patients with improved outcome. These results highlight the importance of trending hemodynamics in therapy. (Figure Presented).

Acute cor pulmonale and mortality in mechanically ventilated patients with COVID-19 acute respiratory distress syndrome

Introduction: Although COVID-19 affects primarily the respiratory system, several studies have shown evidence of cardiovascular alterations and right ventricular dysfunction. Our aim was to evaluated cardiac function and its association with lung function, hemodynamic compromise and mortality. Methods: Prospective, cross-sectional multicenter study in four university-affiliated hospitals in Chile. All consecutive patients with COVID-19 ARDS on mechanical ventilation admitted between April and July 2020 were included. Transthoracic echocardiography was performed within the first 24 h of intubation. Results: Consecutive 140 patients on mechanical ventilation with COVID-19 ARDS were included in the study, the mean age was 57 ± 11 years, PaO2/FiO2 ratio was 155 [IQR 107-177], cardiac output was 5.1 L/min [IQR 4.5-6.2] and 86% of the patients required norepinephrine. ICU mortality was 29% (40 patients). Fifty-four patients (39%) exhibited right ventricle dilation and 20 of them (37%) exhibited acute cor pulmonale (ACP). Eight of twenty (40%) patients with ACP exhibited pulmonary embolism. Patients with ACP had higher norepinephrine requirement, lower stroke volume, tachycardia, prolonged capillary refill time and higher lactate levels. In addition, acute cor pulmonale patients presented lower compliance, higher driving pressure and the presence of respiratory acidosis. Left ventricular systolic function was normal or hyperkinetic in most cases and only thirteen patients (9%) exhibited left ventricular systolic dysfunction (ejection fraction < 45%). In the multivariate analysis acute core pulmonale, PaO2/FiO2 ratio and pH were independent predictors of mortality (Table 1). Conclusions: Right ventricular dilation is highly prevalent in mechanically ventilated patients with COVID-19 ARDS. The presence of acute cor pulmonale is associated with poorer lung function, but only in 40% of patients it was associated to pulmonary embolism. Acute cor pulmonale is an independent risk factor for mortality in the ICU. (Table Presented).