Your browser doesn't support javascript.
Show: 20 | 50 | 100
Results 1 - 20 de 168
Filter
1.
Indian Journal of Transplantation ; 16(2):237-238, 2022.
Article in English | EMBASE | ID: covidwho-2066874
2.
Journal of Translational Internal Medicine. ; 2022.
Article in English | EMBASE | ID: covidwho-2065372

ABSTRACT

The coronavirus disease 2019 (COVID-19) pandemic has brought severe challenges to global public health. Many studies have shown that obesity plays a vital role in the occurrence and development of COVID-19. Obesity exacerbates COVID-19, leading to increased intensive care unit hospitalization rate, high demand for invasive mechanical ventilation, and high mortality. The mechanisms of interaction between obesity and COVID-19 involve inflammation, immune response, changes in pulmonary dynamics, disruptions of receptor ligands, and dysfunction of endothelial cells. Therefore, for obese patients with COVID-19, the degree of obesity and related comorbidities should be evaluated. Treatment methods such as administration of anticoagulants and anti-inflammatory drugs like glucocorticoids and airway management should be actively initiated. We should also pay attention to long-Term prognosis and vaccine immunity and actively address the physical and psychological problems caused by longterm staying-At-home during the pandemic. The present study summarized the research to investigate the role of obesity in the incidence and progression of COVID-19 and the psychosocial impact and treatment options for obese patients with COVID-19, to guide the understanding and management of the disease. Copyright © 2022 Sijia Fei, Xinyuan Feng, Jingyi Luo, Lixin Guo, Qi Pan, published by Sciendo 2022.

3.
International Journal of Stroke ; 17(2 Supplement):6-7, 2022.
Article in English | EMBASE | ID: covidwho-2064670

ABSTRACT

Background: Cerebral venous sinus thrombosis (CVST) is an important cause of stroke with a generally favourable prognosis if diagnosed and treated early. Despite advances over recent years, the management remains variable. The current trend for initial treatment is a dose-adjusted intravenous heparin infusion or low-molecular-weight-heparin (LMWH) such as enoxaparin. Once the patient has stabilized, they are transitioned to longterm anticoagulation such as warfarin therapy or direct oral anticoagulants (DOAC) for 3-6 months, depending on risk factors. The use of a heparin infusion brings many known difficulties and complexities impacting on patient care and length of stay within hospital. Current literature suggests that enoxaparin may be superior to heparin in the treatment of CVST. Aim(s): To conduct an internal audit of patients diagnosed with CVST over a twelve-month period at the Princess Alexandra Hospital. This audit will provide foundation to develop an evidence-based hospital protocol for CVST management. Method(s): A search through the hospital imaging system identified all relevant patients. Information was collected on the initial treatment, specifically comparing the use of heparin to enoxaparin and the duration. Consideration of risk factors, aetiology and complications were summarized. During the recent era of COVID-19, we also collected data on COVID-related CVST and COVID vaccine-related CVST. Finally, we recorded the maintenance anticoagulation treatment that was commenced. Result(s): The purpose of this audit is to critically reflect on current hospital practice with a view to improve patient outcomes, safety, satisfaction, and cost-effective care. We hypothesise that in select cases, it will be a safe and preferable alternative to use enoxaparin as initial therapy over a heparin infusion. Furthermore, with appropriate patient selection, DOACs may be an appropriate maintenance therapy. Conclusion(s): The evidence for medical management of CVST is continuously evolving. This evidence must be carefully evaluated before being widely adopted at a local level.

4.
Otolaryngology - Head and Neck Surgery ; 167(1 Supplement):P20-P21, 2022.
Article in English | EMBASE | ID: covidwho-2064482

ABSTRACT

Introduction: While there is anecdotal evidence that a SARSCoV- 2 (COVID-19) reverse transcription polymerase chain reaction screening nasopharyngeal swab confers an elevated risk of epistaxis, no studies substantiate this. We aim to assess the association between epistaxis and exposure to a provideradministered COVID-19 swab. Method(s): A paired-exposure crossover cohort design was used among all patients who received a single COVID-19 swab between April 2020 and March 2021. Occurrence of epistaxis was compared during the hazard period, the 7 days following the index COVID-19 swab, to the control period, the 7 days preceding the index COVID-19 swab. McNemar test was used to compare rates of control- and hazard-period epistaxis. Conditional logistic regression was used to evaluate sociodemographic and clinical risk factors for epistaxis. Result(s): A total of 827,987 participants were included, with 1047 epistaxis encounters. The prevalence of epistaxis during the hazard and control periods were 0.08% and 0.04%, respectively. Swab exposure was associated with 1.92-fold odds of epistaxis in the hazard period (95% CI, 1.73, 2.12];P<.01). Older age (odds ratio [OR] 1.07;95% CI, 1.02, 1.75), Asian ancestry (OR 1.68;95% CI, 1.40, 2.02), men (OR 1.33;95% CI, 1.16, 1.54), anticoagulation/antiplatelet use (OR 2.88;95% CI, 2.11, 3.92), hypertension (OR 2.31;95% CI, 1.92, 2.78), and prior facial trauma (OR 1.63;95% CI, 1.21, 2.19) were associated with significantly increased odds of epistaxis during the hazard period (P<.01). Conclusion(s): COVID-19 nasal swabs are associated with increased risk of epistaxis. Physicians should provide additional counseling to patients, particularly those at highest risk, including those on anticoagulants/antiplatelets or with hypertension, prior to undergoing a COVID-19 nasal swab.

