COVID-19 pneumonia - increased incidence of pneumothorax/mediastinal emphysema after invasive mechanical and non-invasive ventilation.

Introduction: COVID pneumonia can lead to pneumomediastinum or pneumothorax during non-invasive or invasive mechanical ventilation. This affects the prognosis. Methodology: During the study period, 121 patients with SARS-CoV-2 infections and invasive or non-invasive ventilation therapy were recorded in our hospital. All patients with a pneumothorax or pneumomediastinum were analyzed in more detail. Result(s): Pneumothorax and pneumomediastinum occurred in 12 patients and resulted in 7 deaths. Discussion(s): The incidence of pneumothorax with COVID infection ranges from 0.56 to 1%, reaching 3.5% in our own studies and 4.2% under invasive mechanical ventilation. The incidence of pneumomediastinum was 10% and 9.2% in our own patients. Overall mortality was 58.3% and similar to that reported in the literature, up to 60%.Copyright © 2023 Dustri-Verlag Dr. K. Feistle.

Comparison of High-Flow Nasal Canula and Non-Invasive Mechanical Ventilation in Treating COVID-19 Patients

Objectives: The World Health Organization has declared COVID-19 a global pandemic in March 2020. Multiple COVID-19 waves are putting tremendous stress on healthcare systems. Evidence showed that high-flow nasal canula (HFNC) reduced the need for mechanical ventilation and shortened the time to clinical recovery among patients with severe COVID-19. This study aimed to assess the effect of using HFNC compared to non-invasive mechanical ventilation (NIV), on adult patients with COVID-19. Method(s): This retrospective study included patients hospitalized due to COVID-19 between October 2020 to December 2021 with appropriate ICD-10 diagnosis recorded in a commercially available, all-payer administrative database across 300+ hospitals. The identified patients were divided in two cohorts, one being the patients treated with HFNC as the first line respiratory support and another with NIV. Outcomes included all-cause mortality rate and length of stay. Multivariable analyses were performed to adjust for baseline characteristics. Result(s): Out of 16,534 eligible patients, 4,334 patients received HFNC as the first line respiratory support, whereas 12,200 received NIV. The all-cause mortality rate was 20.24% and 37.14% in the HFNC and NIV group, respectively. After adjusting for baseline characteristics, the all-cause mortality rate in the HFNC group was lower compared to NIV (odds ratio [OR], 0.51;95% confidence interval [CI], 0.47-0.55;p<0.001). The total length of stay was around 15 days for all patients. No different was observed between groups ( mean difference 0.3 days;95% CI, -0.27 - 0.92 days;p>0.05). Conclusion(s): Patients treated with HFNC showed lower mortality rates compared to NIV for hospitalized COVID-19 patients. However, further studies are still needed to better elucidate the clinical and economic benefit of HFNC in COVID-19 patients.Copyright © 2023

Peripartum Covid 19 admissions in an intensive care unit - Case series

Introduction: Peripartum women are at increased risk for severe illness with coronavirus disease (Covid-19) infection. Recent medical literature has drawn attention to the possible influence of COVID-19 on the course of pregnancies and its long-term effects.1-5 Objective: This case series aimed to observe the clinical course of peripartum women with confirmed Covid-19 admitted to a critical care unit in the North-west of England. Method(s): Since the start of the pandemic, all pregnant women with Covid-19 infection admitted to the critical care unit were monitored and followed up. Demographic profile, medical co-morbidities, treatment received, respiratory support and vaccination status were noted. Result(s): From March 2020 until February 2022, 8 women in our practice were shifted to the critical care unit post-partum in view of worsening work of breathing & increasing oxygen requirement after initial management in the delivery suite. All admissions were during the 3rd wave of the pandemic in the UK, between June to October 2021. 5 patients underwent Caesarean section under spinal anesthesia & 3 were shifted post normal vaginal delivery. Mean age in the study population was 33.25 years (SD +/- 3.99) and mean length of stay in the ICU was 6.62 days (SD +/- 3.99). Only one woman required intubation & mechanical ventilation for 10 days and the rest were managed on High Flow Nasal Cannula (HFNC) or Continuous Positive Airway Pressure (CPAP) hood and self-proning manoeuvres. 50% of the patients received Tocilizumab. All women were discharged home and there were no maternal deaths. Pre- admission none of the women were vaccinated, but on follow up 5 out of the 8 had completed their vaccination. All women were emotionally distraught due to being isolated from their family and new born. When reviewed at 12 weeks, one patient experienced post traumatic stress disorder (PTSD) and one had features of long Covid syndrome. On follow up, all new born babies were doing well. Conclusion(s): From the limited amount of data available, psychological stress was common to all patients. Being isolated from their new-born and family was the most difficult emotional aspect for the mothers in addition to finding it difficult to breathe and uncertainty about the future. Most mothers and new-born babies were discharged from the hospital without any serious complications. However, further observation and long term follow up is imperative. Use of guidelines in peripartum patients will aid in appropriate escalation of care. Key words: COVID-19, Pregnancy, Peri-partum, Long Covid syndrome.

