Frequency of antibiotic prescribing in adults hospitalized for SARS-CoV-2 in a high complexity institution in Santiago de Cali, Colombia.

Objective: To determine the frequency of antibiotic use and to know which clinical and socio-demographic variables were related to the probability of suffering infections associated with COVID-19. Method(s): Adults hospitalized for COVID-19 who received one or more antibiotics during hospitalization were evaluated. We performed a descriptive analysis of variables in the general population' bivariate analysis in two groups (documented vs. suspected infection) and multivariate logistic regression of factors associated with mortality. Result(s): It was determined that 60.4% of adults hospitalized for COVID-19 received antibiotics. Coinfection was documented in 6.2% and superinfection in 23.3%. Gram-negative germs were reported in 75.8% of cultures, fungi in 17.8% and gram-positive in 14.2%. Variables such as age, comorbidities, ICU, anemia, steroids, mechanical ventilation, hemofiltration were statistically significantly related to documented infection. High-flow cannula was associated as a protective factor. Overall mortality was 43.9%, 57.8% in the first group and 38.1% in the second (p=0.002). Conclusion(s): There is a considerable frequency of antibiotic use in subjects hospitalized for COVID-19, particularly related to relevant findings of bacterial superinfection, in those with comorbidities, such as diabetes mellitus, immunosuppression, anemia and fragility, in whom the behavior of the disease is more severe and lethal.Copyright © 2023 Asociacion Colombiana de Infectologia. All rights reserved.

Outcomes of renal replacement therapy in critically ill COVID-19 patients

Introduction: Our goal is to describe outcomes of critically ill COVID-19 patients submitted to renal replacement therapy (RRT), in particular the association of RRT with mortality. Multi-system organ failure or direct kidney injury caused by SARS-CoV-2 is associated with the development of acute kidney injury (AKI) which subsequently increases the need for RRT and may affect the outcomes. Method(s): This is a retrospective observational study of 338 critically ill patients admitted with COVID-19 pneumonia in the ICU of a tertiary center in Portugal, between March 2020 and December 2021. Clinical, analytical and baseline patient characteristics were evaluated. Logistic regression analysis was performed to correlate patient data with the need for RRT and ICU mortality. Result(s): From a total of 338 patients, 5% required RRT (n = 16), 25% of which received intermittent hemodialysis (n = 4) and 87,5% continuous veno-venous hemofiltration (n = 14). Baseline characteristics are described in Table 1. In our sample, 61 patients (18%) presented with acute AKI, from whom 14 (23%) were submitted to RRT. From all the patients receiving RRT, 10 (62.5%) did not have pre-existing chronic kidney disease. In the logistic regression analysis, AKI (OR 45.4;95% CI 7.7-269.5;p < 0.001), higher SOFA (OR 1.24;95% CI 103-1.51;p = 0,03), creatinine (OR 2.01;95% CI 1.4-3.0;p < 0.001) and C-reactive protein (OR 1.09;95% CI 1.02-1.16;p = 0,01) on admission were associated with the need for RRT. Additionally, ICU mortality associated with RRT was 75% compared to 28.3% in the group not submitted to RRT (OR 7.6;2.4-24.2;p = 0.001). Conclusion(s): The need for RRT in critically ill COVID-19 patients is associated with an increased mortality rate in our study. We were also able to identify AKI, higher SOFA, creatinine and C-reactive protein at admission as risk factors for RRT. However, due to the retrospective nature of our analysis and our small sample size, more studies on this topic are needed to confirm these results.

Extracorporeal blood purification benefits in post-caesarean patient with severe acute respiratory distress syndrome due to miliary tuberculosis: a case report.

BACKGROUND: Miliary tuberculosis is a life-threatening disease caused by the hematogenous spread of Mycobacterium tuberculosis. It is uncommon in pregnancy. Mortality rates for patients with miliary tuberculosis who require mechanical ventilation are high (60-70%). CASE PRESENTATION: We reported a rare and challenging case, a 35-year-old Asian woman with 34 weeks of pregnancy, and miliary tuberculosis with acute respiratory distress syndrome and septic shock. The patient presented with severe acute respiratory distress syndrome, necessitating mechanical ventilation, vasopressor, and pregnancy termination with caesarean section. The patient underwent blood purification with continuous veno-venous hemofiltration using an oXiris filter for 24 hours. After continuous veno-venous hemofiltration, the patient's condition was greatly improved, and the patient was successfully extubated and was able to breathe spontaneously without vasopressor on the third day. High levels of interleukin-6, interleukin-10, procalcitonin, C-reactive protein, interferon-γ, and tumor necrosis factor-α were found postoperatively. CONCLUSION: The bacterial infection of tuberculosis, acute respiratory distress syndrome, and the stress response from the caesarean section contributed to the high levels of cytokines, which correlated with the patient's severe inflammatory condition. The cytokine levels were greatly reduced after the blood purification procedure and this might be associated with the patient's clinical improvement. Extracorporeal blood purification could help to disrupt the vicious cycle of inflammation.