5.
American Journal of Transplantation ; 22(Supplement 3):874-875, 2022.
Article in English | EMBASE | ID: covidwho-2063454

ABSTRACT

Purpose: To characterize demographics, treatment patterns, and outcomes among 3,998 transplant patients hospitalized for COVID-19 over 16 months of the pandemic (May '20-Aug '21). Method(s): Adult patients in a transplant cohort (TC) and non-transplant cohort (NTC) hospitalized with COVID-19 (ICD-10: U07.1) were compared in the Premier Healthcare Database from May '20-Aug '21. Baseline measures in first two days, demographics, comorbidity, COVID-19 treatments and immunosuppressants were analyzed. Outcomes included mortality (discharge status expired or hospice) and hospital and ICU LOS. Result(s): 3,998 TC patients were hospitalized for COVID-19 in 587 US hospitals. Compared to NTC, TC were younger (61 vs 64 yrs;p<.0001), less likely to be white (59% vs 67%;p<.0001), obese (24% vs 33%;p<.0001) or have COPD (17% vs 24%;p<.0001). TC had higher rates hypertension (84% vs 69%;p<.0001), renal disease (80% vs 22%, p<.0001), diabetes (48% vs 29%;p<.0001) and chronic heart failure (23% vs 18%;p<.0001). During hospitalization, a lower proportion of TC needed any oxygen therapy compared to NTC (p<.05). Compared to NTC, fewer TC received remdesivir (RDV) (44% vs 48%;p<.0001), but more received corticosteroids (87% vs 78%;p<.0001), anticoagulants (44% vs 29%;p<.0001) and convalescent plasma (18% vs 16%;p=0.007). In TC, 44% received MMF, 73% calcineurin inhibitors and 5% mTOR. Use of MMF did not change over time (43% May-Jul 2020;43% Aug- Dec 2020;45% 2021). TC had higher ICU admission rates (31% vs 28%;p.001), but similar hospital LOS and ICU LOS compared to NTC. All-cause mortality in NTC (15% overall;16% May-Jul 2020;16% Aug-Dec 2020;14% 2021) was not significantly different than TC over time (16% overall;13% May-Jul 2020;16% Aug-Dec 2020;16% 2021). Conclusion(s): Very few large studies have assessed COVID-19 management in transplant patients over time. All-cause mortality was comparable in both cohorts despite TC immunosuppression. RDV use was lower in TC. Uncertainty around MMF use in COVID-19 patients did not impact reported use of MMF. Further analyses are needed to evaluate confounding factors (medication sequence, time since transplant, disease severity) and impact of external factors such as earlier testing and treatment for COVID-19, vaccination, and new variants. (Table Presented).

6.
Clinical Toxicology ; 60(Supplement 2):2, 2022.
Article in English | EMBASE | ID: covidwho-2062731

ABSTRACT

Background: Drug shortages represent a longstanding challenge for healthcare providers, including toxicologists, who continue to confront scarcities of antidotes and other agents used to treat poisonings. Prior research examining availability of drugs with toxicologic applications from 2001 to 2013 demonstrated broad shortages including anticholinergic, cholinergic, and cyanide antidotes, anti-hypoglycemics, chelators, antivenom, naloxone, sedative- hypnotics, and decontamination products, many of which were unresolved and involved xenobiotics without therapeutic alternative. Reports of vital agents being scarce or unobtainable have continued since 2013, and new pressures on global and US (United States) supply chains have emerged, most notably the COVID-19 pandemic. Given this, up-to-date analysis of shortages of agents used to treat poisonings is needed. Method(s): US drug shortage data from January 2012 to December 2021 were obtained from the University of Utah Drug Information Service. Shortage data for agents used to treat poisonings were analyzed. Information on drug type, formulation, shortage reason, shortage duration, number of manufacturing sources, substitute availability, and substitute agent shortage during the study period were investigated. Result(s): 1570 drug shortages were reported during the study period;230 (14.6%) involved agents used to treat poisonings. Of the 230 shortages, 21.3% were unresolved as of December 2021. Mean shortage duration was 13.6 months. The longest shortage involved intravenous calcium gluconate and lasted 78 months. Intravenous dextrose products were the agent most frequently affected by shortage, with 20 shortages in total. 58 agents had multiple shortages. Total shortages peaked in 2017 with 33 shortages reported. 20 shortages were reported in 2020 and 24 in 2021 during the COVID-19 pandemic. 10.9% of shortages involved single-source products;however, this number is limited by incomplete reporting. 80.9% of shortages involved parenteral products. Agent classes with the most shortages reported were: Sedative-hypnotics (12.2% of shortages), anti-hypoglycemics (9.6%), anticoagulant reversal (7.8%), vitamins/electrolytes (7.4%), blood pressure support (7%), antihypertensives (6.5%), antimuscarinic delirium (4.8%), and chelators (4.3%). Three naloxone shortages were reported, one of which is ongoing due to increased demand. Buprenorphine and methadone shortages were reported but are resolved as of December 2021. New shortages of multiple pressors and flumazenil were reported. The most common reason for shortage was a manufacturing issue, occurring in 36.1% of shortages. Shortage reason was not reported 37.8% of the time. For 77% of shortages an alternative therapeutic agent was available, however 97% of alternatives were also affected by shortage at some point during the study period. Conclusion(s): Shortages of agents used to treat poisonings remain problematic. For the time period 2011-2021 previously reported shortages of many products persist and new shortages have emerged. The ongoing naloxone shortage is particularly concerning given the continued rise in drug overdose deaths in the US in 2021, as are shortages of buprenorphine and methadone used to treat opioid use disorder. Despite supply chain stressors, total shortages did not peak during the COVID-19 pandemic.

7.
Journal of Cardiac Critical Care ; 6(2):131-140, 2022.
Article in English | EMBASE | ID: covidwho-2062346

ABSTRACT

Numerous systemic infections may have hypercoagulation as one of the complications, which may range from asymptomatic presentation of elevation of biochemical markers of coagulation such as that of fibrin and thrombin generation, to a much severe, symptomatic, life-threatening, disseminated intravascular coagulation (DIC), which results in the formation of thrombi in the microvasculature of various organs. This phenomenon contributes to increase in morbidity and mortality in various infectious diseases. The current review discusses various mechanisms of hypercoagulation during infections such as tissue factor activation, endothelial cell activation, inhibition of physiological anticoagulant pathways, and fibrinolysis inhibition. The review also discusses pathophysiological changes in the coagulation system and its management in the recent pandemic of COVID-19. The article also discusses role of various parenteral and oral anticoagulants in the management of infectious diseases. The review provides clinical data on various anticoagulants used during hospitalization and extended prophylaxis for the management of venous thromboembolism in various infections. Methodology Because this is a review of published literature and no humans or animals were involved, ethical committee approval was not required and patient consent was not required.

