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1.
Respiratory Research ; 23(1) (no pagination), 2022.
Article in English | EMBASE | ID: covidwho-2196285

ABSTRACT

Auto-antibodies (Abs) to type I interferons (IFNs) are found in up to 25% of patients with severe COVID-19, and are implicated in disease pathogenesis. It has remained unknown, however, whether type I IFN auto-Abs are unique to COVID-19, or are also found in other types of severe respiratory illnesses. To address this, we studied a prospective cohort of 284 adults with acute respiratory failure due to causes other than COVID-19. We measured type I IFN auto-Abs by radio ligand binding assay and screened for respiratory viruses using clinical PCR and metagenomic sequencing. Three patients (1.1%) tested positive for type I IFN auto-Abs, and each had a different underlying clinical presentation. Of the 35 patients found to have viral infections, only one patient tested positive for type I IFN auto-Abs. Together, our data suggest that type I IFN auto-Abs are uncommon in critically ill patients with acute respiratory failure due to causes other than COVID-19. Copyright © 2022, The Author(s).

2.
BMC Proceedings. Conference: 6th International Conference on Molecular Diagnostics and Biomarker Discovery, MDBD ; 16(Supplement 7), 2022.
Article in English | EMBASE | ID: covidwho-2196278

ABSTRACT

Background Impaired liver function upon admission has been linked to the severity of COVID-19 infection, yet the data is debated [1]. Therefore, this retrospective study aimed to evaluate the liver function among COVID-19 patients during hospitalization and its association with the disease severity. Methodology Patients aged 18 to 80 years with positive COVID-19 at Hospital Raja Perempuan Zainab II (HRPZ II), Kota Bharu, Kelantan, with available AST, ALT, Bilirubin, and AST/ALT ratio data on admission, were retrospectively evaluated from March 2021 until March 2022. Disease severity was categorized based on the Annex 2e guidelines by Ministry of Health Malaysia, which further classified them into mild to moderate disease (Stage 1-3) and severe to critical illness (Stage 4-5). The AST, ALT, Bilirubin, and AST/ALT ratio levels on Day 1 admission were archived from the electronic medical record system and compared between the two groups. Statistical analysis was performed using SPSS version 27. This study was approved by (JEPeM-USM) with protocol code USM/JEPeM/21100691 and the Ministry of Health Malaysia NMRR-21-762-58458 (IIR). Results and Discussion The study involved a total of 168 COVID-19 patients with a mean (SD) age of 46.67(16.10) for mild to moderate and 56.66(12.41) for severe to critical. There was a significant age group for both groups (pvalue= 0.002). During hospitalization, 16(14.41%) patients progressed to death from severe to critically ill patients. Upon admission, the median (IQR) of AST and ALT were significantly higher in the severe to critical group compared to the mild to moderate group, [AST;39.0(49.0) and 24.0(14.0), ALT 38.0(43.0) and 21.0(18.0)], p<0.05. However, there were no significant differences between both groups for bilirubin level and AST/ALT ratio. Non-survivors had higher AST and ALT levels compared to survivors, with median (IQR) of [AST 98.0(88.0) and 32.0 (26.0), ALT of 67.5(90.0) and 28.0(31.0), (p<0.05). Similarly, there were no significant differences between nonsurvivors and survivors for bilirubin and AST/ALT ratio. Our study supports the idea that abnormal liver function at admission has been shown to be associated with the disease severity and mortality of COVID-19 infection. Therefore, there is a need to observe hepatobiliary sequelae in COVID-19 survivors as there are dynamic changes in liver function following hospital discharge. Conclusion Abnormal AST and ALT level at admission has been shown to be associated with the disease severity and mortality of COVID-19 infection. Further study needed to evaluate liver damage in COVID-19 post-discharge.

3.
Nutrition and health ; : 2601060221149088, 2023.
Article in English | EMBASE | ID: covidwho-2194884

ABSTRACT

Low-carbohydrate, high-fat (LCHF) nutrition therapy is characterized by carbohydrates comprising <26% of the daily caloric intake and a higher proportion of fat. LCHF therapies reduce exogenous glucose load, improve glycemic control, decrease inflammation, and improve clinical outcomes such as respiratory function. Given the altered metabolism in critically ill patients, LCHF nutrition therapy may be especially beneficial as it enables the conservation of protein and glucose for metabolic roles beyond energy use. In critical illness, LCHF diets have the potential to reduce hyperglycemia, improve ventilation, decrease hospital length of stay and reduce hospital costs. The purpose of this commentary piece is to describe LCHF nutrition therapy, summarize its impact on health outcomes, and discuss its role in the intensive care unit (ICU). Additional research on the effects of LCHF nutrition therapy on critically ill patients is warranted, including a focus on COVID-19.

