The use of CytoSorb in a septic shock patient with ARDS due to Sars Cov-2

Background: Septic shock is a clinical condition of sepsis aggravated by circulatory, cellular and metabolic dysregulation. Diagnostic criteria include the need for vasopressors to maintain a PAM>65 and serum lactate levels>2 under adequate fluid therapy. Early identification of critically septic patients is necessary to allow early and adequate treatment with improved prognosis. In this case report we evaluate the haemodynamic impact of CytoSorb therapy in a case of septic shock in a patient with ARDS Sars cov2. Method(s): Patient with Sars Cov-2 ARDS was admitted to our department. He was intubated and had a SOFA Score 7. On day 15 the patient presented an increase in PCT CRP and WBC levels with the need for norepinephrine infusion. Empirical antibiotic therapy was started and after 24 hours also CytoSorb Therapy. Four CytoSorb cartridge columns were used. The first two were changed every 12 h and then the next two were changed every 24 h. Result(s): Two days after CytoSorb therapy there was an improvement in haemodynamic without the need of vasopressor support. There was also a reduction in inflammatory parameters and lactates. The trend of these values was shown in figure 1. Conclusion(s): In this case report we evaluated the impact of CytoSorb therapy in a case of septic shock in a patient with ARDS Sars Cov-2. The early use of hemadsorption with CytoSorb combined with re-evaluation of antibiotic therapy resulted in a marked improvement in the patient's clinical status.

Predictors of poor outcomes in patients with pandemic viral infections (influenza AH1N1pdm09, COVID-19) on a ventilator.

Considering the commonality of the pathogenetic links of the critical forms of COVID-19 and influenza AH1N1pdm09 (cytokine over-release syndrome), the question arises: will the predictors of an unfavorable outcome in patients on mechanical ventilation and, accordingly, the universal tactics of respiratory support in these diseases be identical? Objective. In a comparative aspect, to characterize patients with influenza AH1N1pdm09 and COVID-19 who were on mechanical ventilation, to identify additional clinical and laboratory risk factors for death, to determine the degree of influence of respiratory support (RP) tactics on an unfavorable outcome in the studied category of patients. Patients and methods. Patients treated on the basis of resuscitation and intensive care departments of the State Budgetary Healthcare Institution "SKIB" in Krasnodar and the State Budgetary Healthcare Institution "IB No 2" in Sochi were studied: group 1 - 31 people with influenza AH1N1pdm09 (21 people died - subgroup 1A;10 people survived - subgroup 1B) and group 2 - 50 people with COVID-19 (29 patients died - subgroup 2A;21 people survived - subgroup 2B). All patients developed hypoxemic ARF. All patients received step-by-step tactics of respiratory support, starting with oxygen therapy and ending with the use of "traditional" mechanical ventilation. Continuous variables were compared in subgroups of deceased and surviving patients for both nosologies at the stages: hospital admission;registration of hypoxemia and the use of various methods of respiratory therapy;development of multiple organ dysfunctions. With regard to the criteria for which a statistically significant difference was found (p < 0.05), we calculated a simple correlation, the relative risk of an event (RR [CI 25-75%]), the cut-off point, which corresponded to the best combination of sensitivity and specificity. Results. Risk factors for death of patients with influenza AH1N1pdm09 on mechanical ventilation: admission to the hospital later than the 8th day of illness;the fact of transfer from another hospital;leukocytosis >=10.0 x 109/l, granulocytosis >=5.5 x 109/l and LDH level >=700.0 U/l at admission;transfer of patients to mechanical ventilation on the 9th day of illness and later;SOFA score >=8;the need for pressor amines and replacement of kidney function. Predictors of poor outcome in ventilated COVID-19 patients: platelet count <=210 x 109/L on admission;the duration of oxygen therapy for more than 4.5 days;the use of HPNO and NIV as the 2nd step of RP for more than 2 days;transfer of patients to mechanical ventilation on the 14th day of illness and later;oxygenation index <=80;the need for pressors;SOFA score >=8. Conclusion. When comparing the identified predictors of death for patients with influenza and COVID-19 who needed mechanical ventilation, there are both some commonality and differences due to the peculiarities of the course of the disease. A step-by-step approach to the application of respiratory support methods is effective both in the case of patients with influenza AH1N1pdm09 and patients with COVID-19, provided that the respiratory support method used is consistent with the current state of the patient and his respiratory system, timely identification of markers of ineffectiveness of the respiratory support stage being carried out and determining the optimal moment escalation of respiratory therapy.Copyright © 2022, Dynasty Publishing House. All rights reserved.