8.
Cardiology in the Young ; 32(Supplement 2):S171-S172, 2022.
Article in English | EMBASE | ID: covidwho-2062129

ABSTRACT

Background and Aim: Cardiac involvement is seen in the majority of cases with multisystem inflammatory syndrome in children (MIS-C). Various rhythm and conduction disturbances, as well as repolarization abnormalities, have been described by more than 50% of the patients, while there are few cases with complete heart block or with asystole. Method(s): Case report Results: 8-year old girl presented with a 5-day history of fever, cough, headache, and abdominal pain. Because of the critical con-dition, with respiratory insufficiency and heart failure symptoms, the child was intubated and started on inotropic support. ECG showed complete AV-block with a ventricular rate of 75/min and with ST-T changes;echocardiography revealed dilated left ventricle with reduced contractility, CT-scan of the lungs showed bilateral pneumonia, the inflammatory markers were elevated, in combination with high troponin levels, and positive SARS-CoV2-IgG antibodies. The diagnosis MIS-C was made and treatment with immunoglobulins, antibiotics, corticosteroids, and anticoagulants was initiated. During the next 2 days, the cardiac function deteriorated further, and while still on mechanical ventilation and inotropic support, extreme bradycardia with a ventricular rate of 35/min was regis-tered, and the patient was indicated for temporary emergency pac-ing. Upon induction of anesthesia, the child became asystolic, requiring extensive resuscitation. After circulation recovery, the ECG showed nodal tachycardia with a heart rate of 140-170/min. A temporary transvenous pacemaker (PM) was inserted, and the patient was started on intravenous amiodarone which resulted in a slower ventricular rate of 70/min. 3 days later sinus rhythm was restored, with first-degree AV-block, which allowed removal of the PM 5 days after its insertion. Left ventricular dimensions were normalized and contractility remained low-normal (EF 56%). During the 6-month follow-up, the ECG and the Holter-monitoring showed sinus rhythm with first-degree AV-block. Magnetic resonance imaging (MRI) on day 15 of the hospital stay demonstrated scattered areas of myocarditis and ischemia predominantly in the left ventricle, as well as thickening of the basal septum. Six months later the MRI changes were reduced but still persistent. Conclusion(s): MIS-C can present with serious and life-threatening rhythm and conduction disturbances in children;this is why extensive cardiac monitoring is obligatory by all patients.

9.
Cardiology in the Young ; 32(Supplement 2):S253-S254, 2022.
Article in English | EMBASE | ID: covidwho-2062127

ABSTRACT

Background and Aim: A 15 year old young man with symptoms and signs consistent with MIS-C was admitted to the Intensive Care Unit for inotropic support as he was exhibiting signs of cardiogenic shock. He was previously fit and healthy and he had been exposed to Covid 19 confirmed cases 6-8 weeks prior to becoming unwell. Method(s): The patient received IVIG and steroids as an immuno-modulating regime. On the admission echocardiogram there was a structurally normal heart with large LV thrombuses. The D-Dimers were extremely elevated on admission and the patient received therapeutic heparin infusion. Other prothrombotic causes were excluded. Result(s): The surveillance echocardiogram 24h post admission showed resolution of the thrombuses. The patient never exhibited any signs or symptoms of cardiac ischaemia on the electrocardio-gram or regional wall motion abnormality on the echocardiogram or neurologic impairment and the brain MRI-MRA one week post admission was normal. The patient was discharged home 5 days post admission and on follow ups up to a year after the acute phase remains very well physically and clinically. Conclusion(s): Thromboembolic events are frequently described in COVID-19 patients and in some patients with MIS-C and are the consequence of a hyperinflammatory response and endothelial dysfunction. There might be a potential role of an antiphospholi-pid syndrome secondary to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection as has been proposed. An increase in D-dimer level has been shown to be associated with thromboembolic events, including arterial thrombosis especially in the older population and should be investigated promptly. With the appropriate immunomodulation and antithrombotic treat-ment adverse events are prevented. More studies to assess endothelial function and its role in the MIS-C prothrombotic state are necessary.