Clinical characteristics and risk factors of patients with COVID-19 developing barotrauma

Background: At our hospital, people with COVID-19 (coronavirus disease 2019) had a high rate of pulmonary barotrauma. Therefore, the current study looked at barotrauma in COVID-19 patients getting invasive and non-invasive positive pressure ventilation to assess its prevalence, clinical results, and features. Methodology: Our retrospective cohort study comprised of adult COVID-19 pneumonia patients who visited our tertiary care hospital between April 2020 and September 2021 and developed barotrauma. Result(s): Sixty-eight patients were included in this study. Subcutaneous emphysema was the most frequent type of barotrauma, reported at 67.6%;pneumomediastinum, reported at 61.8%;pneumothorax, reported at 47.1%. The most frequent device associated with barotrauma was CPAP (51.5%). Among the 68 patients, 27.9% were discharged without supplemental oxygen, while 4.4% were discharged on oxygen. 76.5% of the patients expired because of COVID pneumonia and its complications. In addition, 38.2% of the patients required invasive mechanical breathing, and 77.9% of the patients were admitted to the ICU. Conclusion(s): Barotrauma in COVID-19 can pose a serious risk factor leading to mortality. Also, using CPAP was linked to a higher risk of barotrauma.Copyright © 2021 Muslim OT et al.

Extracorporeal membrane oxygenation for airway emergencies

Objectives: Extracorporeal membrane oxygenation (ECMO) is well established in cardiorespiratory failure. Here we report the use of ECMO in an airway emergency to provide respiratory support. Method(s): Informed consent was obtained from patient at the time of admission. Result(s): A 48-year-old with COVID-19 requiring venovenous ECMO (VVECMO) for 32 days and tracheostomy for 47 days had developed tracheal stenosis three months after tracheostomy removal, and undergone tracheal resection and reconstruction. He presented two weeks later with acute dyspnea, bloody drainage and a bulge in his neck with coughing. A computerized tomography (CT) of the cervical spine and chest showed dehiscence of the tracheal wound and a gap in the trachea. He was managed with High Flow Nasal Canula and supported on VVECMO support using 25 Fr. right femoral drainage cannula and 23 Fr. left IJ return cannula. A covered stent was placed, neck wound was irrigated and debrided. Patient was decannulated after 10 days on ECMO. Future therapeutic considerations include mediastinal tracheostomy, aortic homograft interposition of the disrupted segment of trachea with stent placement and permanent self-expandable stent with internal silicone stent. Conclusion(s): ECMO is increasingly used in complex thoracic surgery as well as in the perioperative period as salvage support. One of the areas where it has shown promising results is traumatic main bronchial rupture, airway tumor leading to severe airway stenosis, and other complex airway problems. The ease of cannulation, the technological advances and growing confidence in the management of ECMO patients are the main reasons for the expansion of ECMO use beyond conventional indications. The case described above is an example of the use of ECMO in the perioperative management of impending respiratory failure due to airway obstruction or disconnection. (Figure Presented).

Secondary Infections in Patients with Extremely Severe COVID-19 During ECMO Therapy.