Comparative effectiveness and safety of a pharmacist-managed protocol for the transition from intravenous to subcutaneous insulin

Purpose: To evaluate the effectiveness and safety of a pharmacist-managed protocol for transitioning critically ill patients from intravenous (iv) to subcutaneous insulin compared with a provider-managed process. Method(s): This single-center, retrospective, observational study included patients admitted to the medical or surgical/trauma intensive care unit who received a continuous infusion of iv insulin from January 2019 to April 2021. Patients were excluded if they were less than 18 years of age, pregnant, incarcerated, or received iv insulin for the diagnosis of diabetic ketoacidosis, hyperglycemic hyperosmolar state, calcium channel blocker or beta blocker overdose, or hypertriglyceridemia. The primary outcome was the percentage of blood glucose (BG) concentrations within the target range of 70-150 mg/dL from 0 to 48 h following transition to subcutaneous insulin. Secondary outcomes included percentage of BG concentrations within goal range following transition at 0-12 h and 12-24 h, incidence of hypo- and hyperglycemia, and percentage of patients requiring dose adjustments after initial transition. Result(s): A total of 110 unique patients were included with 70 patients in the provider-managed group and 40 patients in the pharmacist-managed group. On average, pharmacists transitioned patients to 63% basal insulin based on their 24-h total day dose of insulin. The pharmacist-managed group achieved glycemic control in 53% of transitions at 12 h, 40% at 24 h, and 47% from 0 to 48 h, while the provider group achieved glycemic control in 25% of transitions at 12 h, 12% at 24 h, and 18% from 0 to 48 h (p < 0.001 for all time points). As for safety end points, the pharmacist-managed group demonstrated lower rates of hypoglycemia (p = 0.001), severe hypoglycemia (p = 0.332), hyperglycemia (p < 0.001), and severe hyperglycemia (p < 0.001) compared with the provider-managed group. Conclusion(s): Pharmacists can effectively and safely transition critically ill patients from iv to subcutaneous insulin utilizing a standardized protocol.Copyright © 2023 Pharmacotherapy Publications, Inc.

Blood purification treatment and cytokine removal using Cytosorb device in critically ill patients with COVID-19 infection

Introduction: Acute kidney injury (AKI) is a complication of SARS-CoV-2 disease, associated with worse clinical outcomes. Renal replacement therapy (RRT) in combination with sequential extracorporeal blood purification therapies (EBPT) might support renal function, attenuate systemic inflammation, and prevent or mitigate multiple organ dysfunctions. Method(s): We retrospectively analyzed 20 patients admitted in ICU for ARDS and who developed moderate-to-severe AKI requiring RRT. Cytokine hemadsorption with Cytosorb was performed in association with CRRT. The main indication for this treatment was the worsening of hemodynamic and respiratory conditions and suspicion of cytokine storm. The protocol consisted in the use of 3-4 cartridges in total;among these, the first 2 were changed after 12 hours of treatment to maximize cytokine removal, while the others after 24 hours. We examined comorbidities, clinical and laboratory characteristics and the impact of treatment in terms of mortality rate and changes in data before and after treatment. Result(s): Nineteen patients (95%) had an AKI at any time during their ICU stay. Of these, 5 patients (25%) had AKI stage II and 14 patients (70%) had AKI stage III. All patients included in this subgroup were mechanical ventilated and required vasopressor's use. Mean prescribed CRRT dose was 31.2 +/- 11.7 ml/kg/h. The median time to strating RRT after ICU admission was 7 days (IQR 3.5-15 days) and the median duration was 7 days (IQR 2.5-12.5 days). Mean SOFA score at the time of RRT start was extremely high (14.5 +/- 2.8). Mortality rate was important (18 patients, 90%) in our cohort. Comparing clinical and laboratory data before and after treatment, a significant improvement of inflammatory markers was reported, with the reduction of C-reactive protein (CRP, 143 [62.1- 328.5] vs 83.5 [66.7-153.5] mg/L);however, no significant changes in IL-6, WBC and PCT values were observed. A slight increase of PaO2/FiO2 were described, although not statistically significant (PaO2/FiO2 ratio 144 [82.7-174.2] vs 183 [132-355.5] mmHg). Conclusion(s): Our experience supports the need of an adequate timing for the use of Cytosorb in critically ill patients with Covid-19. Although a discrete efficacy in improving inflammatory cascade, the late use of EBPT, when organ dysfunction was already ongoing, didn't impact survival.

Acute liver injury in COVID-19 patients in Cohort Ward, Somdejphrachaotaksin Maharaj Hospital

Objective: To study the prevalence and risk factors for acute liver injury in COVID-19 patients and to assess the clinical outcome of COVID-19 in patients with acute liver injury in cohort ward, Somdejphrachaotaksin Maharaj Hospital. Method(s): A cross-sectional study was done in moderate-to-severe COVID-19 patients who hospitalized in cohort ward, Somdejphrachaotaksin Maharaj Hospital. Demographic data, laboratory results and clinical data were collected during 1st April to 31st October 2021. Result(s): From total of 93 COVID-19 patients, the prevalence of acute liver injury (ALI) were 28% (95%CI 18.6-37.2). Factor associated with acute liver injury was male (p<0.05). Mean absolute lymphocyte count of ALI patients and non-ALI patients were 1154.77 and 1530.02 respectively (p = 0.063). There was no difference in vasopressor support, ventilator support, length of stay and dead of COVID-19 patients between ALI group and non-ALI group. Conclusion(s): The prevalence of acute liver injury among COVID-19 patients was high. Factor associated with acute liver injury were male and tendency of lower absolute lymphocyte count. There were differences in clinical outcome of COVID-19 patients between acute liver injury and non-acute liver injury.