10.
Chest ; 162(4):A2348-A2349, 2022.
Article in English | EMBASE | ID: covidwho-2060936

ABSTRACT

SESSION TITLE: Bedside Ultrasound Cases: Beyond Our Sight SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 09:15 am - 10:15 am INTRODUCTION: A thrombus-in-transit (TT), although rare, occurring in approximately 4-18% of pulmonary embolism (PE) cases, carries a high risk of mortality. One study commenting on 80-100% without treatment;therefore, TT should be considered a medical emergency and treated immediately. CASE PRESENTATION: A 64 years old female patient with history of Hypertension and morbid obesity presented to the Emergency department complaining of shortness of breath for 2 weeks with rapid worsening of symptoms and new chest pain in the previous 2 days. Patient blood pressure was 110/70, heart rate 160 irregularly irregular saturating 91% on room air, respiratory rate of 25. Patient tested positive for SARS-CoV-2, and her basic blood work showed elevated BNP and troponin with significant elevation of D-Dimer. The patient never smoked, had no recent travel and not taking OCPs. Bed side point of care echocardiogram showed large right atrial thrombus floating between the right atrium and right ventricle. Subsequent lower extremity ultrasound showed extensive left femoral thrombosis and pulmonary CT Angiogram showed a PE. The treatment options were discussed with the patient including giving full or half dose thrombolytics, or just anticoagulation with heparin. The patient opted for anticoagulation alone. Unfortunately, the patient had a cardiac arrest few hours later. Thrombolytics were given during CPR but the patient passed away. DISCUSSION: TT refers to free-floating right heart thrombi that travel from a venous source in the lower extremities to the pulmonary arteries. Although rare, the presence of a right heart thrombi in the setting of PE predicts a worse prognosis with a high mortality rate and thus, should be treated as a medical emergency. The diagnostic test of choice for TT is an echocardiogram, which shows an elongated right-sided mass illustrating high and chaotic motility with changing shape that continuously prolapses in and out of the right ventricle. Management of TT is still not well established. Options include anticoagulation with heparin, thrombolysis, or surgical removal. A particular study done by Greco et al. in 1999 used recombinant tissue plasminogen activator (rt-PA) with continuous echocardiogram monitoring, that revealed complete lysis of heart clots in all 7 patients within 24 hours. It also showed no changes in symptoms and ultimately showed improvement in blood pressure and heart rate. CONCLUSIONS: Available treatment options include anticoagulation alone, thrombolysis, or surgical embolectomy. Although anticoagulation can prevent clot propagation, it carries a mortality rate of up to 29%, comparable to surgical intervention. Surgical embolectomies could be an alternative option if contraindications to thrombolytics exist. Ultimately, no significant difference was found among the treatment options, suggesting the need for further research and clinical trials. Reference #1: Bikdeli B, Madhavan MV, Jimenez D, et al. COVID-19 and thrombotic or thromboembolic disease: Implications for prevention, antithrombotic therapy, and follow-up: JACC state-of-the-art review. J Am Coll Cardiol. 2020;75(23):2950–73. Reference #2: Cameron, James, et al. "Right Heart Thrombus: Recognition, Diagnosis and Management.” Journal of the American College of Cardiology, vol. 5, no. 5, 1985, pp. 1239–1243., https://doi.org/10.1016/s0735-1097(85)80031-0. Reference #3: Greco, Francesco, et al. "Successful Treatment of Right Heart Thromboemboli with IV Recombinant Tissue-Type Plasminogen Activator during Continuous Echocardiographic Monitoring.” Chest, vol. 116, no. 1, 1999, pp. 78–82., https://doi.org/10.1378/chest.116.1.78. DISCLOSURES: no disclosure on file for Ahmad alkhatatneh;No relevant relationships by Mohammad Alnabulsi No relevant relationships by Mohd Hazem Azzam No relevant relationships by Kelianne Comitalo

11.
Chest ; 162(4):A1415, 2022.
Article in English | EMBASE | ID: covidwho-2060814

ABSTRACT

SESSION TITLE: Problems in the Pleura Case Posters 1 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Ibrutinib is an irreversible inhibitor of Bruton's tyrosine kinase (Btk), approved for treatment of a variety of B-cell malignancies, including chronic lymphocytic leukemia (CLL). There is an association of increased risk of bleeding with ibrutinib due to platelet dysfunction caused by the medication. Bleeding is usually non-life threating such as subcutaneous or mucosal bleeding, epistaxis, and ecchymosis. But major bleeding has been reported such as intracranial hemorrhage and gastrointestinal hemorrhage. Thoracic complications from ibrutinib are rare. Below is a case report discussing a hemorrhagic pleural effusion thought to be caused by Ibrutinib. CASE PRESENTATION: Patient is a 78-year-old male initially diagnosed with CLL on flow cytometry showing a low-grade B cell lymphoproliferative process. Patient was monitored by Hematology and when kappa light chain numbers began to rise, a bone marrow biopsy was performed showing 90% infiltration of the marrow with lymphoid cells. Patient was started on Ibrutinib therapy and responded well to treatment. A year after starting therapy, patient presented to the emergency room with increased shortness of breath and fatigue. Patient was found to be COVID-19 positive and chest x-ray showed a large right sided pleural effusion. Thoracentesis was performed draining 1650cc of bloody fluid. Fluid studies revealed a lymphocytic effusion with RBC count 1,185375, WBC of 1751. Cultures and cytology were negative. On further history, patient was without recent trauma or surgery, CTA chest was negative for pulmonary embolism. QuantiFERON Gold test was negative, indicating low likelihood of tuberculosis. Patient was not on any antiplatelet or systemic anticoagulation medications. Ibrutinib therapy was held during hospitalization and pleural effusion did not reaccumulate. Patient passed away during hospital stay secondary to respiratory failure due to COVID-19. DISCUSSION: Ibrutinib is an orally bioavailable bruton tyrosine kinase inhibitor (BTKi) and forms an irreversible covalent bound to BTK at the Cysteine-481 residue. Ibrutinib predisposes to bleeding by inhibiting BTK and Tec, which play a role in the inhibitory signaling pathway of platelet collagen receptors such as glycoprotein VI (GP VI) and C-type lectin-like receptor 2 (CLEC-2). Our patient had no other risk factors for developing a hemorrhagic effusion. CLL itself can cause malignant effusions, one study found the incidence of malignant effusions among patients with CLL to be 9%, but the effusion was noted to be serous or serosanguinous and there was pleural involvement in all patients which was not the case in our patient. CONCLUSIONS: There is currently a minimal amount of data to guide clinicians regarding the use of ibrutinib in patients at high risk of bleeding or on anticoagulant or antiplatelet therapy. It is important to realize bleeding complications related to ibrutinib therapy can occur. Reference #1: Shatzel JJ, Olson SR, Tao DL, McCarty OJT, Danilov AV, DeLoughery TG. Ibrutinib-associated bleeding: pathogenesis, management and risk reduction strategies. J Thromb Haemost. 2017;15(5):835-847. doi:10.1111/jth.13651 Reference #2: Burger JA, Tedeschi A, Barr PM, et al. Ibrutinib as Initial Therapy for Patients with Chronic Lymphocytic Leukemia. N Engl J Med. 2015;373(25):2425-2437. doi:10.1056/NEJMoa1509388 Reference #3: Paydas S. Management of adverse effects/toxicity of ibrutinib. Crit Rev Oncol Hematol. 2019;136:56-63. doi:10.1016/j.critrevonc.2019.02.001 DISCLOSURES: No relevant relationships by fatima ali No relevant relationships by Joan Wiley