4.
Circulation Conference: American Heart Association's ; 146(Supplement 1), 2022.
Article in English | EMBASE | ID: covidwho-2194337

ABSTRACT

Introduction: Mortality for patients on VV-ECMO remains high despite increased use during the COVID-19 pandemic. Unlike VA-ECMO which provides life support for cardiac failure and can be used as a bridge to definitive therapy during cardiac arrest (e-CPR), patients who arrest while on VV-ECMO currently may undergo traditional cardiopulmonary resuscitation (CPR). This poses many challenges such as potential cannula position disruption of the VV-ECMO system during compressions and it is unclear if patients on VV-ECMO will benefit from being offered traditional CPR. Hypothesis: Traditional CPR is effective in patients who arrest while on VV-ECMO. Method(s): A retrospective chart review of inpatient cardiac arrest data from a high-volume ECMO center was performed. Patients who arrested while on VV-ECMO were included. Data including demographics, etiology of arrest, return of spontaneous circulation (ROSC) and survival to discharge were reviewed. Survival data was compared with the ECLS International Summary of Statistics. Result(s): We identified 19 patients on VV-ECMO who underwent CPR for cardiac arrest between September 2012 and November 2021. The average age of the patients was 42.7 years and 89.5% (n=17) were men. Seven of the nineteen total patients (36.8%) were being treated for ARDS from COVID-19 pneumonia. The arrest occurred on average 35.6 days into hospitalization (range: 1-132 days). The initial rhythm was pulseless electrical activity in 13 patients (68.4%), and the etiologies of arrest included hypoxemia (n=10, 52.6%), ECMO machine failure or during oxygenator exchange (n=3, 15.8%), pneumothorax (n=2, 10.5%), and cardiac tamponade (n=1, 5.3%). ROSC occurred in all 19 patients (100%), however only 4 patients (21.1%) survived to discharge with good neurologic recovery. Survival to discharge for all-comers on VV-ECMO is 66%. Conclusion(s): While there is limited evidence for the effectiveness of traditional CPR for patients on VV-ECMO, in this sample, ROSC was universal and one-fifth of patients survived to discharge. Future studies should continue to study the utility of CPR on VV-ECMO and how to optimize technique to improve outcomes for these critically-ill patients.

5.
American journal of physiology Lung cellular and molecular physiology ; 03, 2023.
Article in English | EMBASE | ID: covidwho-2194193

ABSTRACT

The human immune system evolved in response to pathogens. Amongst these pathogens, malaria has proven to be one of the deadliest and has exerted the most potent selective pressures on its target cell, the red blood cell. Red blood cells have recently gained recognition for their immunomodulatory properties, yet how red cell adaptations contribute to the host response during critical illness remains understudied. This review will discuss how adaptations that may have been advantageous for host survival might influence immune responses in modern critical illness. We will highlight the current evidence for divergent host resilience arising from the adaptations to malaria and summarize how understanding evolutionary red cell adaptations to malaria may provide insight into the heterogeneity of the host response to critical illness, perhaps driving future precision medicine approaches to syndromes affecting the critically ill such as sepsis and ARDS.

6.
Colorectal Disease ; 23(Supplement 2):41, 2021.
Article in English | EMBASE | ID: covidwho-2192478

ABSTRACT

Aim: SARS-CoV- 2 has been associated with an increased rate of venous thromboembolism (VTE) in critically ill patients (1-4). Since surgical patients are already at higher risk of VTE than general populations, this study aimed to determine if patients with perioperative or previous SARS-CoV- 2 were at further risk of VTE. Method(s): International, multicentre, prospective cohort study of elective and emergency patients undergoing surgery during October 2020. Patient from all surgical specialties were included. The primary outcome measure was VTE (pulmonary embolism or deep vein thrombosis) within 30 days of surgery. SARS-CoV- 2 diagnosis was defined as perioperative (7-days before to 30-days after surgery), recent (1-6 weeks before surgery), and previous (37 weeks before surgery). Result(s): The postoperative VTE rate was 0.5% (666/123,591) in patients without SARS-CoV- 2 diagnosis, 2.2% (50/2,317) in patients with perioperative SARS-CoV- 2, 1.6% (15/953) in patients with recent SARS-CoV- 2, and 1.0% (11/1,148) in patients with previous SARS-CoV- 2. After adjustment for confounding factors, patients with perioperative (adjusted odds ratio 1.48, 95% confidence interval 1.08-2.03) and recent SARS-CoV- 2 (OR 1.94, 1.15-3.29) remained at higher risk of VTE, with a borderline finding in previous SARS-CoV- 2 (OR 1.65, 0.90-3.02). Overall, VTE was independently associated with 30-day mortality (OR 5.39, 4.33-6.70). In SARS-CoV- 2 infected patients, mortality without VTE was 7.4% (319/4,342) and with VTE was 40.8% (31/76). Conclusion(s): Patients undergoing surgery with a perioperative or recent SARS-CoV- 2 diagnosis are at increased risk of VTE compared to non-infected surgical patients.