The Complexities of Managing Hypertriglyceridemia-Induced Pancreatitis in a Critically-Ill COVID-19 Patient

Introduction: Hypertriglyceridemia-induced pancreatitis (HTP) is a variant of pancreatitis requiring unique management. The complications of COVID-19 and its treatments can make HTP therapy more nuanced. This case describes a patient who presented in diabetic ketoacidosis (DKA) with HTP, and COVID-19. The patient developed renal and respiratory failure, necessitating hemodialysis (HD) and extracorporeal membrane oxygenation (ECMO), complicating an otherwise straightforward medical management plan. Case Description: A morbidly obese (BMI 38.9 kg/m2) 43-year-old male presented to an outside hospital with abdominal pain, and vomiting, and was found to have HTP with triglycerides (TG) >2000 mg/dL (<149 mg/dL) and presumed new-onset type 2 Diabetes (HbA1c 10.9%) with DKA. Treatment with fluids, intravenous (IV) insulin infusion and plasmapheresis were initiated. He developed hypoxia after receiving over 17 liters of fluids and was intubated, subsequently developing renal failure and was transferred to our tertiary center for HD and ECMO. On admission, he tested positive for COVID-19, rhabdomyolysis [creatinine kinase 5600 U/L (30-200 U/L)], HTP [TG 783 mg/dL (<149 mg/dL), lipase 461 U/l (7-60 U/L)], glucose 269 mg/dL (not in DKA), transaminitis [AST 184 U/L (4-40 U/L), ALT 61 U/L (4-41 U/L)] and renal failure (GFR 10 ml/min/1.73m2). IV insulin infusion was initiated for hyperglycemia worsened by COVID-19 dexamethasone treatment. Plasmapheresis was performed twice with minimal effect at maintaining a low TG. Fenofibrate was not initiated due to renal failure;Lovaza could not be given via oral gastric tube;Atorvastatin was attempted once rhabdomyolysis resolved, with subsequent worsening of liver function tests. Heparin infusion was initiated for deep vein thrombosis treatment and HTP but was stopped after development of heparin induced thrombocytopenia. The patient developed worsening hypoglycemia requiring cessation of IV insulin, hypotension requiring maximum pressor support, and worsening sepsis leading to his death. Discussion(s): This case illustrates the challenges of managing a patient with HTP and COVID-19. It demonstrates how a normally straightforward treatment algorithm can become increasingly complex when factoring the patient's comorbid conditions. The case highlights the importance of knowing both treatment indications and contraindications for HTP. In this case, HTP may have been the initial diagnosis, straightforward for most endocrinologists, but its treatments and comorbid conditions ultimately made the landscape more challenging, limiting effective management and ultimately leading to this patient's demise.Copyright © 2023

Fungal pneumonia in COVID-19 patients: Risk factors and early prediction

Objective To determine the risk factors for developing secondary fungal pneumonia in moderate to severe coronavirus disease 2019 (COVID-19) cases. Using predictors of fungal infection helps to guide the diagnosis and treatment in these cases and save their lives. Patients and methods A total of 257 patients with moderate to severe COVID-19 pneumonia were examined in this retrospective study at Al Qassimi Hospital of EHS. An assessment of clinical, laboratory, and radiologic findings was performed upon admission. The data were collected and analyzed. Results Overall, 32% of critically ill COVID cases had fungal infection;47% of them were candida, whereas aspergillosis and yeast were positive in 26.5% each. At the time of hospitalization, computed tomography chest findings had a strong correlation with fungal culture results in COVID-19 cases. Fungal infection in COVID-19 cases correlated strongly with metabolic acidosis, high erythrocyte sedimentation rate, high blood sugar, need for mechanical ventilation at admission, vasopressor use, renal replacement, long duration of steroid treatment, long stay in ICU, and long duration on mechanical ventilation. The longer the duration of PCR positivity, the higher the incidence of positive sputum fungal culture result. Conclusion COVID-19-infected patients with other risk factors for fungal infections should always be considered to have fungal infections if pathogenic organisms are isolated from respiratory secretions or other microbiological or immunological markers appear positive. Computed tomography chest finding in COVID-19 cases is an important predictor for fungal infection.Copyright © 2023 The Egyptian Journal of Chest Diseases and Tuberculosis.

Predictors of poor outcomes in patients with pandemic viral infections (influenza AH1N1pdm09, COVID-19) on a ventilator.

