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1.
Biol Methods Protoc ; 7(1): bpac027, 2022.
Article in English | MEDLINE | ID: covidwho-2188263

ABSTRACT

Background: With the results of the largest randomized controlled trial (RECOVERY) and the most extensive retrospective cohort study on coronavirus disease 2019 (COVID-19) recently published, we performed a meta-analysis on the association of aspirin with mortality of COVID-19. We aimed to investigate the role of aspirin in COVID-19 hospitalizations. Materials and Methods: We searched PubMed, EMBASE and Cochrane databases for studies from 1 January 2020 until 20 July 2022, that compared aspirin versus non-aspirin use in hospitalized COVID-19 patients. We excluded case reports, review articles and studies on non-hospitalized COVID-19 infections. We used the inverse variance method and random effects model to pool the individual studies. Results: Ten observational studies and one randomized controlled trial met the criteria for inclusion. There were 136 695 total patients, of which 27 168 were in the aspirin group and 109 527 were in the non-aspirin group. Aspirin use was associated with a 14% decrease in all-cause mortality compared with non-aspirin use in patients hospitalized with COVID-19 [relative risk (RR) 0.86, confidence interval (95% CI) 0.76-0.97; P = 0.002; I 2 =64%]. Among subgroups of studies reporting in-hospital mortality in COVID-19 hospitalizations, aspirin use was associated with a 16% decrease in in-hospital mortality compared with non-aspirin use (RR 0.84, 95% CI 0.71-0.99; P = 0.007; I 2 =64%). Conclusion: Our study shows that aspirin decreases in-hospital mortality in patients hospitalized with COVID-19. Further studies are needed to assess which COVID-19 patient populations benefit most, such as patients on aspirin for primary versus secondary prevention of atherosclerotic disease. In addition, significant bleeding also needs to be considered when assessing the risk-benefit of aspirin use.

2.
Ann Med Surg (Lond) ; 82: 104748, 2022 Oct.
Article in English | MEDLINE | ID: covidwho-2176133

ABSTRACT

The goal of this study was to investigate in-hospital mortality in patients suffering from acute respiratory syndrome coronavirus 2 (SARS-CoV-2) relative to the neutrophil to lymphocyte ratio (NLR) and to determine if there are gender disparities in outcome. Between February 26 and September 8, 2020, patients having SARS-CoV-2 infection were enrolled in this retrospective cohort research, which was categorized by NLR levels ≥9 and < 9. In total, 6893 patients were involved included of whom6591 had NLR <9, and 302 had NLR ≥9. The age of most of the patients in the NLR<9 group was 50 years, on the other hand, the age of most of the NLR ≥9 group patients was between 50 and 70 years. The majority of patients in both groups were male 2211 (66.1%). The ICU admission time and mortality rate for the patients with NLR ≥9 was significantly higher compared to patients with NLR <9. Logistic regression's outcome indicated that NLR ≥9 (odds ratio (OR), 24.9; 95% confidence interval (CI): 15.5-40.0; p < 0.001), male sex (OR, 3.5; 95% CI: 2.0-5.9; p < 0.001) and haemoglobin (HB) (OR, 0.95; 95% CI; 0.94-0.96; p < 0.001) predicted in-hospital mortality significantly. Additionally, Cox proportional hazards analysis (B = 4.04, SE = 0.18, HR = 56.89, p < 0.001) and Kaplan-Meier survival probability plots also indicated that NLR>9 had a significant effect on mortality. NLR ≥9 is an independent predictor of mortality(in-hospital) among SARS-CoV-2 patients.

3.
Nepalese Heart Journal ; 19(2):5-7, 2022.
Article in English | EMBASE | ID: covidwho-2198414

ABSTRACT

Background and Aims: The COVID 19 pandemic have affected the patients with ST segment elevation myocardial infarction as the number of patients presenting with STEMI declined substantially and those who underwent primary PCI had poor outcome. Our aim was to analyze the in-hospital and 30-days mortality in STEMI undergoing Primary PCI during second wave of COVID 19. Method(s): A prospective cohort study was conducted at Shahid Gangalal National Heart Centre, Bansbari, Kathmandu. Convenience sampling of patients who underwent primary PCI were enrolled in this study and were followed up for 30 days. Numerical variables were described as Mean +/- Standard Deviation (SD) and categorical variables were described as frequency and percentage. p values were calculated and considered significant if < 0.05. Result(s): During this study period of 2 months from 1st May 2021 to 30th June 2021, 97 patients with STEMI underwent primary PCI, including 12 (12.47%) COVID 19 positive cases. 30 days mortality was 15.4% including in-hospital mortality of 11.34%. Among COVID 19 positive cases, in-hospital mortality was 33.33% and 30-days mortality was 55.55% which was significantly higher than non COVID 19 patient who underwent primary PCI (P=0.003). Conclusion(s): Overall, mortality rate of primary PCI during COVID 19 second wave has been increased and mortality of COVID 19 positive patients who underwent primary PCI was significantly higher than non-COVID 19 patients who underwent primary PCI. Copyright © 2022 Cardiac Society of Nepal. All rights reserved.