7.
Pediatric Critical Care Medicine Conference: 11th Congress of the World Federation of Pediatric Intensive and Critical Care Societies, WFPICCS ; 23(11 Supplement 1), 2022.
Article in English | EMBASE | ID: covidwho-2190809

ABSTRACT

BACKGROUND AND AIM: The clinical manifestations of the pediatric population with Sars-Cov-2 infection vary and seem to be milder than adults. Although, seldom, children can manifest life-threatening respiratory disease. This study aims to present the experience of a single-center Pediatric Intensive Care Unit (PICU). METHOD(S): A retrospective review was performed between October 2020 and January 2022 in children, hospitalized with SARS-CoV-2 infection, in a referral PICU. The medical records of the patients were reviewed in terms of demographic characteristics, clinical and laboratory data. All patients, from birthday day to 16 years old, admitted with confirmed SARS-CoV-2 infection, with respiratory involvement, were included. RESULT(S): The data of 16 patients were analyzed, 9 (56%) were males, with median age 6 years. Comorbidities were ascertained in 5 patients, concerned mainly obesity (n=3), and neurological disorders (n=2). The mean duration of the hospitalization was 6,1 days. Twelve patients had an X-ray chest consistent with Covid-19. Six patients had cardiovascular involvement. Only three patients were supported with mechanical ventilation, two had co-morbidities. A mild prevalence of leukopenia was observed (n=8). Fifteen patients received corticosteroids, 12 Remdesivir and 6 immunomodulatory treatment. All patients received antibiotics. Two patients died, one was a newborn, without past medical history and the other had co-morbidities. CONCLUSION(S): This study highlights that there is a low but not negligible risk of a life-threatening disease which can be combined with the age and the co-morbidities of the patient. Additional studies are needed to evaluate clinical and laboratory findings so to analyze possible correlations.

8.
Pediatric Critical Care Medicine Conference: 11th Congress of the World Federation of Pediatric Intensive and Critical Care Societies, WFPICCS ; 23(11 Supplement 1), 2022.
Article in English | EMBASE | ID: covidwho-2190806

ABSTRACT

BACKGROUND AND AIM: Obesity has been associated with poor clinical prognoses for patients hospitalized with COVID-19. It remains unclear how obesity relates to clinical trajectory in the pediatric intensive care unit (PICU). We aim to describe body mass index (BMI) among children admitted to the PICU, determine if BMI can discriminate poor clinical trajectory, and explore differences and risk-factors among children with good versus poor clinical trajectories. METHOD(S): We performed a single-center, retrospective cohort study among children hospitalized in a PICU from June 2021 through October 2021. Patients had documented positive COVID-19 infection or multisystem inflammatory syndrome in children (MIS-C). The primary outcome was a composite for clinical trajectory including (1) index mortality, (2) invasive respiratory therapy, (3) acute venous thromboembolism, (4) and extracorporeal life support. Descriptive, comparative, discriminatory, and exploratory statistics were employed. RESULT(S): Of 80 patients, 44 (55%) comprised the poor clinical trajectory cohort. Those with poor clinical courses (Table 1) had greater BMI (31.8 +/- 17.3 versus 21.1 +/- 6.2, P<0.001), were more commonly Hispanic/Latino (38.6% versus 16.7%, P=0.046), had greater frequency of COVID-19 infections compared to MIS-C (88.6/11.4% versus 66.7/13.9%, P=0.019), and longer median LOS (7.4 [interquartile range: 4.7,13.9] versus 4.5 [interquartile range:2.3,7.4], P<0.001). ROC curve analysis (Figure 1) yielded an AUC of 0.693 (95% confidence interval [CI]: 0.576-0.810). CONCLUSION(S): Clinical trajectory was associated with BMI. Threshold values for obesity and severe obesity reflected high discriminatory capacity. These data should inform next-step public health initiatives for COVID-19 management and efforts to mitigate pediatric obesity.