Considering the commonality of the pathogenetic links of the critical forms of COVID-19 and influenza AH1N1pdm09 (cytokine over-release syndrome), the question arises: will the predictors of an unfavorable outcome in patients on mechanical ventilation and, accordingly, the universal tactics of respiratory support in these diseases be identical? Objective. In a comparative aspect, to characterize patients with influenza AH1N1pdm09 and COVID-19 who were on mechanical ventilation, to identify additional clinical and laboratory risk factors for death, to determine the degree of influence of respiratory support (RP) tactics on an unfavorable outcome in the studied category of patients. Patients and methods. Patients treated on the basis of resuscitation and intensive care departments of the State Budgetary Healthcare Institution "SKIB" in Krasnodar and the State Budgetary Healthcare Institution "IB No 2" in Sochi were studied: group 1 - 31 people with influenza AH1N1pdm09 (21 people died - subgroup 1A;10 people survived - subgroup 1B) and group 2 - 50 people with COVID-19 (29 patients died - subgroup 2A;21 people survived - subgroup 2B). All patients developed hypoxemic ARF. All patients received step-by-step tactics of respiratory support, starting with oxygen therapy and ending with the use of "traditional" mechanical ventilation. Continuous variables were compared in subgroups of deceased and surviving patients for both nosologies at the stages: hospital admission;registration of hypoxemia and the use of various methods of respiratory therapy;development of multiple organ dysfunctions. With regard to the criteria for which a statistically significant difference was found (p < 0.05), we calculated a simple correlation, the relative risk of an event (RR [CI 25-75%]), the cut-off point, which corresponded to the best combination of sensitivity and specificity. Results. Risk factors for death of patients with influenza AH1N1pdm09 on mechanical ventilation: admission to the hospital later than the 8th day of illness;the fact of transfer from another hospital;leukocytosis >=10.0 x 109/l, granulocytosis >=5.5 x 109/l and LDH level >=700.0 U/l at admission;transfer of patients to mechanical ventilation on the 9th day of illness and later;SOFA score >=8;the need for pressor amines and replacement of kidney function. Predictors of poor outcome in ventilated COVID-19 patients: platelet count <=210 x 109/L on admission;the duration of oxygen therapy for more than 4.5 days;the use of HPNO and NIV as the 2nd step of RP for more than 2 days;transfer of patients to mechanical ventilation on the 14th day of illness and later;oxygenation index <=80;the need for pressors;SOFA score >=8. Conclusion. When comparing the identified predictors of death for patients with influenza and COVID-19 who needed mechanical ventilation, there are both some commonality and differences due to the peculiarities of the course of the disease. A step-by-step approach to the application of respiratory support methods is effective both in the case of patients with influenza AH1N1pdm09 and patients with COVID-19, provided that the respiratory support method used is consistent with the current state of the patient and his respiratory system, timely identification of markers of ineffectiveness of the respiratory support stage being carried out and determining the optimal moment escalation of respiratory therapy.Copyright © 2022, Dynasty Publishing House. All rights reserved.

Trends And Outcomes Of Heart Failure Hospitalizations During Covid 19 Pandemic In California

INTRODUCTION: Coronavirus disease 2019 (COVID-19) has affected hospitalization of cardiac patients, both in terms of number of hospitalizations as well as hospital outcomes. In this study, we intended to understand the effects of COVID-19 pandemic on heart failure hospitalizations in the state of California. HYPOTHESIS: We hypothesized that adverse hospital outcomes such as in-hospital mortality, mechanical ventilation, mechanical circulatory support, vasopressor use, and acute respiratory distress syndrome (ARDS) would be higher among heart failure hospitalizations during 2020, compared to 2019. METHOD(S): The current study was a retrospective analysis of data collected and stored in California State Inpatient Database (SID) during March to December of 2019 and 2020. All adult (>=18 years of age) hospitalizations with heart failure were included for the analysis. ICD-10-CM diagnosis and procedure codes were used for identifying hospitalizations and procedures. We used propensity score matching and conditional logistic regressions to find the association between hospitalizations during 2019 versus 2020 with respect to outcome variables. RESULT(S): There were 101,032 (56.0%) heart failure hospitalizations during March to December of 2019, compared to 79,637 (44.0%) during March to December of 2020 (relative decrease, 21.2%). Hospitalizations for COVID-19 increased from 2,252 to 46,217 during the same period (relative increase, 19521.3%). Adverse hospital outcomes such as in-hospital mortality rates (2.9% versus 2.7%, P=0.003), mechanical ventilation (2.9% versus 2.2%, P<0.001), mechanical circulatory support (0.7% versus 0.5%. P<0.001), vasopressor use (1.3% versus 1.0%, P<0.001), and ARDS (0.1% versus 0.06%, P=0.007) were significantly higher in 2020, compared to 2019. Conditional logistic regression analysis showed that the odds of adverse clinical outcomes such as in hospital mortality (OR, 1.09;95% CI, 1.06-1.11), mechanical ventilation (OR, 1.07;95% CI, 1.05-1.09), vasopressor use (OR, 1.07;95% CI, 1.04-1.10), and ARDS (OR, 1.74;95% CI, 1.58-1.91) were significantly higher among heart failure hospitalizations in 2020. However, the odds of mechanical circulatory support did not differ between the two-time frames. CONCLUSION(S): Our study found that patients with heart failure hospitalized during the COVID-19 pandemic had greater in-hospital adverse events such as greater in-hospital mortality, mechanical ventilation use, vasopressor use, and ARDS. These findings warrant that heart failure requires prompt hospitalization and aggressive treatment irrespective of restrictive mandates during COVID-19 pandemic.Copyright © 2022