2022 ABA Annual Meeting Abstracts/Poster

The proceedings contain 7 papers. The topics discussed include: pediatric burn care: how burn camps survived and thrived during the coronavirus pandemic;a retrospective chart review to determine hypophosphatemia incidence and phosphorus supplementation requirements in patients with severe thermal cutaneous injuries receiving high-volume hemofiltration;setting the standard: using the aba burn registry to benchmark risk adjusted mortality;burn injury from smoking electronic cigarettes while on supplemental oxygen;focused wound care handoff improves burn center physician-nursing communication and wound care education;modified frailty index is an independent predictor of death in the burn population: a secondary analysis of the transfusion requirement in burn care evaluation (TRIBE) study;and topical hemostatic agents in burn surgery: a systematic review.

Toxicokinetics of metformin overdose treated with CVVHDF

Background: Metformin is the most commonly used diabetes medication and at supratherapeutic levels can result in a severe type-A metabolic lactic acidosis known as metformin-associated lactic acidosis (MALA). Treatment of MALA includes aggressive fluid resuscitation, supporting blood pressure and correcting acidosis. Renal replacement therapy (RRT), usually hemodialysis (HD) is recommended in severe cases with refractory acidosis (with elevated lactate), altered mental status, or shock. To our knowledge, this is the second report of metformin half-life during treatment with continuous veno-venous hemodiafiltration (CVVHDF). Case report: A 53-year-old man died following a reported acute on chronic ingestion of 80 g of his metformin tablets resulting in severe, refractory shock and MALA. His peak serum metformin concentration was 53mcg/mL (therapeutic range 1-2mcg/mL), peak lactic acid concentration was 49.7 mmol/L, and arterial pH nadir was 7.06. Serial serum metformin concentrations were obtained while on RRT;both HD and CVVHDF. The switch from HD to CVVHDF was done due to staffing shortages during the COVID-19 pandemic. The patient died despite aggressive therapy with renal replacement therapy and multiple vasopressors on hospital day five. Serial metformin concentrations during CVVHDF suggested a half-life of 33-h. Discussion(s): Hemodialysis has been reported to clear metformin at a rate greater than 200mL/min and continuous venous-venous hemofiltration (CVVH) at greater than 50mL/min. In this case, metformin levels appear to follow first-order elimination kinetics during CVVHDF with an estimated half-life of 33 h. Comparatively, metformin has a half-life of 4.7-5.5 h during HD. To our knowledge, this is the second report of estimated metformin half-life while using the CVVHDF form of continuous renal replacement. The previous case report measured a half-life of 16.5 h on CVVHDF. This case report shows CVVHDF decreases half-life of metformin and provides first order elimination in the setting of overdose. Conclusion(s): The early initiation of HD appears warranted but prognostic indicators have not been well established. In the absence of HD availability, other forms of RRT (e.g., CCVHDF) can be used and may provide first-order elimination of metformin.