9.
Pediatric Critical Care Medicine Conference: 11th Congress of the World Federation of Pediatric Intensive and Critical Care Societies, WFPICCS ; 23(11 Supplement 1), 2022.
Article in English | EMBASE | ID: covidwho-2190790

ABSTRACT

BACKGROUND AND AIM: A child's critical illness is a stressful event for the entire family, causing significant emotional distress among parents and changes to family functioning. Family-centered care (FCC) has been endorsed by major professional organizations. The SARS-CoV-2 pandemic has abruptly caused modifications in visitation policies of PICUs in many countries. We hypothesized that caregivers with no or severely restricted access to PICUs would demonstrate elevated psychological distress compared to those who had limitless access to PICU. METHOD(S): Sociodemographics variables, levels of psychological distress, family functioning and ability to cope with stressful events were collected with an online survey in a group of caregivers (N=43) after their child hospitalization. A Pediatric Risk of Mortality-II (PRISM-II) score was calculated at child admission. Ratings of psychological distress were compared between caregivers with no/severely restricted (NA) and with limitless access (LA) to PICUs. All data were analyzed in the context of the Generalized Linear Model (GLZM). RESULT(S): Levels of depression, anxiety and the global severity index of psychological distress were significantly higher in NA with respect to LA (respectively LR chi2=9.885, p=0.001, LR chi2=5.54 p=0.08, LR chi2=6.928 p=0.008), correcting for gender, age, PRISM-II levels and personal ability to cope with stressful events. No significant effect of family functioning scores or other sociodemographic variables was found. CONCLUSION(S): Restrictions imposed to visitation policies in PICU during the pandemic negatively impacted on families' psychological well-being. A balance between safety of patients, families and health care professionals and meeting the needs of families is of utmost importance.

10.
Pediatric Critical Care Medicine Conference: 11th Congress of the World Federation of Pediatric Intensive and Critical Care Societies, WFPICCS ; 23(11 Supplement 1), 2022.
Article in English | EMBASE | ID: covidwho-2190772

ABSTRACT

BACKGROUND AND AIM: Multisystem inflammatory syndrome in children (MIS-C) is a new serious emerging disease related to previous exposure to coronavirus infection disease (COVID-19). AIM: To describe the clinical features, laboratory findings, therapies, and outcomes of children with MIS-C in a Tunisian PICU. METHOD(S): Prospective study conducted between 01 November and 30 December 2021. Patients aged less than 15 years, admitted to our PICU, and met the criteria for MIS-C according to the WHO definition case, were included. Demographic and clinical data, laboratory test results, echocardiographic findings, treatment, and outcomes were collected during hospitalization. RESULT(S): The median age was 9 years (IQR: 5-10). Obesity was noted in 1 patient. Ten patients were boys. Median delay between symptom and PICU admission was 6days (IQR:5-7). Fever and gastrointestinal symptoms were reported in all cases. Five patients had marked abdominal pain and were examined by the surgeon for a possible appendicitis. Cardiac dysfunction was reported in 13 cases with a median LVEF 42% (IQR: 33-50). Two patients had a vasoplegic shock and needed norepinephrine. Median CRP was 281mg/l (166-347). Median lymphocyte count was 880cells /mm3(520-1270). Median D-Dimers was 4631 ng/ ml (1582-8672). Median troponin was 339ng/L (IQR: 36 879). Median pro BNP was 9199pg/ml (2825-25000). All patients had positive SARS-COV-2 serology. Only 4 patients required mechanical ventilation. All patients received inotropes, immunoglobulins, methyl prednisolone and a low dose of aspirin. One patient died. CONCLUSION(S): We report herein clinical features, management, and outcomes of critically ill children with MIS-C to highlight the severity of clinical presentation with a good prognosis.

11.
Critical Care Medicine ; 51(1 Supplement):554, 2023.
Article in English | EMBASE | ID: covidwho-2190671

ABSTRACT

INTRODUCTION: There is a wide range in the reported incidence of pneumothorax (PTX) and pneumomediastinum (PMN) in patients with coronavirus disease 2019 (COVID-19). PTX alone and PTX/PMN combined has also been associated with higher mortality in patients with COVID-19 related acute respiratory distress syndrome (ARDS), however, current data regarding outcomes or predictors of PTX and PMN in COVID-19 ARDS is limited. The purpose of this study was to determine if the incidence of PTX/PMN in a large cohort with COVID-19 related respiratory failure was associated with mortality. Further, we looked to determine which clinical factors or ventilator management strategies may have impacted mortality in underserved patient population with PTX. METHOD(S): We conducted a retrospective analysis of data from a single center COVID-19 intensive care unit of an urban tertiary safety net hospital including all adult patients admitted with COVID-19 associated ARDS requiring mechanical ventilation between March 2020 and January 2021. Following identification of a cohort with radiographic evidence of PTX and/or PMN, demographics, ventilator data, radiographic data, position, information regarding chest tube and sedation management and outcome data were obtained from the electronic medical record. RESULT(S): Among 502 patients admitted to the ICU with COVID-19 related ARDS, PTX was identified in 103/ 502 (20.5%), predominantly affecting Hispanic (88%) and male (66%) patients. Thirty-four patients had PMN (18.7%) alone. Of patients with documented PTX, 60 (50.8%) had preceding or co-morbid PMN. PTX with/without PMN was associated with increased mortality (OR 2.19, p=0.0027) even after adjustment for ventilator days. There was no significant association between PMN alone and mortality (OR 0.82, p=0.60). Conservative management without tube thoracostomy was rarely possible (18.4% of PTX). Time to development of PTX was not associated with mortality, but PTX was associated with longer survival times (HR 2.10;p< 0.001). CONCLUSION(S): There is a high incidence of PTX/PMN in critically ill patients with COVID-19. PTX, but not PMN alone, is associated with higher mortality in ICU patients.