Impact of early readmission to the cardiac ICUon in-hospital mortality and hospital length of stay in 30,942 cardiac patients

Background: The need for cardiac intensive care unit (ICU) beds remains high in order to monitor and treat emergency patients with severe cardiovascular diseases, particularly during the COVID-19 pandemic. Therefore, timely discharge strategies from the cardiac ICU to peripheral wards are crucial to meet the increasing demand for cardiac ICU beds. Early patient transfer from ICU to the peripheral ward may result in worsening of the patient's clinical condition and outcome with readmission to the ICU, while late transfer may require prolonged expert care and generate unwanted costs. Purpose(s): To investigate whether unplanned readmission of cardiac patients to the cardiac ICU within 72 hours after the index ICU stay is associated with increased mortality risk (primary outcome) and prolonged total hospital length of stay (LOS) (secondary outcome), as well as to identify predictors of ICU readmission in cardiac patients. Method(s): Adult patients who were admitted to the cardiac ICU due to a primary cardiac admission diagnosis at a tertiary care center between 2003 and 2021 were included. Outcomes were analysed with multivariable regression models adjusted for 26 a priori defined variables on patient demographics, underlying comorbidity levels, ICU procedures and administered ICU drugs. Result(s): 30,942 cardiac patients were included, out of whom 1,499 patients (4.84%) were readmitted to the cardiac ICU within 72 hours. 1,023 (68.2%) of readmitted patients were male. Compared to non-readmitted patients, readmitted patients were older, had more underlying comorbidities (Charlson Index), had more severe disease courses (SOFA score, TISS, APACHE II score and SAPS), as well as required more frequently vasopressor therapy, renal replacement therapy and coronary angiographies (Table 1). Readmission to the cardiac ICU was associated with higher in-hospital mortality risk (Odds Ratio 7.52, 95% Confidence Interval (CI) 4.15-12.27, P<0.001) and prolonged hospital LOS (Incidence Rate Ratio 1.56, 95% CI 1.15-1.58, P<0.001). Patients who were readmitted to the ICU had been discharged 18% earlier during the index ICU stay compared to non-readmitted patients (P<0.001). Of note, readmitted and nonreadmitted patients had similar vital parameters at time of ICU discharge after their index ICU stay. During the index ICU stay, non-readmitted patients were prescribed more beta blockers (65.3% vs. 45.8%), ACE inhibitors (37.0% vs. 27.2%) and blood transfusions (10.7% vs. 7.7%). Conclusion(s): Early readmission to the cardiac ICU was associated with increased in-hospital mortality and prolonged hospitalisation. Readmitted patients had been discharged earlier from their index ICU stay and required more comprehensive critical care. ICU discharge strategies should optimally be based on objective patient assessments to facilitate patient safety and shorten hospital length of stay. Artificial intelligence-based algorithms may support clinicians with safe ICU discharge. (Table Presented).

EXTRACORPOREAL THERAPY IN CRITICALLY ILL PATIENTS WITH COVID-19: A SINGLE-CENTER EXPERIENCE.

Aim To assess the safety and efficacy of extracorporeal therapy in patients with COVID-19. The study included 27 patients aged 67+/-9.7 [min 38, max 87] years with a laboratory-confirmed SARS-CoV-2 and bilateral polysegmental pneumonia, various concomitant chronic diseases who were admitted to Intensive Care Unit and received extracorporeal therapies. All patients had the mean NEWS score of 6.9+/-2.7 [min 4, max 9] and the mean SOFA score of 8.1+/-3.1 [min 3, max 16] at admission Methods to the ICU. 19 patients (70.4%) had severe lung lesions over 75% according to the chest CT scans. 48 extracorporeal therapies were performed using the Multifiltrate (Fresenius Medical Care, Germany) and Aquarius (Nikkiso Aquarius RCA, Great Britain) medical devices. Indications for extracorporeal therapy initiation included cytokine storm associated with acute respiratory distress syndrome and septic shock. Generally, each patient received at least one extracorporeal therapy. 11 patients underwent 2 to 6 sessions. Isolated plasma separation and hemoperfusion helped to reduce vasopressor / cardiotonic support, slightly improved ventilation parameters, with a significant, but not long-term decrease in the levels of inflammation markers. Combining different modalities of extracorporeal therapy that provide rapid elimination of agents, controlled temperature response and hydration, maintaining Results homeostasis and detoxification, appeared to be most optimal. Extracorporeal therapy did not improve the volume of lung parenchyma or lung parenchyma damage. However, 19 (70.4%) patients who received extracorporeal therapy transitioned from mechanical ventilation to spontaneous breathing, whereas 8 (29.6%) patients had severe lung lesions (over 75%) according to the repeated chest CT scans. The mean length of stay in the ICU among survivors was 9+/-3.5 [min 4, max 22]. The 28-day mortality and in-hospital mortality rate was 25.9% (7). Prolonged extracorporeal therapy in patients with SARS-Cov-2 has demonstrated Conclusion efficacy in relieving organ dysfunctions and shock states, but did not significantly affect the remaining lung parenchyma damage.Copyright © 2022 University of Latvia. All Rights Reserved.