Up to 70% of patients hospitalized for COVID-19 need respiratory support, up to 10% need high-flow oxygen therapy, non-invasive and invasive ventilation. However, standard methods of respiratory support are ineffective in 0.4-0.5% of patients. In case of potentially reversible critical refractory respiratory failure that patients may require ECMO. Management of patients with extremely severe COVID-19 associates with numerous clinical challenges, including critical illness, multiple organ dysfunction, blood coagulation disorders, requiring prolonged ICU stay and care, use of multiple pharmacotherapies including immunosuppressive drugs. Pharmacological suppression of immunity is associated with a significant increase in the risk of secondary bacterial and fungal infections. Currently, data on epidemiology of secondary infections in patients with COVID-19 undergoing ECMO is limited. Aim. To study the prevalence and etiology of secondary infections associated with positive blood cultures in patients with extremely severe COVID-19 requiring ECMO. Materials and methods. A single-center retrospective non-interventional epidemiological study including 125 patients with extremely severe COVID-19 treated with ECMO in April 2020 to December 2021. Results. Out of 700 blood culture tests performed in 125 patients during the study, 250 tests were positive confirming bacteremia/fungemia. Isolated pathogens varied depending on the duration of ECMO: gram-positive bacteria (primarily coagulase-negative staphylococci) dominated from the initiation of ECMO support;increased duration of ECMO associated with an increasing the proportion of pathogens common in ICU (Klebsiella pneumoniae and/or Acinetobacter baumannii with extensively drug resistant and pan-drug resistant phenotypes, and vancomycin-resistant Enterococcus faecium). When ECMO lasted more than 7-14 days, opportunistic pathogens (Candida species, Stenotrophomonas maltophilia, Providencia stuartii, non-diphtheria corynebacteria, Burkholderia species and others) prevailed as etiological agents. Conclusion. Longer duration of ECMO resulted in increasing the rates of infectious complications. In patients undergoing ECMO for more than 14 days, the microbiological landscape becomes extremely diverse, which hampers choosing an empirical antimicrobial therapy. Since potential pathogens causing secondary infections in patients during ECMO are difficult to predict, rapid identification of rare opportunistic pathogens and their sensitivity profile, followed by targeted administration of antimicrobials, seems most beneficial.Copyright © 2023, V.A. Negovsky Research Institute of General Reanimatology. All rights reserved.

Diagnosis and treatment of a patient with pneumoconiosis and tuberculosis complicated with severe COVID-19

The removal and defense mechanisms of the respiratory system of patients with pneumoconiosis are impaired. Once patients with pneumoconiosis and other underlying lung diseases are infected with novel coronavirus, they are likely to progress to severe cases with COVID-19, a tough condition with a high mortality and poor prognosis. Herein we presented a case of pneumoconiosis and tuberculosis complicated with severe COVID-19. Active administration of anti-viral, anti-infection, phlegm-removing, anti-asthmatic, and high-flow oxygen therapies did not alleviate the patient's acute respiratory distress syndrome symptoms. Then tracheal intubation, ventilator assisted breathing, and lung protective ventilation were given but did not effectively treat the patient's respiratory failure. Finally, the patient died clinically despite use of extracorporeal membrane oxygenation (ECMO).Copyright © 2021, Shanghai Municipal Center for Disease Control and Prevention. All rights reserved.

Respiratory support for adult patients with COVID-19

The COVID-19 pandemic is creating unique strains on the healthcare system. While only a small percentage of patients require mechanical ventilation and ICU care, the enormous size of the populations affected means that these critical resources may become limited. A number of non-invasive options exist to avert mechanical ventilation and ICU admission. This is a clinical review of these options and their applicability in adult COVID-19 patients. Summary recommendations include: (1) Avoid nebulized therapies. Consider metered dose inhaler alternatives. (2) Provide supplemental oxygen following usual treatment principles for hypoxic respiratory failure. Maintain awareness of the aerosol-generating potential of all devices, including nasal cannulas, simple face masks, and venturi masks. Use non-rebreather masks when possible. Be attentive to aerosol generation and the use of personal protective equipment. (3) High flow nasal oxygen is preferred for patients with higher oxygen support requirements. Non-invasive positive pressure ventilation may be associated with higher risk of nosocomial transmission. If used, measures special precautions should be used reduce aerosol formation. (4) Early intubation/mechanical ventilation may be prudent for patients deemed likely to progress to critical illness, multi-organ failure, or acute respiratory distress syndrome (ARDS).Copyright © 2020 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of the American College of Emergency Physicians.

Aerosol Medication Use in COVID-19 Pandemic

Administration of aerolized drugs to patients diagnosed with COVID-19 leads to the risk of transmission of patient-generated infectious aerosols to healthcare providers.While the COVID-19 pandemic is ongoing, in order to provide the best treatment for patients and at the same time to protect healthcare providers at the highest level, it is necessary to increase access to information and pay maximum attention to preventive measures.Copyright © 2020 Bilimsel Tip Yayinevi. All rights reserved.