12.
Critical Care Medicine ; 51(1 Supplement):554, 2023.
Article in English | EMBASE | ID: covidwho-2190670

ABSTRACT

INTRODUCTION: Since the start of the COVID-19 pandemic there has been an evolution of variant strains that have spread throughout the world. As time has passed, clinicians have appreciated that these variants have different symptomology and clinical course. As our understanding of the disease process has progressed, medical management has evolved. Throughout, cancer patients have represented a uniquely at-risk population. We sought to compare the characteristics of critically ill cancer patients with Omicron variant to those infected with the ancestral strain. METHOD(S): Single-center retrospective cohort study analyzed all cancer patients >=18 years of age with current or past (< 2 years) diagnosis of cancer, who were admitted to ICU with COVID-19. The ancestral strain period was defined as March 1 to June 30, 2020, and the Omicron variant period was December 15, 2021 to April 1, 2022. Demographics, clinical and laboratory data of critically ill cancer patients were extracted from electronic health record and an ICU database. RESULT(S): A total of 127 patients were analyzed (38 Omicron and 89 ancestral strain). Median age was similar (67 years Omicron, 65 ancestral) and slightly higher male (47% Omicron, 58% ancestral). There was a higher number of hematologic malignancy (53% Omicron, 43% ancestral). Mechanical ventilation and vasopressors were less commonly used (58% and 53% Omicron, 67% and 71% ancestral), respectively. Prone positioning was utilized less frequently (47% Omicron, 56% ancestral) as was tracheostomy (11% omicron, 34% ancestral). ICU mortality was similar in both groups, (39% vs 37% however, hospital mortality was higher (55% Omicron group, 45% ancestral). CONCLUSION(S): Critically ill cancer patients infected with the Omicron variant may be less likely to undergo tracheostomy however, they are more likely to die during their hospitalization. Even with higher hospital mortality Omicron patients also seemed to be less acutely ill as their requirement for mechanical ventilation, vasopressors and prone positioning was lower. This should be considered as we counsel patients and set expectations about what might happen during a COVID admission to the ICU.

13.
Critical Care Medicine ; 51(1 Supplement):550, 2023.
Article in English | EMBASE | ID: covidwho-2190665

ABSTRACT

INTRODUCTION: Tracheostomy is the most frequent surgical procedure performed in critically ill patients, mostly in patients requiring prolonged mechanical ventilation. We aimed to describe the outcomes associated with tracheostomies in critically ill COVID-19 patients admitted to our ICU. METHOD(S): We studied a cohort of adult patients admitted with the diagnosis of COVID-19 to a mixed ICU between 03/2020 and 06/2021. We collected patients' demographics, severity of illness, ICU resource utilization, and outcomes. Descriptive statistics were reported. RESULT(S): A total of 275 patients with confirmed COVID-19 were admitted to our ICU during the study period. Among them, 26 patients (9.45%) underwent tracheostomy. There were 10 females (38.4%) with an average age of 60 years (range 53-67). Median body mass index was 31 (range 26-41). Patients identified themselves as African American (39%), Caucasian (27%), and the remaining as other or declined to answer. Median Sequential Organ Failure Assessment (SOFA) score on admission was 10 (range 8-12) and max SOFA score was 13 (range 11-17). Mean mechanical ventilation-days was 19 days (range 12-23). Median ICU length of stay (LOS) was 41 days (range 31-48) and hospital LOS was 46 days (range 32-60). The ICU and hospital mortality rates were 23% and 27% respectively. There were no procedural causes of death. CONCLUSION(S): Although the mortality of the patients that underwent tracheostomies was relatively high, these patients were less than 3% of the total cohort of COVID-19 patients admitted to the ICU and had lower mortality than expected adjusted for their severity of illness based on the SOFA score.