Post Covid-19 Syndrome Dysautonomia: A Tertiary Referral Centre Experience

Post-coronavirus disease 19 (COVID-19) syndrome has substantial health and economic implications. It is multi-systemic, with prevalent autonomic symptoms. Understanding presentations and potential autonomic causes may help guide treatment strategies and recovery. All patients with a suspected or confirmed history of COVID-19 infection who underwent autonomic testing between May 2020 and October 2021 were reviewed retrospectively. We evaluated 62 patients (20 male, 42 female, mean age of 41.38 +/-11.52). COVID-19 was PCR confirmed in 15 patients (26%), and five (8%) required acute hospital intervention. Most common symptoms included palpitations (81%), lightheadedness/ dizziness (62%), dyspnoea (48%), fatigue (46%), or cognitive symptoms (33%) Autonomic testing showed normal blood pressure responses to pressor stimuli, a mean respiratory sinus arrhythmia of 18.89b/m, and Valsalva ratio of 2.09. Postural tachycardia syndrome (PoTS) was diagnosed in 12 patients, autonomically mediated syncope (AMS) in 11, neurogenic orthostatic hypotension (NOH) in two, and initial orthostatic hypotension (IOH) in seven. Normal supine and upright plasma noradrenaline levels were measured in 34 patients (mean 283.38 pg/ml supine;472.43pg/ml tilted). Autonomic testing was reassuring (PoTS and syncope) in the majority with abnormal testing (n=32, or 52%). Further phenotyping of PoTS to exclude neuropathic pathology may be needed. IOH and OH are important considerations.

The association of angiotensin-converting enzyme inhibitors and angiotensin 2 receptor blockers with renal protection in patients with SARS-CoV-2

Background: Kidney dysfunction is a prevalent disease that leads to many complications over time, such as hypertension, heart disease, and death. ACEI/ARBs are known to be renoprotective. However, few studies describe the association between ACEI/ARB use and kidney dysfunction in patients with SARS-CoV-2 infection. Purpose(s): To explore the association between patients with SARS-CoV- 2 and kidney dysfunction in patients taking an ACEI/ARB. We hypothesize a negative association between patients with SARS-CoV-2 taking an ACEI/ARB and kidney dysfunction. Method(s): A retrospective query between March 2020 and April 2021 was performed in patients 18 years and older who tested positive for SARSCoV- 2 using a polymerase chain reaction test. Patients were divided into two groups: Kidney dysfunction and no kidney dysfunction. Kidney dysfunction was defined as any diagnosis of chronic kidney disease or acute kidney injury. Primary outcomes were all-cause mortality and hospitalization rate. Secondary outcomes included myocardial infarction (MI), hypotension, intubation, vasopressor use, ventricular tachycardia, and ventricular fibrillation. We used multivariate logistic regression to adjust for baseline characteristics. Result(s): We identified 996 patients with kidney dysfunction and 22,106 without kidney dysfunction who tested positive for SARS-CoV-2. The incidence was 258 (25.9%) for ACEI/ARB use in patients with kidney dysfunction. Adjusted odds ratio (OR) for patients with kidney dysfunction was 5.705 (95% Confidence Interval [CI]: 4.554-7.146;p<0.001) for hospitalization, 0.895 (95% CI: 0.707-1.135;p<0.361) for patients taking ACEI/ARB, and 0.529 (95% CI: 0.333-0.838;<0.007) for mortality in patients with kidney dysfunction who took ACEI/ARB. All secondary outcomes had significantly greater adjusted OR (p<0.001), except for MI (p<0.339), ventricular tachycardia (p<0.697), and ventricular fibrillation (p<0.060). Conclusion(s): To date, the benefits of ACEI/ARB in SARS-CoV-2 patients have been controversial. While ACEI/ARB is known to have renoprotective properties, we did not find a significant association between ACEI/ARB and kidney dysfunction in patients with SARS-CoV-2. However, we found the use of ACEI/ARB in patients with kidney dysfunction to be associated with lower mortality. Therefore, clinicians should continue using this medication for its mortality benefits in patients with kidney dysfunction and its cardioprotective effects.

Secondary sclerosing cholangitis in patients with COVID-19 ARDS-a specific entity associated with high mortality?

Introduction SSC-CIP (secondary sclerosing cholangitis in critically ill patients) is characterized by biliary tract destruction after long intensive care treatment. Hypotension and vasopressor therapy are main risk factors. Increased prevalence of SSC-CIP occurred in patients with COVID-19 ARDS that were treated by endoscopic retrograde cholangiography (ERC). Aims The aim of the study was to analyze clinical, laboratory, microbiological and endoscopic fndings of patients with SSC-CIP with COVID-19 ARDS. Methods Data of 17 patients with SSC-CIP with COVID-19 ARDS between February 2020 and August 2022 were analyzed retrospectively. The focus was on endoscopic fndings, laboratory and microbiological values and on clinical parameters and potential risk factors during COVID-19 ARDS. Results 14 male and 3 female patients were included. The mean age was 60 years (range 40-76). All patients were mechanically ventilated, 11 patients were treated with ECMO. All patients required catecholamine therapy but only low dosed when compared with other septic conditions. On average 2.6 ERCs were performed. Biliary casts were found in 94 % of the patients and rarefcation of the intrahepatic bile ducts in 50 %. Bile duct stenosis was detected in 3 patients. Casts were extracted and stenoses were dilated. 13 patients died, 4 patients are in follow-up with repeated endoscopic intervention and re-evaluation in regard to liver transplantation. Discussion Mortality rate in patients with SSC-CIP with COVID-19 ARDS is high. Vasopressor therapy and hypotension was not prominent in this cohort. Endo-scopic treatment may improve liver function, however these patients must be evaluated for liver transplantation.