COVID-19 and intensive care

COVID-19 caused by SARS-CoV2 has spread rapidly across the world, resulting in many patients in need of intensive care support. Severe pneumonia, acute respiratory distress syndrome (ARDS), sepsis/septic shock, and multi-organ failure may occur during the disease course among many other complications. There still is not a definite cure, but supportive care is important to minimize complications. Patients in need of respiratory support and interventions should preferably be placed in negative pressure isolation rooms, with utmost care to decrease viral spread. Points to consider during oxygen therapy, non-invasive and invasive mechanical ventilation, and shock management of COVID-19 patients are discussed. Patients with mild hypoxia may be managed with conventional oxygen therapy, while others will benefit from high flow nasal oxygen therapy and mechanical ventilation. Although corticosteroids are not recommended for other viral pneumonia, there are recent reports suggesting that steroids may have a place in the treatment of COVID-19 patients with hypoxia. Shock may complicate the course of the disease and a search for the etiology of shock should be carefully planned. Thromboembolic events are common;prophylaxis and/or treatment of thromboembolic events should be managed according to the guidelines. Meanwhile, the results of ongoing randomized, controlled trials on antiviral and immunomodulatory agents are expected to offer better treatment options for COVID-19 patients in the near future.Copyright © 2020 Bilimsel Tip Yayinevi. All rights reserved.

Delayed intubation with high flow nasal cannula in COVID: a comparison between a first and second pandemic wave

Introduction: High flow nasal cannula (HFNC) treatment is an efficient treatment for hypoxemia in acute respiratory distress syndrome (ARDS). Before the COVID pandemic, non-invasive ventilation was associated with higher mortality in ARDS, and early intubation was advocated. We hypothesized that HFNC treatment was more restrictive in the first wave of the COVID pandemic compared to the second wave respecting the pre-COVID conceptual consensus of early intubation in ARDS. Method(s): We conducted this retrospective observational singlecenter study in a tertiary ICU in Brussels during the COVID pandemic. The first flare-up ranged from March to May 2020, and the second flare-up from September to January 2021. All patients with COVID pneumonia and HFNC before intubation were included. We considered a delayed intubation a ROXi < 3.85 at the start of HFNC. ROXi is the ratio of SpO2/ FiO2 to the respiratory rate. The primary outcome was delayed intubation based on the ROXi in the number of days. The secondary outcome was mortality. Result(s): We included 60 patients in the first wave and 70 in the second wave. The duration of HFNC treatment before intubation was longer during the second wave, based on ROXi < 3.85: 1.6 days versus 2.8 days, p < 0.05 (Fig. 1). There was no significant difference in mortality, 18% versus 29%. The length of intubation was similar in both groups. The CCI, SOFA, APACHE III and SAPS II scores were similar in both groups. Conclusion(s): The duration of HFNC treatment in COVID-19-related ARDS before intubation has significantly been extended in the second pandemic wave. The delayed intubation based on the ROXi was in this study without significantly increased mortality. However, a trend toward higher mortality after prolonged HFNC was seen in the second pandemic wave.

Outcomes following application of high flow nasal cannula and non-invasive ventilation during the second COVID-19 wave in Singapore

Introduction: COVID-19 pneumonia can result in significant morbidity and mortality in affected individuals. Our audit aims to study the respiratory outcomes of patients with COVID-19 pneumonia following the use of HFNC and NIV during the second wave of the pandemic. Method(s): We analysed the outcomes of 94 patients admitted to a tertiary combined HDU/ICU with severe COVID-19 pneumonia requiring non-invasive support between July and December 2021. Result(s): 94 patients were admitted during the study period. ICU mortality rate was 22% (21/94), total in-hospital mortality was 38% (36/94). HFNC was used as first line respiratory support in 58/94 cases, of which 39.6% required intubation. Of those patients who failed HFNC, time to intubation was significantly higher in those patients who passed away than those who were intubated and survived (mean 6.08 days vs 2.86 days, p < 0.05 one sided T-test). In all patients, very late intubation defined as intubation > 5d post admission to ICU, occurred in 6/41 patients, of which the mortality rate was 100%. ROX score performed at 12 h post intubation was unable to discriminate those who succeeded with HFNC and those who required intubation (mean ROX 7.24 vs 7.9, p > 0.05). NIV was used in combination with HFNC pre-intubation in 5/23 HFNC cases with 100% mortality rate. Extubation failure rates were low (5/94) and use of tracheostomy was uncommon (4/94;all 4 survived ICU stay, 3 eventually died in hospital). Conclusion(s): HFNC failure with prolonged use of HFNC and use of multiple non-invasive device strategies before intubation was associated with a high risk of mortality. Conventional measurements of HFNC failure in the form of a 12 h ROX score could not assist the clinician in predicting those patients at risk of HFNC failure.