12.
Chest ; 162(4):A1060, 2022.
Article in English | EMBASE | ID: covidwho-2060762

ABSTRACT

SESSION TITLE: Issues After COVID-19 Vaccination Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Ever since the global introduction of adenovirus-vector COVID-19 vaccines, cases of cerebral venous sinus thrombosis and thrombocytopenia after immunization has been reported, posing a challenge to global effects on vaccine implementation. CASE PRESENTATION: A previously healthy 33 year old male presented to emergency room with altered mental status after a left sided seizure episode at home. Patient had a 1week history of occipital headache after receiving Ad26.COV2·S Johnson and Johnson vaccine 2 weeks prior. MRI showed superior sagittal sinus thrombosis and right high frontal hemorrhage 8.6x4.7x4.9 cm. CT angiography confirmed nearly occlusive thrombosis of superior sagittal sinus with extension to right transverse sinus. Noted to have a hemoglobin of 15, platelet count of 74000, PT/INR 16/1.2 and PTT of 28. Started on intravenous heparin and intubated for GCS of 4. Heparin was stopped due to supra therapeutic PTT of 200 overnight, drop in platelet count to 55 and hemoglobin to 13. Repeat ct head done for change in neurological exam of dilated right pupil, showed frontoparietal hemorrhage 9.3 cmx4.1 cm and 7 mm midline shift. Heparin was reversed with protamine and transfused 1 unit platelets prior to emergent decompressive craniectomy and thrombectomy. Heparin induced platelet antibody and SRA came back positive confirming vaccine induced thrombocytopenia and thrombosis. Treatment was initiated with argatroban and IVIG. Platelet count improved with no further propagation of thrombus. Patient underwent feeding tube and tracheostomy placement after 10 days due to prolonged ventilator weaning period and poor mental status. Patient's neurological status continued to improve significantly over subsequent months in acute rehabilitation facility with only residual left sided hemiparesis. Patient was successfully decannulated and anticoagulation switched to apixaban DISCUSSION: Possible pathophysiology is thought to be due to a trigger in spike protein production after biodistribution of adenovirus vaccine and a subsequent autoimmune response resulting in thrombosis. Similar to HIT, platelet consumption leads to thrombocytopenia and the continued platelet and monocyte activation increases thrombin generation, resulting in thrombosis. CDC advices to maintain a high suspicion of cases with symptoms that may indicate an underlying thrombotic event along with simultaneous thrombocytopenia. Heparin use is discouraged, unless HIT testing is negative. The International Society on Thrombosis and Hemostasis (ISTH), recommend considering non-heparin anticoagulants and high-dose intravenous immunoglobulin (IVIG). While platelet transfusions are avoided, rapid progression with rising ICP may necessitate transfusion to enable neurosurgical intervention CONCLUSIONS: Management of complications including seizures and elevated intracranial pressure (ICP) is essential to reduce morbidity and mortality risk. Reference #1: Greinacher A, Thiele T, Warkentin TE, Weisser K, Kyrle PA, Eichinger S. Thrombotic thrombocytopenia after ChAdOx1 nCov-19 vaccination. N Engl J Med 2021;384:2092–101. Reference #2: Muir KL, Kallam A, Koepsell SA, Gundabolu K. Thrombotic thrombocytopenia after Ad26.COV2.S vaccination. N Engl J Med 2021;384:1964–5 Reference #3: Pavord S, Scully M, Hunt BJ, et al. Clinical Features of Vaccine-Induced Immune Thrombocytopenia and Thrombosis. N Engl J Med 2021;385:1680–9 DISCLOSURES: No relevant relationships by Axel Duval No relevant relationships by Nadish Garg No relevant relationships by ARCHANA SREEKANTAN NAIR

13.
Chest ; 162(4):A828, 2022.
Article in English | EMBASE | ID: covidwho-2060697

ABSTRACT

SESSION TITLE: Close Critical Care Calls SESSION TYPE: Case Reports PRESENTED ON: 10/18/2022 11:15 am - 12:15 pm INTRODUCTION: Heparin is the preferred anticoagulant for use in pregnancy while on extracorporeal membrane oxygenation (ECMO) (1). Alternatives to heparin in this patient population are not well studied as heparin-induced thrombocytopenia is rare in pregnancy. Parenteral non-heparin anticoagulants available in the United States include the direct thrombin inhibitors argatroban and bivalirudin, both of which are utilized in ECMO. Guidelines recommend avoidance of these agents in pregnancy if at all possible (2). Whereas case reports support the safe use of argatroban in pregnancy, to our knowledge, there are no known documented reports of bivalirudin use in this patient population (3). Here we describe the successful use of bivalirudin during pregnancy. CASE PRESENTATION: A 25 year old G2P1 was transferred to our institution at 28 weeks gestation for further management of acute hypoxic respiratory failure secondary to COVID-19. On hospital day 2 the patient was urgently placed on venovenous (VV) ECMO for refractory hypoxemia, high dead space with acidosis, and the inability to provide adequate gas exchange and lung protection with mechanical ventilation alone. Following ECMO cannulation with a 25f cannula in the right femoral vein and a 21f cannula in the right internal jugular vein, she was anticoagulated with heparin at a rate of 12 units/kg/hr. This was titrated to target a PTT goal of 60-80 seconds. On ECMO day 2, the TEG demonstrated a markedly hypocoagulable state, and the heparin nomogram called for increasing heparin dosing based on PTT. Given the already high dose of heparin that the patient was on (32.9 units/kg/hr), the decision was made to switch from heparin to bivalirudin to prevent over anticoagulation and reduce bleeding risk. Bivalirudin was titrated to a goal PTT of 50-60 seconds, with an initial rate of 0.15 mg/kg/hr (dose range 0.15-0.22 mg/kg/hr). Therapy was continued and on ECMO day 11, at 29w6d the patient delivered via cesarean section. Bivalirudin was discontinued 2.5 hours prior to the surgical procedure which resulted with no fetal bleeding complications. The patient was decannulated from ECMO on day 20 and was later discharged from the hospital. The newborn is developing well and meeting age adjusted milestones. DISCUSSION: Bivalirudin was selected based on institutional experience and the pharmacokinetic properties of the drug (half-life of 25 minutes) as we considered a situation where an emergent delivery may be indicated. Bivalirudin successfully prevented clotting of the circuit with no maternal or fetal bleeding complications during its use. CONCLUSIONS: Our case report describes a multidisciplinary approach to managing a pregnant patient on ECMO requiring anticoagulation using an alternative medication to heparin. This is the first documented use of bivalirudin in pregnancy. Reference #1: ELSO Guidelines for Cardiopulmonary Extracorporeal Life Support Extracorporeal Life Support Organization, Version 1.4 August 2017. Ann Arbor, MI, USA www.elso.org. Reference #2: Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, Vandvik PO. VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141(Suppl): e691S–736S Reference #3: Young SK, Al-Mondhiry HA, Vaida SJ, et al. Successful use of argatroban during the third trimester of pregnancy: case report and review of the literature. Pharmacotherapy 2008;28: 1531–6. DISCLOSURES: No relevant relationships by Jacqueline Finger No relevant relationships by Caitlin Gluck No relevant relationships by Cameron Hypes No relevant relationships by John Rathbun