Cytokine Adsorbing Column in Severe Covid-19 Patients with Acute Kidney Injury

Introduction: Novel coronavirus disease 2019 (COVID-19) is a highly infectious, rapidly spreading viral disease, as of writing this article there are over 6.3million people are affected. The virus can result in a dysregulated immune response and cytokine storm which is associated with disease severity, leading to capillary leak syndrome, progressive lung injury, respiratory failure, and acute respiratory distress syndrome (ARDS). CytoSorb is a European Union-approved extracorporeal cytokine adsorber, designed to broadly reduce cytokine storm and other inflammatory mediators in the blood. On 10 April 2020, the US Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) for emergency use of CytoSorb to treat patients 18 years of age or older with confirmed COVID-19 admitted to the ICU. In this case report, we discuss two COVID-19 positive patients who were admitted to the ICU with severe ARDS and were treated with VV ECMO and Cytosorb. Cytosorb has been extensively studied in patients with sepsis however the reports of treating patients with COVID-19 in cytokine storm are scanty hence this descriptive article will benefit the institutions who are planning on adopting this mode of therapy to treat COVID-19 patients Methods: We discuss COVID-19 positive patients who were admitted to the ICU with severe ARDS, AKI and were treated with VV ECMO, Cytosorb and CRRT. Cytosorb has been extensively studied in patients with sepsis however the reports of treating patients with COVID-19 in cytokine storm are scanty hence this descriptive article will benefit the institutions who are planning on adopting this mode of therapy to treat COVID-19 patients Results: In this case series we have described an improvement clinically in terms of reducing pressor and fio2 requirements which co-related well with the reduction of IL-6 levels however there were other confounding factors like administration of Tocilizumab and VV ECMO which could have contributed to the improvement of the patients. The patients are now dialysis dependent and became hemodynamically stable 3-4 weeks into their admission and were eventually extubated Conclusion(s): Cytokine adsorbing column in severe COVID-19 patients with Acute kidney injury does help in improvement of pressor and fio2 requirements which co-related well with the reduction of IL-6 levels in a short period of time. With other centers adapting Cytosorb we will eventually have better information about the overall outcome of these patients No conflict of interestCopyright © 2023

COVID-19 Could Be More Severe and Fatal in the Octogenarian and Nonagenarian Population in Intensive Care Unit

Objectives: In this study, it was aimed to determine demographic and clinical characteristics, supportive treatments in intensive care unit (ICU), mortality rates and factors affecting mortality by grouping COVID-19 intensive care patients as octogenarian and nonagenarian groups, and patients younger than 80-years-old. Method(s): The patients aged >=18 years diagnosed with COVID-19 with PCR positivity in ICUs between March 19, 2020 and March 31, 2021 were included in this retrospective observational study. Result(s): Of the 1004 PCR positive patients, 58.7% were male. The youngest patient was 20, the oldest patient was 100-years-old. There were 738 patients in Group 1 (20-79 years) and 266 patients in Group 2 (>=80 years). Between the two groups, gender, APACHE II score, need for intubation, need for vasopressor/inotrope, and patients in need of care were higher in Group 2 (p<0.001 for all). Only the patients in Group 1 were established ECMO. Hypertension (HT), cardiovascular, respiratory and neurological diseases, number of comorbidity, and mortality rate were higher significantly in Group 2 (p<0.001, p=0.001, p=0.006, p<0.001, p<0.001, and p<0.001;respectively). Age, male gender, HT, intubation, and vasopressor/inotrope requirement were found to be predictors of mortality. Conclusion(s): COVID-19 may have a more severe and fatal course in the octogenerian and nonagenerian age group with high comorbidity in the ICU.©Copyright 2022 by The Cardiovascular Thoracic Anaesthesia and Intensive Care.