14.
Critical Care Medicine ; 51(1 Supplement):492, 2023.
Article in English | EMBASE | ID: covidwho-2190651

ABSTRACT

INTRODUCTION: Glycemic control is an important component of quality improvement bundles within the ICU. Dysglycemia among intensive care unit (ICU) patients has been associated with greater morbidity and mortality. The COVID-19 pandemic has been shown to influence hypoglycemia in patients presenting to the emergency department. The purpose of this study is to evaluate risk factors for dysglycemia during the COVID-19 pandemic in critically ill ICU patients on subcutaneous insulin. METHOD(S): Single-center, retrospective quality improvement study of adult critically ill patients admitted to the ICU in 2020. Patients were included if they were on subcutaneous insulin and primarily managed by an intensive care unit multidisciplinary team. Patients were excluded with active endocrinology consultation or receiving intravenous insulin infusion. Rates of hyperglycemia (blood glucose (BG) greater than or equal to 180 mg/dL), severe hyperglycemia (BG > 300 mg/dL), hypoglycemia (less than or equal to 70 mg/dL), or severe hypoglycemia (BG < 54 mg/dL) were evaluated. Basic patient demographics, including history of diabetes, steroid use, COVID-19 diagnosis were obtained. Regression analysis was performed adjusting for age, past medical history of diabetes, use of corticosteroid medications, COVID-19 diagnosis and use of a self-adjusting insulin calculator. RESULT(S): There were 244 adult ICU patients and 2,198 patient days evaluated in this study. History of diabetes was associated with greater odds of hyperglycemia (odds ratio (OR) 2.09 (1.57-2.78), p< 0.01), severe hyperglycemia (OR 1.82 (1.02-3.24), p=0.04), and lower risk for severe hypoglycemia (OR 0.24 (0.07-0.81), p=0.02). Corticosteroid use was associated with greater risk of hyperglycemia (OR 3.04 (2.31-3.99), p< 0.01) and severe hyperglycemia (OR 4.54 (2.59-7.95), p< 0.01), with no significant difference in hypoglycemia. COVID-19 diagnosis was associated with greater hyperglycemia (OR 1.49 (1.11-2), p=0.007) and hypoglycemia (OR 3.93 (1.32-11.73), p=0.01). CONCLUSION(S): In our quality improvement analysis, dysglycemia was found to be more prevalent in patients with corticosteroid use, history of diabetes and patients with a COVID-19 diagnosis. Larger studies would be beneficial to confirm these results.

15.
Critical Care Medicine ; 51(1 Supplement):467, 2023.
Article in English | EMBASE | ID: covidwho-2190643

ABSTRACT

INTRODUCTION: Ketamine is an NMDA receptor antagonist which has had a resurgence in sedation for critically ill patients. During the COVID-19 pandemic, there was an increase in acute respiratory distress syndrome (ARDS) where deep sedation was required. Ketamine has a lenient hemodynamic profile, opioid sparing properties, bronchodilating and anti-inflammatory effects. These characteristics make it a desirable agent for sedation in COVID-19 ARDS. METHOD(S): This is a single-center retrospective study where time-to-event data of 144 patients admitted to the ICU was analyzed. Kaplan-Meier curves were applied to summarize time from ICU admission to death. Competing risks regression analysis was performed to test the association between ketamine use and ICU-to-floor time, time-to-transfer or discharge to LTAC. RESULT(S): 58 of 144 patients who received ketamine were younger, had higher BMI, and lower APACHE II (median age 59 years, BMI 34.4, APACHE II Score 14) compared to 86 patients who did not receive ketamine. A higher percentage of patients receiving ketamine were on extracorporeal membrane oxygenation (ECMO) (25.9% vs 5.8%). There was no significant difference in time-to-death between the two groups (p=0.124). Patients on ketamine had a lower incidence of being transferred to acute care floors (SHR:0.45, 95% CI) and had prolonged intubation (SHR 0.24, 95% CI). Ketamine was not associated with increased incidence of reintubation. CONCLUSION(S): Among COVID-19 ARDS patients requiring sedation, there was no significant change in time to death in those sedated with ketamine when compared to those without. Patients who required Ketamine had a more prolonged course of invasive mechanical ventilation and required ECMO. It is likely that they had been already on high amounts of sedation at the previous institution leading to higher tolerance to ketamine. However, patients sedated with ketamine in our sample had a higher predicted mortality since admission. Ketamine might still have role in sedation for ARDS COVID-19, but the effects are still unknown and further trials are needed to elucidate its role and possible benefits.