SARS-COV-2 INFECTION AND HEMOFILTRATION-TARGETING VIREMIA

SESSION TITLE: COVID-19 Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: The SARS-CoV-2 pandemic spawned the use and study of novel therapeutics, re-purposed drugs, and interventions– all with limited success. Seraph® 100 Microbind Affinity Blood Filter® [Seraph®] is an investigational device that was given Emergency Use Authorization (EUA) by the Food and Drug Administration in 2019 to treat severe coronavirus disease. Higher viremia is correlated with higher mortality. Seraph® uses extracorporeal filtration to aid the innate immune system by reducing viral load and mitigating downstream effects of inflammation. CASE PRESENTATION: A forty-eight year old gentleman presented to the emergency room with coughs and fever of 101° F. He tested positive via polymerase chain reaction [PCR] testing for SARS-CoV-19 pneumonia. A computed-tomography angiogram [CTA] of the chest was negative for pulmonary embolism, but demonstrated significant bilateral ground-glass opacities consistent with viral pneumonia. Vitals were notable for an oxygen saturation of 69% on room air that improved to 96% on 6 liters/minute [L/min] of supplemental oxygen via nasal cannula. He was initiated on both dexamethasone and remdesivir. Within hours, the patient's oxygen requirements escalated to 15 L/min via non-rebreather to high flow humidified nasal cannula with a flow rate of 40 L/min and 60% FiO2. On day three, he was transferred to the ICU for treatment with Seraph®. After one treatment, the patient was weaned from high flow humidified nasal cannula to room air. On day five, after a second treatment, he transferred to the floor. He was discharged on day six, on room air, having completed his course of remdesivir, with an additional 5 days of oral steroids. DISCUSSION: Preliminary data regarding Seraph® remain limited with only select eligible patients undergoing therapy. Cases like our patient demonstrate dramatic improvements with even one or two treatments which correlate well with data that show up to 99% reduction in the bloodstream of targeted pathogens per pass. While database collection data have revealed trends towards improved outcomes, further investigation into populations most likely to benefit from treatment is needed. Timing, immunocompromised status and other comorbidities that raise or lower the chances of successful hemofiltration need to be considered. CONCLUSIONS: Studies in the SARS-CoV-2 pandemic augment ongoing research as filtration devices are used to target bacterial infections, cytokines and inflammatory markers. Since the invention of antibiotics, multi-drug resistant organisms have increased in prevalence. Novel interventions such as Seraph® warrant investigation to prevent infectious diseases from becoming unmanageable threats. Reference #1: Kielstein JT, Borchina DN, Fühner T, Hwang S, Mattoon D, Ball AJ. Hemofiltration with the Seraph® 100 Microbind® Affinity filter decreases SARS-CoV-2 nucleocapsid protein in critically ill COVID-19 patients. Crit Care. 2021;25(1):190. Published 2021 Jun 1. doi:10.1186/s13054-021-03597-3 Reference #2: Pape A, Kielstein JT, Krüger T, Fühner T, Brunkhorst R. Treatment of a Critically Ill COVID-19 Patient with the Seraph 100 Microbind Affinity Filter. TH Open. 2021;5(2):e134-e138. Published 2021 Apr 14. doi:10.1055/s-0041-1727121 Reference #3: Schmidt JJ, Borchina DN, van T Klooster M, et al. Interim-analysis of the COSA (COVID-19 patients treated with the Seraph® 100 Microbind® Affinity filter) registry [published online ahead of print, 2021 Dec 7]. Nephrol Dial Transplant. 2021;gfab347. doi:10.1093/ndt/gfab347 DISCLOSURES: No relevant relationships by Aneesa Afroze No relevant relationships by Lydia Meece No relevant relationships by Angela Park

OUTCOME OF ADULT HEMATOPOIETIC TRANSPLANT RECIPIENTS AFTER ADMISSION TO INTENSIVE CARE UNIT (ICU): SINGLE CENTRE EXPERIENCE

Background: Intensive care unit (ICU) admission during hematopoietic stem cell transplant (HSCT) is associated with poor prognosis1,2. Published series report a range of ICU admission rates from 24-40% of transplant patients, most frequent reasons involving septic shock, respiratory failure and veno-occlusive disease3. In addition, patients undergoing HSCT are at a high risk of severe morbidity and mortality associated with COVID-194. Aims: The aim of this study was to analyze outcome of HSCT patients requiring ICU admission in our center. Methods: We retrospectively analysed outcome of 752 patients who underwent HSCT in our centre from January/2008 to June/2021. Data were collected from patients' clinical histories. Results: 103 (14%) patients required ICU admission (baseline and HSCT characteristics on table). Median time to ICU admission was 42 days (-2-1765). Seven of these patients were admitted to ICU on two occasions giving a total of 110 consecutive ICU admissions available for analysis. Main reason for ICU admission was respiratory distress (74;67%), mainly due to pneumonia (53%) including a 3% caused by COVID19, pulmonary edema (26%) and pulmonary haemorrhage (8%). Septic shock was second most common cause for ICU admission (26;24%) due to gram-negative bacilli (47%), fungal (15%) gram-positive bacteria (13%), virus (10%) and others/idiopathic (16%). Other less frequent causes were veno-occlusive disease (11;10%), hepatic failure/encephalopathy (8;7%), haemorrhagic complications (6;5%), cardiorespiratory arrest (2%), GVHD (2%), cardiogenic shock (2%). Of the 110 ICU admissions, 37 (34%) required hemofiltration, of which 30 (81%) died;and 77 (70%) required orotracheal intubation, of which 59 (77%) died. During the 110 ICU admissions, 67 patients (61%) died in the ICU;of these, 40 (37%) received unrelated donor HSCT, 36 (33%) sibling donor, 16 (15%) haploidentical and 17 (16%) autologous. Median ICU length of stay of these patients was 13 days (range 1-76). The cause of death was the same reason for ICU admission. Eighteen (16%) patients were discharged from ICU and died prior to Hospital discharge and 24 (22%) survived to Hospital discharge and were classified as post-discharge survivors. Of these 24 cases, 19 (79%) remain alive while the others (5;21%) succumbed to underlying disease or complications post-HSCT. Off note, both patients with COVID19 pneumonia (haploidentical and autologous HSCT respectively) were discharged from ICU and remain alive to date, without major complications. Summary/Conclusion: In our study 14% of transplant recipients required ICU admission, slightly lower than previous reports. Most common cause of admission was respiratory failure, consistent with reported. Mortality rate during ICU admission was 61%;higher death rate observed in allogeneic transplantation and those requiring aggressive ICU treatments such as mechanical ventilation or hemofiltration. Although patients with COVID19 pneumoniae who require ICU admission are usually associated with adverse outcome, in our series they responded successfully to intensive treatment. ICU admission following HSCT is associated with poor prognosis, but should not be considered futile. (Table Presented).