14.
Chest ; 162(4):A786, 2022.
Article in English | EMBASE | ID: covidwho-2060688

ABSTRACT

SESSION TITLE: Rare Cases of Nervous System and Thrombotic Complication Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Rivaroxaban is a dose-dependent inhibitor of factor Xa. It is approved by the FDA to help reduce the risk of blood clots. Although bioavailability is not significantly affected at lower doses (80-100%), bioavailability at higher doses (≥15 mg) is as low as 66% when given without food [1] [3]. Here, we present a patient with poor oral intake who developed deep vein thrombosis (DVT) while on high dose Xarelto. CASE PRESENTATION: Our patient was a 48-year-old male with a history of pulmonary embolism diagnosed two months prior to admission (on 20 mg rivaroxaban daily at home) and morbid obesity who presented with dyspnea, fever, and decreased appetite. His viral PCR was positive for COVID-19, and CT angiogram showed multifocal ground glass opacities but was negative for pulmonary embolism. He was severely hypoxic on room air and required noninvasive ventilatory support in the intensive care unit. He was treated with remdesivir, dexamethasone, and baricitinib. His food intake was extremely poor due to near continuous use of noninvasive ventilation and decreased appetite. A nasogastric (NG) tube was offered, but the patient declined and elected to continue diminished oral feedings. He was able to take all of his home medications including rivaroxaban during this time. On day four, clinical nutrition was consulted because he had 3% loss of body weight. On day seven, the patient developed a fever of 101.6° F. Ultrasound of his lower extremities revealed acute DVTs in his left popliteal vein, posterior tibial vein, and peroneal vein. His anticoagulation was switched to full-dose enoxaparin and a NG tube was placed. On day ten, he was intubated due to worsening hypoxia. Unfortunately, the patient deteriorated into multiorgan failure and died on day seventeen. DISCUSSION: The latest expert guidelines suggest that direct oral anticoagulants (DOAC) should be used over vitamin K antagonists (VKA) in patients with acute venous thromboembolism (VTE) due to lower rates of major bleeding and recurrent VTE as well as convenience. Although VKAs are preferred in situations with extreme weight and renal impairment, DOACs have been proven to be effective for the large majority of patients [2]. Unlike rivaroxaban, the bioavailabilities of other DOACs like apixaban, edoxaban, and dabigatran are all unaffected by food and should be preferred in patients with tenuous oral intake [3]. It is well known that COVID-19 can produce a hypercoagulable state. This factor, combined with our patient's predisposition to blood clots and poor appetite, ended up precipitating new onset VTEs in his left leg despite rivaroxaban therapy. CONCLUSIONS: In patients with decreased oral intake, DOACs other than rivaroxaban should be considered. Patients should be briefed on the importance of taking high dose rivaroxaban with food. Our goal is to bring awareness to providers about this significant pharmacodynamic property of rivaroxaban. Reference #1: Mueck W, Stampfuss J, Kubitza D, Becka M. Clinical pharmacokinetic and pharmacodynamic profile of rivaroxaban. Clin Pharmacokinet. 2014 Jan;53(1):1-16. doi: 10.1007/s40262-013-0100-7. PMID: 23999929;PMCID: PMC3889701. Reference #2: Stevens SM, Woller SC, Baumann Kreuziger L, Bounameaux H, Doerschug K, Geersing GJ, Huisman MV, Kearon C, King CS, Knighton AJ, Lake E, Murin S, Vintch JRE, Wells PS, Moores LK. Executive Summary: Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. Chest. 2021 Dec;160(6):2247-2259. doi: 10.1016/j.chest.2021.07.056. Epub 2021 Aug 2. PMID: 34352279. Reference #3: Lexicomp Online. Copyright © 1978-2022 Lexicomp, Inc. DISCLOSURES: No relevant relationships by Rishika Bajaj No relevant relationships by Ann Hylton No relevant relationships by Roger McSharry No relevant relationships by Krupa Solanki