Correlation of clinical, laboratory, ventilation, and outcome parameters in hospitalized Coronavirus Disease 2019-infected patients with computed tomography severity score

Context Widespread prevalence of Coronavirus Disease 2019 (COVID-19) infection with high rates of morbidity and mortality necessitates early case definition and severity grading to predict prognosis and improve disease outcome parameters. Purpose To correlate computed tomography severity score (CTSS) in COVID-19-infected patients with their clinical, laboratory, method of ventilation, and disease outcome parameters. Patients and methods A retrospective analysis was performed on 139 COVID-19-infected patients with typical or indeterminate COVID radiological patterns with a correlation between CTSS and their clinical, laboratory, ventilation, hospital stay, and survival data. Results A total of 139 cases were included, with a mean age of 59.81 +/- 12.29 years, 63.3% males, 28.77% were noncomorbid, and oxygen saturation of 82.53 +/- 6.58 SD. They were subgrouped based on CTSS. A significant correlation was found between high CTSS and oxygen saturation, C-reactive protein, ferritin, D-dimer, lymphopenia, diabetes comorbid patients, need for high-flow oxygen therapy, need for noninvasive or invasive ventilation, mortality, and number of hospital stay in days. Conclusion Different parameters are correlated with high CTSS, especially low oxygen saturation, high C-reactive protein or ferritin values, diabetes, and long hospital stay.Copyright © 2023 Wolters Kluwer Medknow Publications. All rights reserved.

Causes of mortality of severe COVID-19 patients receiving high-flow oxygen therapy

Introduction: High-flow oxygen therapy (HFOT) is used to provide oxygenation and reduce the need for intubation in severe pneumonia cases caused by SARS-CoV-2 virus. In this study, causes of mortality during hospitalization in the intensive care unit (ICU) in patients receiving HFOT therapy were investigated. Method(s): The data of 215 adult patients, who were admitted to ICU of a university hospital between April 2020 and October 2021, with severe COVID pneumonia and received HFOT were enrolled retrospectively in our study. Result(s): Total mortality among patients was 158 (73.4%). The overall mean age was 72 years, 61 in the survivor group and 73 in the mortality group (p < 0.001). It was determined that mortality rates decreased as the length of stay (LoS) in ICU and HFOT duration of the patients increased (p = 0.008 and < 0.001, respectively). The increase in respiratory rate on arrival was found to be significantly associated with increased mortality. Although the goal of HFOT is to improve oxygenation, no significant mortality-related difference was found in terms of pO2, pCO2 and P/F values calculated at the time of admission. The ROC curve was applied to examine the differential effect of Apache-II, SOFA, ROX and Procalcitonin measurements according to the survival. The area under the curve (AUC) and cut-off values were calculated as follows: APACHE-II (63.9%, 5,) SOFA (62.8%, 2), ROX index (66.8%, 4.72), Procalcitonin (65.7%, 0.23) (Fig. 1). Conclusion(s): Unlike reports in literature on mortality in ICU, LoS was found to have a decreasing effect on mortality rate [1]. In addition to the well-known scoring systems such as APACHE-II and SOFA, the ROX index, which is used to predict the success of HFOT, has emerged as a predictive value for mortality at admission to the intensive care unit [2].

Ventilator avoidance among critically ill COVID-19 patients with acute respiratory distress syndrome