Hemofiltration for a Positive Il6 Balance in Severe COVID-19 Pneumonia: A Single Centre Experience

Aim and background: A high interleukin-6 (IL-6) level in COVID- 19 plays a major role in the pathophysiology and is considered a relevant parameter in predicting the most severe course of the disease. In COVID-19 extracorporeal blood, purification is proposed as adjuvant therapy and aims at controlling the dysregulation in the autoimmune system. It essentially reduces high levels of several mediators and by this controls the cytokine storm, rather than actively targeting individual pathways of inflammation. Positive IL-6 balance post polymethyl methacrylate (PMMA) filter used for cytokine storm in COVID-19 patients with dialysis has shown to be an independent predictor of mortality. We present outcomes of severe COVID pneumonia patients with cytokine storm, acute kidney injury, chronic kidney disease, sepsis, and septic shock at our centre over a year. Objective: A retrospective analysis of data to understand the effect of hemofiltration for severe COVID-19 pneumonia. Materials and methods: All patients admitted to our unit, with severe COVID pneumonia with chronic kidney disease, sepsis, septic shock, and cytokine storm were included from August to December 2020. Demographic variable, clinical, and laboratory data were compared pre and post filtration with PMMA filters. Dialysis vintage, duration of mechanical ventilation, length of stay, and hospital were analysed. Results: We analysed 17 severe COVID patients (P/F ratio < 100) requiring ventilator support in whom hemofiltration was used for cytokine storm with dialysis, sepsis, and septic shock. The average age of these patients was 70.2 ± 18.2 years with no difference in the distribution of age and comorbidities. They all were divided as responders or non-responders groups based on the decrease or no change and increase, respectively, in their pre and post filtration levels of IL-6. Non-responders (N = 11) had 3.6-fold increase in IL-6 levels post hemofiltration with the majority of them on vasopressors;pre (8/11-72.7%) and post (9/11-81.8%) hemofiltration. None of the non-responders survived and we noted 54.5% of this group received hemofiltration post intubation. The non-responders also had a positive IL-6 balance post-hemofiltration which guided us to use this therapy early in the disease. Therefore, subsequent 6 patients were offered hemofiltration early, where we found a decrease in IL-6 levels by 21.4%. Out of the 6 responders, 4 survived and demonstrated a reduction in the IL-6 of 66.7%. None of these survivors required vasopressor support and we were able to avoid or reduce the need for ventilator support in them. Survivors had an average length of stay in ICU of 24 days and were discharged by the 30th day. One of the two non-survivors had succumbed secondary to a cardiac event, while the other was intubated before filtration in view of heart failure. Conclusion: The most prominent finding was the distinct increase in the IL-6 levels in non-survivors which was directed towards the early use of hemofiltration treatment. The present data though limited to a small subgroup of severe COVID patients suggest the need to prevent the positive IL-6 balance. Hemofiltration may be an alternative to be considered early in to prevent the cytokine storm and its ill effects.