15.
Chest ; 162(4):A293, 2022.
Article in English | EMBASE | ID: covidwho-2060554

ABSTRACT

SESSION TITLE: Global Case Reports in Critical Care SESSION TYPE: Global Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Thrombotic complications in patients diagnosed with COVID-19 pneumonia are emerging as an important and significant morbidity and mortality burden, with overwhelming inflammation, hypoxia, immobilization, and diffuse intravascular coagulation among possible causes of a procoagulant state (1). Obstructive sleep apnea (OSA), with intermittent arterial oxygen desaturation, may in its turn contribute to a procoagulant state, causing hemodynamic alterations as polycythemia and sluggish blood flow (2). Here we report on a case of sudden and massive non-lethal pulmonary thromboembolism (PTE) in a patient with COVID-19 severe pneumonia, for whom OSA was suspected and documented as a possible concurrent mechanism of thromboembolic complication during follow-up. CASE PRESENTATION: A 55-year-old male non-smoker obese (BMI 33 Kg/m2) was admitted to our hospital after 9 days of fever. In the Emergency Room, a chest HRCT scan showed bilateral diffuse ground glass opacities. He was treated with subcutaneous Tocilizumab (324 mg) single shot, Remdesivir (200 mg/day for first day and 100/daily for further 4 days), methyl-prednisolone 40 mg/daily, Enoxaparin 6000 UI/twice daily, azithromycin 500 mg/daily, high flow nasal cannula oxygen (50 L/min, TC 34°C, FiO2 35%) for moderate acute respiratory failure due to COVID-19 pneumonia (pO2: 58 mmHg, PCO2 34 mmHg pH 7.50, P/F 275). After 10 days, patient's clinical conditions worsened, needing non-invasive respiratory support;D-dimer increased abruptly, rising to 10 ng/mL, with findings consistent with PTE at a computed tomographic angiography (CTA, Fig 1). The patient was successfully treated with 10 mg/daily subcutaneous fondaparinux for 12 days, while assisted in the Intensive Care Unit, being discharged home in room air shortly later with oral anticoagulants. At the 3-month follow-up visit, OSA was suspected due to reported excessive daytime sleepiness and weakness, snoring, disturbed night sleep, morning headache in the last 4 years. The patient underwent a home sleep apnea test (HSAT) overnight. Test results revealed an AHI of 50 events/h, with several prolonged episodes of obstructive sleep apnea (307 apnea and hypopnea (A+H) events, 70 obstructive apnea and 233 hypopnea events, with a mean duration of 10% and an average arterial saturation of 93% (Fig. 2). He was adapted to CPAP therapy, with benefit and good correction of polygraphic indexes. DISCUSSION: The pathogenetic mechanisms of COVID 19 and OSA could have played a synergistic effect on endothelial damage, thus increasing the risk of thromboembolism. CONCLUSIONS: The presence of underdiagnosed comorbidities may well worsen the clinical course and complication of COVID-19;an earlier diagnosis of OSA is a prerequisite for timely treatment and, potentially, improved long-term clinical outcomes. Reference #1: Suh YJ, et al. Pulmonary embolism and deep vein thrombosis in COVID 19: a systematic review and meta-analysis. Radiology 2021;298 (2): E70-E80. Reference #2: Alfonso-Fernandez A., Garcia Surquia A., de la Pena M. OSA is a risk factor for recurrent VTE Chest. 2016;150 (6): 1291-1301. DISCLOSURES: no disclosure on file for Antonietta Esposito;no disclosure on file for Antonella Frattari;no disclosure on file for Giustino Parruti;no disclosure on file for Giorgia Patrizio;no disclosure on file for Pierpaolo Prosperi;no disclosure on file for Giorgia Rapacchiale;No relevant relationships by ANTONELLA SPACONE no disclosure on file for Giacomo Zuccarini;

16.
Journal of Comprehensive Pediatrics ; 13(Supplement 1):17-18, 2022.
Article in English | EMBASE | ID: covidwho-2058426

ABSTRACT

The side effects of COVID-19 vaccines can be divided into three categories: (1) common but non-significant complications;(2) uncommon but significant complications;(3) complications that currently have no causal relationship with the COVID-19 vaccine and are more commonly referred to as associations. Non-significant complications can be local or systemic, such as pain at the injection site, swelling, redness, axillary lymphadenopathy on the injection site, fever, chills, headache, nausea, tiredness, joints pain, nausea and vomiting. Significant side effects include the following four: (1) anaphylaxis;(2) myocarditis/ pericarditis;(3) thrombosis with thrombocytopenia syndrome (TTS);(4) Guillain-Barre syndrome. Cases such as tinnitus, Bell's palsy, pulmonary embolism, and deep vein thrombosis (DVT) without further thrombocytope18 nia are now referred to as associations. Thrombosis with Thrombocytopenia Syndrome: Currently, adenovirus vector vaccines such as AstraZeneca and Johnson & Johnson vaccines are accused of causing these two complications, and mRNA vaccines have not been shown to produce such a complication. Myocarditis/Pericarditis: mRNA vaccines such as Pfizer and Moderna have been implicated in causing this complication, and no adenovirus vector vaccines such as Johnson & Johnson have been reported. Contraindications to the Injection of COVID-19 Vaccines: Any immediate allergic reaction to the vaccine or its associated ingredients with any severity such as anaphylaxis and urticaria that occurs within 4 hours of injection. Precautions for COVID-19 Vaccines: History of any Immediate Allergies to Other Vaccines and Injectable Drugs: A history of anaphylaxis to mRNA vaccines for Johnson & Johnson vaccine and a history of anaphylaxis to Johnson & Johnson vaccine for mRNA vaccines is considered a precaution. If you have a history of heparin-induced thrombocytopenia within the last 90 days, the CDC recommends that you do not get AstraZeneca, and Johnson & Johnson vaccine. However, a history of any thrombotic events without thrombocytopenia is not prohibited for any type of corona vaccine. Items that are Neither Contraindications nor Precautions: Presence of erythematous skin lesions with a sharp border at the injection site, usually one week after receiving the mRNA vaccine Consumption of Anticoagulants: Swelling of the face at the site of application of cosmetic skin fillers following the use of mRNA vaccine.