Introduction: Misinformation citing mechanical ventilation, not the virus, as causing death in COVID-19 patients with respiratory failure has led to ventilator avoidance (initial refusal of intubation) during the pandemic. Method(s): Prospective observational cohort study (March 2020- June 2021) evaluating the incidence and significance of initial refusal of intubation in patients with critical COVID-19 defined as ARDS requiring > 55% sustained FiO2 on high flow nasal canula (HFNC), non-invasive positive-pressure ventilation (NIPPV) or requiring intubation. Outcomes included in-hospital mortality and 1-year modified Rankin Scale (mRS) score. Logistic regression was used to estimate the age and Charlson Comorbidity Index adjusted odds ratio (OR) of in-hospital death. The Wilcoxon rank-sum test was used to evaluate differences in the mRs. Result(s): The cohort was predominantly non-Latino white (76%), male (65%), unvaccinated (99.4%), mean age of 66, and good pre- COVID-19 functional status (median mRs score of 0). Overall, 315 patients were critically ill due to COVID-19 with an in-hospital mortality of 41.9% (132/315;95% CI 36-47%). In patients in whom intubation was recommended 39% initially refused (40/102;95% CI 30-49%). Utilization of HFNC (90%) and NIPPV (72%) were similar between groups, however actual use of mechanical ventilation differed (98.4% in those that did not initially refuse compared to 20% in those that initially refused (p = 0.001)). In-hospital mortality was 79.3% (49/62) in those who initially did not refuse intubation compared to 77.5% (31/40) in those who refused (adjusted OR 1.3;95% CI 0.5-.5). The distribution of 1-year mRS was not significantly different between groups (p = 1.0) (Fig. 1). Conclusion(s): Among critically ill patients with COVID-19 associated ARDS, ventilator avoidance was common however, it was not associated with increased in-hospital mortality or a difference in 1-year functional outcome.

Lung ultrasound scoring system vs ROX index as a predictor for progression to the invasive mechanical ventilation in COVID-19 patients

Background: During the outbreak of the highly contagious Coronavirus disease 19 (COVID19), rapid and simple prognostic tools were needed to support clinical decisions and predict the need of invasive mechanical ventilation. the ROX index, and the lung ultrasound score (LUSS) were proposed to objectively predict patient prognosis in addition to the subjective clinical assessment Aim: This study aimed to compare lung ultrasound score with ROX index in predicting the need of invasive ventilation in COVID-19 patients requiring advanced oxygen therapy. Patients and Methods: We studied 50 patients with severe COVID-19 pneumonia in the intensive care unit in the isolated area at Kasr Al-Ainy hospital. Complete Medical history, physical examination and laboratory investigations were obtained on admission. All patients underwent bedside lung ultrasonography scan and LUSS was calculated at the 2nd and the 12th hours, also ROX index was calculated at the 2nd, 6th and 12th hours from initiating the advanced oxygen therapy. Result(s): From a total of fifty patients with COVID-19, 56.0% were males, with mean age of 65.98 + 11.68 years, and mortality rate was 68%. The optimal cut off value of the ROX index at (2, 6, 12 hour) is (2.495, 2.675, 3.06) respectively, (p <0.001) with sensitivity 90.9% and specificity 76.5% at the 12 hour. Also the optimal cut off point of LUSS is 25.50 (p <0.001) with sensitivity 93.9% and specificity 88.2% for prediction of the invasive mechanical ventilation. Conclusion and recommendations: The study concluded that LUSS is more sensitive in predicting the need of invasive mechanical ventilation than ROX index.Copyright © 2023, Codon Publications. All rights reserved.

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).

42nd International Symposium on Intensive Care and Emergency Medicine

The proceedings contain 369 papers. The topics discussed include: effective FiO2 delivered by a new frugal CPAP system with low oxygen needs: from bench to clinical observations;effect of non invasive respiratory support on interstitial lung disease with acute respiratory failure: a systematic review and meta analysis;causes of mortality of severe COVID 19 patients receiving high flow oxygen therapy;patient ventilator interaction during noninvasive ventilation with helmet: a comparison between pressure support ventilation and the new neural pressure support (NPS) software;tidal volume measurement during non invasive respiratory support by helmet continuous flow CPAP is feasible and accurate in a bench model;delayed intubation with high flow nasal cannula in COVID: a comparison between a first and second pandemic wave;outcomes following application of high flow nasal cannula and non invasive ventilation during the second COVID 19 wave in Singapore;ventilator avoidance among critically ill COVID 19 patients with acute respiratory distress syndrome;and mortality rate, intensive care unit length of stay and time to orotracheal intubation of COVID 19 patients under different non invasive ventilatory therapies: retrospective cohort study.