Inner Branch Endovascular Repair in Complex Secondary Aortic Intervention in Case of Abdominal and Thoraco-Abdominal Aneurysmal Progression: An Early Single Centre experience

Introduction: Aortic aneurysmal disease is an evolving pathology: when treating an aortic aneurysm, we must consider the possibility of a thoraco-abdominal evolution aneurysm, which might lead to further treatments. In case of challenging anatomies (narrow aortic lumen at the level of visceral arteries, aortic wall thrombus, true lumen in an aortic dissected aneurysm, and focal aortic narrow diameter), unfavourable both for fenestrated endovascular aneurysm repair (FEVAR) and branched endovascular aneurysm repair (BEVAR), an inner branched custom made device could represent a potential feasible solution. Inner branched endografts have a typical configuration that combines the advantageous characteristics of both fenestrated and side branched endografts, thus showing advantages over other custom made grafts. Our study aimed to investigate the potential role of this technique in a broad variety of aortic anatomies unfavourable for FEVAR and BEVAR, in patients who received different previous aortic treatments. Methods: In our institution, between July 2018 and July 2020, 20 consecutive patients underwent a FEVAR/BEVAR procedure to treat complex abdominal aortic aneurysm or thoracic aortic aneurysm. Nine patients who were deemed untreatable with a fenestrated/branched graft due to aortic anatomy and/or previous treatments were treated with a custom made, four inner branch E-xtra design endograft (I BEVAR). All patients were treated for a complex aortic abdominal and thoraco-abdominal aneurysm: two patients were previously treated with frozen elephant trunk and TEVAR;three patients were previously treated with TEVAR;and one with TEVAR + abdominal aortic surgical treatment. Two patients received abdominal aortic surgical treatment only. The last patient was previously treated with EVAR, which was then complicated with a type 1A endoleak (EL). Five of six TEVARs were placed before BEVAR as staged procedures, to decrease spinal cord ischaemia risk. All patients had a lumbar cerebrospinal fluid drainage during the BEVAR procedure. In total, the bridging stents placed included 43 balloon expandable and four self-expandable stents. Results: In our experience, all cases were treated with a four inner branch endograft with a total revascularisation of 36 target vessels. Technical success was achieved in all nine cases (100%), with precise deployment of the inner branched endograft and effective engagement and bridging of all branches. Major clinical complications occurred in three (33%) patients: one case of continuous veno-venous haemofiltration treatment for a transient acute renal failure in a chronic renal disease;one case of hepatic decompensation in patient with a chronic cirrhosis, which led to liver failure (Child Pugh C10, MELD 19, still under medical treatment);and one patient with a pulmonary infection disease (COVID-19 related), which then resolved. No patient suffered spinal cord ischaemia. The mean follow up was 12.8 months ± 6.79 months, with an estimated one year survival rate of 89%. One patient with a thrombophilic disorder died on postoperative day 48 as a result of multiple organ failure after acute four inner branches simultaneous occlusion. During follow up, the target vessel primary patency rate was 89%, associated with four (11%) bridging stent ELs. At 30 days, computed tomography angiography detected five BS ELs in four patients: one type III BS EL (2.7%), and four type I BS ELs (11%). Re-intervention was needed in one patient (11%) with a type III and I BS EL associated with an aneurysm sac enlargement treated with bridging stent relining in the left renal artery and superior mesenteric artery. Conclusion: Our experience shows the feasibility of treating complex aortic anatomies with an inner branched graft in patients which were anatomically unfit for FEVAR/BEVAR treatment, allowing complex visceral vessels recanalisation and an adequate sealing. When a re-intervention is needed, we have to consider that previous surgical and endovascular treatments modify the aortic anatomy, and the graft deploy ent may be tougher, with a higher risk of malrotation. Inner branched endograft could be a valid option in case of complex anatomies, but long term follow up is needed.

Case Report of a COVID-19 patient treated with Seraph® 100 on Extracorporeal Life Support