Influenza a Myocarditis Vs Multisystem Inflammatory Syndrome Causing Cardiogenic Shock in a 34-Year-Old

Background Cardiogenic shock is a rare complication of influenza myocarditis and multisystem inflammatory syndrome. We present the case of a 32-year-old female in cardiogenic shock who met criteria for both entities. Case A 34-year-old female with hypothyroidism presented after being found down and covered in feces. She had cough and weakness the preceding days. She was febrile and hypotensive. Point of care ultrasound showed severe biventricular dysfunction and she was started on norepinephrine. She was influenza A positive with a lactate of 5.1. Right heart catheterization on 2ug/kg/min of norepinephrine showed a cardiac index (CI) of 2.82 L/min/m2 and a systemic vascular resistance (SVR) of 300 dynes/sec/cm-5. She was started on vasopressin, stress dose steroids, and oseltamivir. She received 6 amps of bicarbonate with aggressive electrolyte repletion. CI as per the Fick equation was within normal limits but lactate continued to rise. Thermodilution showed a CI of 1.6 L/min/m2 and an SVR of 2200 dynes/sec/cm-5, indicating mixed cardiogenic and distributive shock. The patient developed severe abdominal pain and was found to have elevated COVID-19 spike domain and nucleocapsid antibodies, meeting criteria for multisystem inflammatory syndrome (MIS-A). Decision-making The patient was started on dobutamine after thermodilution showed decreased CI. Intravenous immunoglobulin was started after meeting criteria for MIS-A. Her pressor requirements were weaned and then her dobutamine requirements. Follow up cardiac MRI showed mild global hypokinesis of the left ventricle and subtle hypokinesis of the right ventricular inferior wall. Left ventricular ejection fraction was 51%. The patient's cardiac MRI findings were not specific. However, her rapid improvement was suggestive of MIS-A. Additionally, consistent discordance between Fick and thermodilution resulted in confusion regarding optimization of pressors and inotropes. Conclusion The patient responded to dobutamine and MIS-A treatment after an initial impression of myocarditis. Infectious processes should be considered in any patient with new onset heart failure.Copyright © 2023 American College of Cardiology Foundation

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

The Importance of CMV Reactivation in COVID-19-Related ARDS Patients

Objectives: Cytomegalovirus (CMV) reactivation is a significant cause of morbidity and mortality in critically ill patients. Existing or newly developed immunosuppression appears to be the main factor for reactivation. COVID-19 patients with acute respiratory distress syndrome can be affected by a variety of conditions that cause immunosuppression. Clarifying CMV reactivation and notably its predictive features became important during the epidemic. Method(s): This is a retrospective, observational, and cohort study. All COVID-19 patients admitted to the ICU between March 11, 2020 and March 11, 2021 were analyzed. All of the information was gathered from the hospital's electronic records. CMV reactivation was defined as CMV DNA >=1000 copies/ml in tracheal samples. The patient population was analyzed in two groups, namely, patients with CMV reactivation and patients without reactivation. Result(s): During the study period, 99 of all COVID-19 ARDS patients fulfilled the inclusion criteria, and CMV reactivation was detected in 55 (55.6%) of them. Age, BMI, APACHE-II score, hypertension, chronic respiratory disease, the usage of interleukin blockers, the duration of steroid usage, procalcitonin (PCT), and CD-8 T-cell levels differed significantly from the patients without CMV reactivation. Furthermore, the reactivation group had longer ICU stays, longer durations of mechanical ventilation, and higher mortality. Conclusion(s): CMV can be reactivated in critically ill COVID-19 ARDS patients, which appears to correlate with worse outcomes. Obesity, the usage of IL-blockers and steroids >12 days, high PCT, and low CD-8 T-cell levels appear to be risk factors. Critically ill COVID-19 patients should be closely monitored with regard to immunosuppression and CMV status.Copyright © 2022 by The Cardiovascular Thoracic Anaesthesia and Intensive Care.

The predictive role of Troponin I levels for mortality in geriatric patients transferred to the intensive care unit for COVID-19 pneumonia

Aim: Troponin I is an important prognostic marker in critically ill patients with COVID-19, similar to cytokines and other inflammatory mediators. The aim of this study was to evaluate the predictive value of troponin I levels for mortality in geriatric patients transferred to the intensive care unit for COVID-19 pneumonia according to age group. Material(s) and Method(s): Seventy-four patients with COVID-19 pneumonia were grouped according to age (Group 1:65-74 years, Group 2: 75-84 years, and Group 3: >= 85 years) and retrospectively analyzed. Demographics, clinical findings, laboratory results upon admission to the intensive care unit, and outcomes were compared among the groups. Predictive value of troponin I levels upon admission to intensive care unit (Troponin Iicu), difference in troponin levels between general wards and intensive care unit (Troponin Idiff), C-reactive protein, ferritin, lactate dehydrogenase, neutrophil-to-lymphocyte ratio, procalcitonin, and D-dimer levels for mortality were also investigated. Result(s): The mortality rate was 74.3% for the patients overall, and increased, albeit insignificantly, with increasing age. Neither Troponin Iicu nor Troponin Idiff was predictive for mortality for any of the age groups or for the patients overall. Ferritin, lactate dehydrogenase, neutrophil-to-lymphocyte ratio, and C-reactive protein levels were predictive for mortality for patients overall (p= 0.016, p= 0.001, p= 0.013, and p < 0.001, respectively). Discussion(s): For geriatric patients, troponin I levels at the time of the first admission to the ICU are not sufficient to predict mortality alone and should be evaluated together with other parameters.Copyright © 2022, Derman Medical Publishing. All rights reserved.