Potential Predictors for Disease Severity in Hospitalised COVID-19 Patients

Background and Objectives Several studies have shown that SARS-CoV-2 can induce a cytokine release storm which is a major cause of disease severity and death. Therefore, cytokine levels in the serum may predict disease severity and survival in patients with COVID-19. Methods We included 88 COVID-19 patients who were hospitalised at the Division of Pulmonology of the Vienna General Hospital between January and May 2021 in this observational trial. Blood samples for serum peptide measurements were drawn at the time closest to hospitalisation, at day 5, 9 and 13( +/- 1). We correlated the type of ventilation (nasal oxygen therapy, high flow nasal canula, non-invasive ventilation or mechanical ventilation), occurrence of consolidations on chest X-ray or if available HRCT and the level of care (general ward, IMCU or ICU) with serum peptide values. We assessed the concentration of cytokines (IL-1a, IL-1b, IL-1RA, IL-6, L-7, L-10, IFN- gamma and TNF-alpha), chemokines (CCL-3, CCL-4 and CCL-7) and growth factors (G-CSF, GM-CSF and VEGF). Results Patients were 68 years of age (median) and stayed in hospital between 5-171 days. The peak inspiratory pressure in patients receiving non-invasive ventilation or mechanical ventilation was significantly associated with IL-1RA, G-CSF and IFN-gamma and the fraction of inspired oxygen in patients receiving highflow nasal canula oxygen therapy was significantly associated with IL-6, IL-7, IFN-gamma, and CCL-7. Results are shown in Table 1. No investigated cytokine correlated with the type of ventilation, occurrence of consolidations on imaging and in-hospital mortality. Conclusions In conclusion, concentrations of IL-1RA, G-CSF, IL-6, IL-7, IFN-gamma, and CCL-7 were associated with more severe disease progression in hospitalised COVID-19 patients.

Analysis of High Flow Nasal Cannula Utilization During Pediatric Critical Care Transport

Objective: There are limited studies on the safety and efficacy of high flow nasal cannula (HFNC) utilization in pediatric critical care transport (CCT). This 15-month retrospective study was designed to describe HFNC utilization by our transport team and to track escalations in respiratory support within 24 hours of hospital admission including increased liter flow, non-invasive ventilation (NIV), or intubation. Method(s): This study was conducted at a large quaternary free standing children's hospital with a dedicated pediatric transport team that completes an average of 5,500 transports per year. Data was collected from January 1, 2019, to March 31, 2020. A total of 6,279 pediatric transports were completed during the study period. Inclusion criteria: >30 days and <18 years old, required HFNC >=4 L/min during transport, and admitted to our pediatric facility. Our institutions HFNC pediatric floor (Peds) criteria: <2 years of age, no comorbidities, suspected respiratory viral illness, max 2 L/kg and/or 15 L/min, <=40% FiO2. All patients used the standard HFNC equipment in our department. No new equipment was trialed during this study. We did not include SARS-COVID-19 patients given the initial variability in non-invasive respiratory support. Result(s): A total of 382 charts reviewed;358 patients met inclusion criteria. Median age 0.7 years old, with an interquartile range (IQR) of 0.3-1 year of age. Median weight 8.4 kilograms (kg), IQR 6.2-11 kg. Median transport time 80 minutes (min), IQR 69-115 min. Most of our HFNC volume was initiated by the referral (279, 78%) and we initiated the remainder (79, 22%). The majority of our HFNC patients were transported from the (ER) (184, 51%) and Peds (119, 33%) with the remainder being from urgent care (UC) (42, 12%), and Pediatric Intensive Care Unit (PICU) (13, 4%). We transported (210, 41%) back to the PICU versus (148, 41%) to Peds. Of the 279 patients that were on HFNC started by the referral, 42 (15%) had their flow weaned by the transport team. Median HFNC 10 L/min with an IQR of 6-15 L/min appreciated at drop-off regardless of HFNC status (initiated by transport, weaned by transport, or continued referral settings) (p-value 0.122). Escalations of care were tracked up to 24 hours after patient drop-off. A total of 118 patients (33%) had an escalation of care;90 (76%) required an increase in flow, 28 (24%) required NIV, and 0 (0%) required intubation within 24 hours. Escalations of care typically occurred within the first 6 hours after patient drop-off, 96 (27%), with a median HFNC 10.25 L/min, IQR 8-14 L/min (p-value range <=0.310). Conclusion(s): Our data suggests HFNC utilization in pediatric patients during CCT is a safe modality for non-invasive oxygen delivery with minimal risk of escalation requirement and no need for intubation. The number of escalations in liter flow after patient drop-off (~25% of high flow volume) was likely due to inpatient protocol to place all HFNC patients on 2 L/kg or max of 15 L/min. In the future, we plan to implement a HFNC protocol for management guidelines during CCT while conducting further research and review.Copyright © 2022