Background: The Seraph® 100 Microbind ® Affinity Blood Filter (Seraph ®100) is an extracorporeal broad-spectrum sorbent hemoperfusion filter that removes pathogens and cytokines from the blood and has Emergency Use Authorization (EUA) for the treatment of severe COVID-19. Seraph® 100 can be adapted and primed to a NxStage continuous renal replacement therapy (CRRT) machine and connected to the patient's ECMO circuit. This form of hemofiltration provided a safe and effective approach to decreasing pathogen response within the blood and was tested in our center. Case Review: A 42-year-old male with a past medical history of obesity, hypertension and hypothyroidism was admitted for acute hypoxemic respiratory failure secondary to COVID-19. His 65 day ECMO course was complicated by encephalopathy, right heart dysfunction, severe epistaxis, esophageal ulcers and enterococcus faecalis bacteremia. On ECMO day 16, the patient became febrile, C-reactive protein increased to 215 mg/L and he became hypotensive. In addition to appropriate antibiotics, the multidisciplinary team decided to initiate Seraph® 100 for the E.faecalis bacteremia. The filter was adapted and primed into the NxStage machine by the nurse caring for the patient. The NxStage lines were then connected to the ECMO circuit via pigtail connections. The blood was cycled from the post-oxygenator pigtail to the NxStage and returned to the pre-oxygenator pigtail on the ECMO circuit. The target time for continuous Seraph® 100 therapy is between 24-48 hours. Cultures were collected from the NxStage line pre-filter and again, six hours later, from a port post-filter. The pre-filter cultures came back positive for E.faecalis and the post-filter cultures were negative. Additional blood cultures collected the following day remained negative. The patient's condition improved rapidly and allowed him to begin physical therapy and reduce ventilator support over the next 48 days on ECMO. He was discharged from the hospital to rehab for two weeks before going home. Discussion: Introduction of hemofiltration by Exthera provided an additional therapy that has proven to be effective in the reduction of sepsis causing pathogens when used in conjunction with conventional care for patients with COVID-19 suffering from bacteremia. In this case, incorporating hemofiltration via the ECMO circuit showed no increase in undue risk to the patient with an efficacy in decreasing bacteremia, contributing to the survival of the patient.

Frequent CRRT circuit failure in COVID-19: observations of a novel anticoagulation approach

Background: Continuous renal replacement therapy in the treatment of patients with active COVID-19 is frequently complicated by thrombosis in the extracorporeal circuit resulting in reduced filter lifespan, necessitating a revisited anticoagulation strategy. Methods: The standard regional citrate anticoagulation dose of 2.2 mmol/l was increased to a starting dose of 3.0 mmol/l and routine thrombosis prophylaxis with low-molecular-weight heparin was adjusted from a single dose of nadroparin 2850 IU to 5700 IU twice daily. In a non-randomised cohort study, the efficacy of high-dose anticoagulation was compared with a control group with standard anticoagulation. Results: Eleven COVID-19 patients requiring continuous renal replacement therapy were included, 42 filter sets in the control group and 37 filter sets in the high-dose anticoagulation group. The median filter lifespan was 48 hours in the high-dose anticoagulation compared with 18 hours in the control group (p<0.001). No significant effect on ionised calcium levels was observed in the high-dose group. Conclusion: The combination of high-dose regional citrate anticoagulation and increased-dose LMWH appears to prolong filter lifespan in patients with COVID-19.

Extracorporeal membrane oxygenation for critically ill patients with COVID-19 pneumonia: a retrospective cohort study

Introduction: In patients with severe respiratory failure from COVID- 19, extracorporeal membrane oxygenation (ECMO) can facilitate lung-protective ventilation and may improve outcome. The aim of this study is to investigate the clinical course, characteristics and outcomes of patients supported with ECMO for COVID-19 pneumonia. Methods: All adult patients with a confirmed diagnosis of COVID- 19 pneumonia admitted to the ICU of Jessa Hospital, Belgium and treated with ECMO between March 13, 2020, and June 30, 2021, were included. Data were prospectively entered into a database that included medical history, demographic data, laboratory results, ventilator settings, ventilator-derived parameters, therapeutic interventions and clinical outcomes. This database was retrospectively reviewed. The primary endpoint is ICU mortality. The study population is categorized based on primary endpoint. A Student t test or Mann Whitney U test and a Chi Square or Fisher's Exact tests were used to evaluated differences between survivors and non-survivors. A p < 0.05 is considered statistically significant. Results: A total of 295 COVID-19 patients were admitted to the ICU, 24 needed ECMO and were analysed. Medical history, demographic data, laboratory results, ventilator settings, ventilator-derived parameters, therapeutic interventions and clinical outcomes, stratified for ICU mortality were analysed. ICU mortality was 45.8% (11/24). Only the following variables were significantly associated with ICU mortality: lower hospital length of stay (p = 0.01), need of continuous veno-venous hemofiltration (CVVH) during ECMO (p = 0.01), higher incidence of stroke (p = 0.04) and major bleeding (p = 0.004) (Table 1). Conclusions: We were not able to identify baseline variables, treatment and/or ventilator strategies nor laboratory results that are associated with ICU mortality in this small cohort of COVID-19 patients supported with ECMO. Our results suggest that CVVH, stroke or major bleeding during EMCO treatment may increase the risk of ICU mortality. (Figure Presented).