16.
Critical Care Medicine ; 51(1 Supplement):465, 2023.
Article in English | EMBASE | ID: covidwho-2190640

ABSTRACT

INTRODUCTION: Airway pressure release ventilation (APRV) may be an alternative to low tidal volume ventilation for patients with acute respiratory distress syndrome (ARDS). We conducted an investigator-initiated, pilot feasibility randomized controlled study (RCT) comparing APRV to low tidal volume ventilation in critically ill adults with ARDS (ClinicalTrials.gov identifier NCT 04156438). METHOD(S): Participants with moderate-to-severe ARDS admitted to an intensive care unit (ICU) in Regina, Saskatchewan, were randomized on an open-label basis to APRV or low tidal volume ventilation, over a one-year period. The primary feasibility outcomes were the informed consent rate, recruitment rate, and protocol adherence rate. A successful informed consent rate was defined as at least 70% of eligible patients approached for study participation consenting to participation. Enrollment of at least 15 participants during the one-year recruitment period was considered a successful recruitment rate. Protocol adherence was defined as the number of patient-days of complete adherence to the study protocol, with a rate of at least 80% considered successful. The secondary efficacy outcomes were 28-day mortality, in-hospital mortality, ICU length of stay, hospital length of stay, length of mechanical ventilation, and incidence of tracheostomy. RESULT(S): Due to interruptions in study recruitment from the COVID-19 pandemic, this study took place between July 1, 2020 to December 31, 2021 to ensure a one-year recruitment window. Of the 165 ARDS patients admitted to the ICU during this period, 42 (25.5%) were screened for eligibility, with 17/42 patients (40.5%) meeting the eligibility criteria. 13/17 (76.5%) secondary decision makers were approached for informed consent, with only one (7.7%) giving consent for participation. Clinical documentation limited ability to assess protocol adherence. Efficacy outcomes were not analyzed due to low recruitment. No adverse events associated with trial participation were identified. CONCLUSION(S): Our study did not meet the pre-specified feasibility outcomes for recruitment, informed consent, or protocol adherence. Future studies of ventilation strategies for ARDS at our center may need to consider the impacts of COVID-19 pandemic on recruitment strategies, institutional resources and policies.

17.
Critical Care Medicine ; 51(1 Supplement):442, 2023.
Article in English | EMBASE | ID: covidwho-2190623

ABSTRACT

INTRODUCTION: Acute respiratory distress syndrome (ARDS) develops in approximately 33% of hospitalized coronavirus disease 19 (COVID-19) patients with 75% of COVID-19-related intensive care unit (ICU) admissions caused by an ARDS diagnosis. Currently, there is conflicting evidence regarding the mortality benefit of early neuromuscular blocking agents (NMBAs) being used in moderate-to-severe ARDS, and data is especially lacking in COVID-19-related ARDS despite increased NMBA utilization. This study aims to assess if early versus late initiation of a cisatracurium infusion in critically ill COVID-19 adults with moderate-to-severe ARDS has an effect on 28- day breathing without assistance. METHOD(S): Retrospective cohort study conducted at a multi-hospital community health system between March 2020 and November 2021. Eligible patients included adults >= 18 years, admitted to the ICU with COVID-19 infection and moderate-to-severe ARDS requiring mechanical ventilation, and received a cisatracurium infusion for at least four hours. Patients were divided into two groups: early (within 48 hours) versus late (greater than 48 hours) initiation of cisatracurium infusion from the time of mechanical ventilation. RESULT(S): A total of 118 patients were included in the final analysis. At day 28, there were no significant differences in the rate of breathing without assistance between the early and late group (15.3% and 10.2%, respectively;p = 0.407). Similarly, there were no significant differences between groups in all-cause mortality or death in the ICU at day 28. Intensive care unit length of stay was significantly shorter among the early group with a median of 10.6 days versus 15.1 days in the late group (p = 0.028). Additionally, mechanical ventilation duration was significantly shorter in the early group compared to the late group (median, 7.3 and 11.6 days, respectively;p = 0.001). Incidence of barotrauma during cisatracurium infusion did not differ between groups. CONCLUSION(S): Early initiation of a cisatracurium continuous infusion was not associated with a significant improvement in breathing without assistance at day 28 in moderate-to-severe ARDS patients with COVID-19. The utilization and timing of cisatracurium in this patient population remains uncertain.

18.
Critical Care Medicine ; 51(1 Supplement):436, 2023.
Article in English | EMBASE | ID: covidwho-2190614

ABSTRACT

INTRODUCTION: Ventilatory ratio (VR) is a bedside index of impaired ventilation that can be used as a surrogate marker for pulmonary dead space fraction (VD/VT). Vasculopathy is hypothesized to increase VD/VT in patients with acute respiratory distress syndrome (ARDS) due to COVID-19. The purpose of this study was to investigate associations between VR and markers of inflammation in critically ill COVID-ARDS patients. METHOD(S): We conducted a retrospective study of patients admitted to an intensive care unit due to SARS-CoV-2 infection. All subjects required invasive mechanical ventilation and met the Berlin criteria for ARDS. Clinical lab values were collected at two timepoints: 2-8 hours after intubation (T1) and 2-24 hours before tracheostomy (T2). VR was split into high (VR>2) and low (VR< 2) groups. Comparisons were performed using student's t, Mann-Whitney, and z tests for difference in proportions with alpha=0.05. RESULT(S): Of the 139 subjects enrolled at T1, 67 (48%) had high VR (>2), with an overall mean VR of 2.08. High VR was significantly associated with leukocyte count (WBC) (13.3 vs. 10.6 x10