17.
U.S ; Pharmacist. 47(9):41-46, 2022.
Article in English | EMBASE | ID: covidwho-2057848

ABSTRACT

The global health crisis of coronavirus disease 2019 (COVID-19) continues to challenge the standard of care in both the inpatient and outpatient setting. One area that has been heavily impacted is effective management of anticoagulation. COVID-19 has led to new and innovative ways to manage vitamin K-antagonist therapy in the ambulatory care clinics, with increased utilization of drive-through testing sites, home international normalized ratio monitoring, and conversions to direct oral anticoagulants. The COVID-19 infection has been found to have an increased risk in venous thromboembolism events due to its complex inflammatory response. Since 2019, multiple strategies have been trialed in the inpatient setting, including therapeutic, intermediate, and prophylaxis anticoagulation using heparin or low-molecular-weight heparin. Vaccines and therapeutics for COVID-19 have added complexity to the clinical situation, including an FDA warning for a vaccine-induced immune thrombocytopenia with the adenoviral vector vaccine (Ad26.COV2.S) and the potential for drug interactions between COVID-19 therapeutics and anticoagulation therapy. Copyright © 2022, Jobson Publishing Corporation. All rights reserved.

18.
ASAIO Journal ; 68(Supplement 3):18, 2022.
Article in English | EMBASE | ID: covidwho-2057749

ABSTRACT

Houston Methodist Hospital treated 130 patients requiring ECMO from January 2021 to June 10, 2022. Out of this targeted population, 37 patients belonged to the long group with > 6 weeks ECMO run. This group has 2 (5.4%) VA and 35 (94.6%) VV and 78% of these patients had been diagnosed with COVID-19. The second group with a shorter ECMO run, had 93 ECMO cases, with 44 (47.3%) VA and 49 (64.6%) VV including 2 currently admitted. 54% were diagnosed with COVID-19. Result(s): Bleeding complications (GI, surgical, peripheral, pulmonary) occurred in both groups. There was no association between the length of ECMO runs to the day of bleeding occurrences in either groups where heparin was the anticoagulant of choice. Fifty-eight percent of the COVID patients ended up with transplants, the remaining expired, recovered, or are still in the hospital. Currently, the mortality rate in this group of COVID-19 patients on prolonged ECMO therapy is 29% where superimposed respiratory infection was identified and 54% had bacteremia. The survivors in this group went to rehab, LTACH, or home with 3 patients still in the hospital. Conclusion(s): Based on the data analysis of 130 patients from a single institution, the results showed no difference in the mortality in both groups based on length of ECMO run. Common ECMO-related complications like bleeding, acute kidney injury and limb ischemia may also not affect mortality. The question arises about how long an ECMO can be run without transplant and meaningful recovery. How and when to define futility.

19.
Middle East Journal of Digestive Diseases ; 14(2):265-267, 2022.
Article in English | EMBASE | ID: covidwho-2044375

ABSTRACT

Coronavirus disease 2019 (COVID-19) had caused pandemia with a high rate of mortality and morbidity. Lung involvement is the main cause of mortality, but central nervous system and cardiac disease, and thromboemboli may participate in increasing mortality. A wide spectrum of organs involvement and complication has been reported as data gathering during the pandemia has progressed. We report a 69-year-old man who was admitted to Imam Khomeini hospital in Tehran and complained of severe abdominal pain and fever. He had been admitted 10 days earlier because of dyspnea and fever. At the first admission, based on the findings in the lung computed tomography (CT) and a positive nasopharyngeal polymerase chain reaction (PCR) test for COVID-19, he was treated with intravenous remdesivir for 5 days and prophylactic anti-coagulant heparin during hospital admission. Two days before the new admission, he was discharged with relative recovery. During the new admission, because of the absence of hypoxemia and leukocytosis diagnostic approach to abdominal pain was planned. In abdominal imaging, evidence of bowel perforation appeared. In laparotomy, suppurative peritonitis and proximal jejunal perforation without definite etiology were seen, and bowel resection and primary anastomosis were done. After 5 days, the patient was discharged in good condition. This case is reported to inform that bowel perforation due to ischemia or vasculitis may complicate the course of COVID-19 and, in cases of gastrointestinal symptoms, should be considered.

20.
TH Open ; 2022.
Article in English | EMBASE | ID: covidwho-2042369

ABSTRACT

Background: Most symptoms of COVID-19 are mild;however, some patients experience cardiovascular complications, including thromboembolic events and death. Data are needed to better inform prevention and treatment of these events. This analysis was designed to describe patient characteristics, medication use, thromboembolic events, and all-cause mortality in hospitalized COVID-19 patients in the United States. Methods: This retrospective, observational cohort study identified adults hospitalized with COVID-19 (01/21/2020-01/07/2021) in the de-identified Optum® COVID-19 Electronic Health Records dataset. Thromboembolic events and all-cause mortality were collected at any time during the variable follow-up period (up to 50 weeks). Results: Of 181,995 COVID-19 patients who met eligibility criteria, 40,524 (22.3%) were hospitalized with COVID-19. Hospitalized patients had a mean age of 63 years and a Quan-Charlson comorbidity index of 1.3. Anticoagulants were used in 89.2% of patients during hospitalization and in 18.7% of post-discharge patients. Of hospitalized patients, 17.6% had a thromboembolic event during the entire follow-up period (mean time to first event of 15 days), of whom 13.4% had an event during hospitalization;of discharged patients, 4.3% had a thromboembolic event (mean time from discharge to event of 43 days). Death during the follow-up period was reported in 15.0% of patients. Conclusions: In this large, observational cohort study, patients hospitalized with COVID-19 had high rates of thromboembolic events during hospitalization and in the post-discharge period;mortality was also high in this population. Anticoagulant use was common during hospitalization. These findings support further study to optimize in-hospital and extended prophylaxis for hospitalized COVID-19 patients.

SELECTION OF CITATIONS
SEARCH DETAIL