A rare case of cardiogenic shock due to lupus myocarditis in a patient with HIV

INTRODUCTION: Lupus Myocarditis is a rare and severe manifestation of systemic lupus erythematosus. We describe a patient with Human Immunodeficiency Virus (HIV) presenting with cardiogenic shock due to lupus myocarditis. DESCRIPTION: A 33 year old man with history of congenital HIV infection on anti-retroviral therapy, CD4 count 338/ mm3 and undetectable viral load, recurrent Pneumocystis jirovecii pneumonia, disseminated zoster and chronic kidney disease stage 3 presented with shortness of breath for 2 weeks and hypotension with cold extremities and leg edema. Transthoracic echocardiogram demonstrated acute severe biventricular dysfunction with ejection fraction of 10%. CXR showed ground glass opacities with bibasilar consolidation. He was subsequently intubated for acute hypoxic respiratory failure and admitted to the cardiac intensive care unit for management of cardiogenic shock mixed with sepsis due to presumed multifocal pneumonia. He was treated with high dose vasopressors, inotropes and empiric antibiotics. Infectious work up revealed methicillin-resistant Staphylococcus aureus (MRSA) in respiratory culture and negative viral infection including SARS-CoV-2. His course was complicated by worsening renal function with proteinuria and refractory metabolic acidosis required continuous venovenous hemofiltration and he suffered pulseless electrical activity (PEA) arrest with return of spontaneous circulation in 5 minutes. Coronary angiogram was normal. Auto-immune work up revealed elevated serologies: anti-Ds DNA >300 IU/ ml, Anti-Smith Ab: 1 (0-0.9 AI), Anti-chromatin Ab >8 (0 to 0.9 AI) with markedly low complement levels. Endomyocardial biopsy revealed lymphocytic infiltrate in endocardium and myocardium with no granulomas or thrombi. Based on these findings, he was diagnosed with lupus myocarditis and lupus nephritis. The patient clinically improved after treatment with pulse dose steroids and cyclophosphamide. His renal function recovered and cardiac function improved. He was weaned off from the ventilator and discharged to rehabilitation facility. DISCUSSION: Lupus Myocarditis requires urgent clinical attention as it may progress to heart failure and fatal cardiogenic shock. Early diagnosis with high index of suspicion and treatment with steroids and immunotherapy are the keys for better outcome.

Coupled Plasma Filtration Adsorption as a Potential Therapy for Critically III Covid-19 Patients

The Corona-19 virus disease (Covid-19) continues to cause an increasing number of deaths, mainly due to acute respiratory disorders. The high pandemic mortality and morbidity prompted clinicians to seek suitable adjunctive therapeutic methods to eliminate high cytokine levels effectively. This study aimed to review the combined plasma filtration adsorption (CPFA) technology and its potential efficacy in treating critically ill Covid-19. CPFA combines plasma separation, adsorption, and hemofiltration techniques that meet the need to remove substances such as cytokines. Findings from the report suggest an immune dysregulation known as cytokine storm syndrome plays a role in severe and critically ill Covid-19 patients. Extracorporeal blood purification targets cytokine elimination and is preferred as a bridging strategy to improve survival. Combined adsorption plasma filtration (CPFA) can remove various substances, including cytokines, without depleting physiologically essential proteins. CPFA can be considered and assessed in clinical trials to treat critically ill Covid-19 patients. Paired Plasma Filtration Adsorption (PPFA) can be viewed as a potentially effective therapy in treating Covid-19 patients in critical condition. © 2022 by SPC (Sami Publishing Company).

Blood Purification in Severe and Critical COVID-19 Patients: A Case Series of 5 Patients.