19.
Critical Care Medicine ; 51(1 Supplement):367, 2023.
Article in English | EMBASE | ID: covidwho-2190596

ABSTRACT

INTRODUCTION: Sedative and analgesic agents are used for patient comfort during mechanical ventilation (MV) but can cause deleterious effects such as prolonged MV and delirium. Maintaining light sedation and performing daily awakening trials (DATs) can reduce untoward effects. We assessed the relationship between sedative and analgesic dose and 28-day MV-free survival in medical ICU (MICU), surgical ICU (SICU), and cardiac (CICU) patients, hypothesizing that higher doses would be associated with lower 28-day MV-free survival. METHOD(S): In this single-center retrospective study, MICU, SICU, and CICU patients admitted to a tertiary care hospital from 1/1/21-6/30/21 and on MV admitted for 1-7 days were randomly selected if their goal Sedation Agitation Scale (SAS) score was 3-4. Baseline demographics and clinical characteristics were collected. The primary outcome was correlation between average sedative or analgesic dose and 28-day MV-free survival. Secondary outcomes included time at goal SAS score, DAT completion, and deep sedation (SAS < 3) within 48 hours of intubation. The primary outcome was evaluated using linear regression;secondary outcomes were assessed with descriptive statistics. RESULT(S): 411 subjects, including 99 MICU, 54 SICU, and 27 CICU patients, were evaluated. 53% were male and the median age and weight were 66.5 years (IQR, 56-77) and 84 kg (IQR 70-100), respectively. 8% of MICU patients but no SICU or CICU patients had Covid-19. A history of chronic opioid use was most common in MICU and SICU patients (19% and 17%, respectively) and CICU patients most often had a history of chronic kidney disease (33%). Doses of dexmedetomidine, propofol, midazolam, and fentanyl demonstrated poor correlation with 28-day MV-free survival among all patients, with R-squared values of 0.002, 0.06, 0.01, and 0.1, respectively. The association of sedative dose was strongest for midazolam in MICU patients, with each 1mg/hr increase corresponding to a 0.6 day reduction in 28- day MV-free survival. SAS scores were 3-4 70% of the time, SATs were completed in 73% of appropriate cases, and 57% of patients were deeply sedated within 48 hours of intubation. CONCLUSION(S): In this regression analysis, sedative and analgesic doses were not associated with 28-day MV-free survival in a mixed critically ill population.

20.
Critical Care Medicine ; 51(1 Supplement):305, 2023.
Article in English | EMBASE | ID: covidwho-2190584

ABSTRACT

INTRODUCTION: Hospital-acquired venous thromboembolism (HA-VTE) has an incidence of 2.2% among critically ill children. Although risk factors have been described (e.g., immobility, central venous catheterization [CVC], and systemic inflammation), insufficient data exists to recommend routine thromboprophylaxis (TP) in the pediatric intensive care unit (PICU). Children undergoing mechanical ventilation (MV) may represent an at-risk population due to illness severity, intentional immobility, and frequent CVC presence. We sought to estimate the rate and timing of HAVTE for children undergoing MV and explore for variation in HA-VTE rates by MV parameters. METHOD(S): We performed a single-center, retrospective cohort study of children < 18 years of age in the PICU undergoing MV from October 2020 - March 2022 excluding those with tracheostomy, HA-VTE prior to MV, and a total MV exposure of < 24 hours. The primary outcome was HA-VTE identified after intubation confirmed by imaging. Secondary outcomes were HA-VTE characteristics (i.e., timing, location, and CVC-related), MV parameters (i.e., barometric, volumetric, and compliance data within 72-hours of intubation), and other known HA-VTE risk factors. Descriptive and comparative statistics (Fisher's exact, Wilcoxon rank sum, and Student's t tests) were employed. RESULT(S): Of 170 subjects studied, 18 (10.6%) developed a HA-VTE (limb deep venous thromboses) at median of 4 (interquartile range [IQR]:1.4,6.4) days after intubation. Those with HA-VTE had a greater frequency of comorbid CVC (88.9% vs 61.8%, P=0.034) and prior history of HA-VTE (27.8% vs 8.6%, P=0.027). No differences in demographics, anthropometrics, severity of illness indices, immobility, applied TP, rates of comorbid hematologic malignancy, sepsis, COVID-19, trauma, or postoperative admission were noted. No differences were observed for rates of conventional MV, high-frequency oscillation, intubation timing, or MV duration. Ventilator parameters were not different between those with and without HA-VTE. CONCLUSION(S): In our study, the rate of HA-VTE among critically ill children undergoing MV was 10.6% and more common to children with comorbid CVC. Although HA-VTE rates were not observably different by MV exposure, duration, or intensity, prospective studies are still required.

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