Objective: The ongoing coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to a worldwide pandemic. Currently, supportive care measures remain the standard of care for severe and critical COVID-19 patients, such as ventilation oxygenation, fluid management and blood purification. In this study, we aimed to evaluate the effects of early blood purification therapy upon severe and/or critical COVID-19 patients. Patients and Methods: From January 31, 2020 to March 1, 2020, a total 5 patients with COVID-19 (3 critical type cases and 2 severe type cases) received early blood purification treatment in the intensive care unit (ICU) of Affiliated Hospital of Zunyi Medical University. Clinical indexes, including oxygen concentration, blood gas analysis, oxygenation index, and laboratory test as well as disease scores were recorded and analyzed before and after the treatment with blood purification. Results: Among the 5 patients, 4 were males ranging from 35 to 80 year old (Mean age = 63 ± 17.87). All cases with characteristics of OI <300 mm Hg, decline in lymphocyte (LYMPH)%, boost in lactate dehydrogenase (LDH), troponin T (TNT), B-type brain natriuretic peptide (BNP), interleukin-6 (IL-6) and interferon-alpha (IFN-a), three with high flow nasal cannula (HFNC), two with non-invasive ventilation (NIV) and acute kidney injury (AKI), and one with shock and IV. Blood purification therapy significantly decreased the serum levels of inflammatory cytokine, ameliorated the concomitant symptoms and complications. Finally, one case was discharged from the hospital, 4 cases were transferred to the general ward, and all the 5 cases survived. Conclusion: Continuous blood purification therapy held promising prospects for alleviating the deteriorative progression of severe and critical types of COVID-19 in the early stage, together with ameliorating the accumulation of inflammatory cytokine and the concomitant symptoms and complications by efficacious immunoadsorption. Trial Registration: www.chictr.org.cn, Identifier (ChiCTR2000031930).

Extracorporeal Treatment for Chloroquine, Hydroxychloroquine, and Quinine Poisoning: Systematic Review and Recommendations from the EXTRIP Workgroup.

BACKGROUND: Although chloroquine, hydroxychloroquine, and quinine are used for a range of medical conditions, recent research suggested a potential role in treating COVID-19. The resultant increase in prescribing was accompanied by an increase in adverse events, including severe toxicity and death. The Extracorporeal Treatments in Poisoning (EXTRIP) workgroup sought to determine the effect of and indications for extracorporeal treatments in cases of poisoning with these drugs. METHODS: We conducted systematic reviews of the literature, screened studies, extracted data, and summarized findings following published EXTRIP methods. RESULTS: A total of 44 studies (three in vitro studies, two animal studies, 28 patient reports or patient series, and 11 pharmacokinetic studies) met inclusion criteria regarding the effect of extracorporeal treatments. Toxicokinetic or pharmacokinetic analysis was available for 61 patients (13 chloroquine, three hydroxychloroquine, and 45 quinine). Clinical data were available for analysis from 38 patients, including 12 with chloroquine toxicity, one with hydroxychloroquine toxicity, and 25 with quinine toxicity. All three drugs were classified as non-dialyzable (not amenable to clinically significant removal by extracorporeal treatments). The available data do not support using extracorporeal treatments in addition to standard care for patients severely poisoned with either chloroquine or quinine (strong recommendation, very low quality of evidence). Although hydroxychloroquine was assessed as being non-dialyzable, the clinical evidence was not sufficient to support a formal recommendation regarding the use of extracorporeal treatments for this drug. CONCLUSIONS: On the basis of our systematic review and analysis, the EXTRIP workgroup recommends against using extracorporeal methods to enhance elimination of these drugs in patients with severe chloroquine or quinine poisoning.

Filter clotting with continuous renal replacement therapy in COVID-19.

Coronavirus disease 2019 (COVID-19) appears to be associated with increased arterial and venous thromboembolic disease. These presumed abnormalities in hemostasis have been associated with filter clotting during continuous renal replacement therapy (CRRT). We aimed to characterize the burden of CRRT filter clotting in COVID-19 infection and to describe a CRRT anticoagulation protocol that used anti-factor Xa levels for systemic heparin dosing. Multi-center study of consecutive patients with COVID-19 receiving CRRT. Primary outcome was CRRT filter loss. Sixty-five patients were analyzed, including 17 using an anti-factor Xa protocol to guide systemic heparin dosing. Fifty-four out of 65 patients (83%) lost at least one filter. Median first filter survival time was 6.5 [2.5, 33.5] h. There was no difference in first or second filter loss between the anti-Xa protocol and standard of care anticoagulation groups, however fewer patients lost their third filter in the protocolized group (55% vs. 93%) resulting in a longer median third filter survival time (24 [15.1, 54.2] vs. 17.3 [9.5, 35.1] h, p = 0.04). The rate of CRRT filter loss is high in COVID-19 infection. An anticoagulation protocol using systemic unfractionated heparin, dosed by anti-factor Xa levels is reasonable approach to anticoagulation in this population.