4.
Circulation Conference: American Heart Association's ; 146(Supplement 1), 2022.
Article in English | EMBASE | ID: covidwho-2194394

ABSTRACT

Introduction: According to recent global estimates there are nearly 530 million cases and 6.3 million deaths due to novel coronavirus disease 2019 (COVID-19) pandemic. Studies have shown that COVID-19 disproportionately affects males than females. In this study we looked at differences in in-hospital outcomes of COVID-19 based on sex using a larger administrative database. Hypothesis: The adverse in-hospital outcomes of COVID-19 will be significantly higher among males. Method(s): This was a retrospective analysis of the California State Inpatient Database 2020. All COVID-19 hospitalizations with age 18 years and above were included for the analysis. These hospitalizations were classified into males and females. The main outcomes of the study were inhospital mortality, prolonged length of stay, vasopressor use, mechanical ventilation, and ICU admission. Any length of stay >=75th percentile value for the entire cohort was considered as prolonged length of stay. Logistic regression analyses after adjusting for covariates were used to compare COVID-19 related outcomes between males and females. Result(s): A total of 95,180 primary COVID-19 hospitalizations were included for the analysis. Of these 52465 (55.1%) were males and 42715 (44.9%) were females. Among these hospitalizations, mortality (12.4% versus 10.1%, P<0.001), prolonged length of stay (30.6% versus 25.8%, P<0.001), vasopressor use (2.6% versus 1.6%, P<0.001), mechanical ventilation (11.8% versus 8.0%, P<0.001), and ICU admission (11.4% versus 7.8%, P<0.001) were significantly higher among males. Logistics regression analysis showed that males had significantly greater odds for mortality (aOR, 1.38, 95% CI: 1.32-1.44), prolonged length of stay (aOR, 1.35, 95% CI: 1.31-1.39), vasopressor use (aOR, 1.59, 95% CI: 1.51-1.66), mechanical ventilation (aOR, 1.62, 95% CI: 1.47- 1.78), and ICU admission (aOR, 1.58, 95% CI: 1.51-1.66). Conclusion(s): Adverse outcomes such as mortality, prolonged length of stay, vasopressor use, mechanical ventilation, and ICU admission were independently associated with male sex. These findings could be due differences to both biological and social factors between the sexes. Future studies should explore these factors to efficiently control COVID-19.

5.
Circulation Conference: American Heart Association's ; 146(Supplement 1), 2022.
Article in English | EMBASE | ID: covidwho-2194371

ABSTRACT

Introduction: Sex differences in COVID-19 outcomes are well-known and have been ascribed to numerous factors including age-dependent sex hormones. We hypothesize that the protective effect of female sex in hospitalized COVID-19 patients attenuates with age. Method(s): We retrospectively analyzed patients who were hospitalized for COVID-19 infection at three hospitals of the Rush University System for Health (RUSH) (Chicago, IL) between March to December 2020. The primary endpoints were in-hospital mortality and major adverse cardiovascular events (MACE), defined as a composite of acute myocardial infarction, cardiac arrest, acute heart failure, and stroke. Stratified logistic regression was performed to estimate the odds ratios of these endpoints in male compared to female patients by age group (<45, 45-55, 55-65, 65-75, and >=75 years). Result(s): Of 1705 patients (age 58.1+/-16.9 years, 54.3% male, 24.6% White) who were hospitalized for COVID-19 infection, 179 (10.5%) patients experienced in-hospital mortality and 290 (17.0%) patients experienced MACE, respectively. The incidence of these outcomes progressively increased with age in both sexes. In patients <45 years of age, there was a trend towards increased risk for inhospital mortality (aOR 4.47;95% CI: 0.54 - 42.38) and MACE (aOR 2.43;95% CI: 0.97 - 6.10) in men compared to women. However, this trend attenuated with increasing age strata and there was a slight decrease in risk for in-hospital mortality (aOR 0.79;95% CI: 0.39 - 1.58) and MACE (aOR 0.70;95% CI: 0.38 - 1.28) among middle-aged (55-65 years of age) men compared to women. Conclusion(s): In this multi-hospital registry of COVID-19 patients, there was a reverse J-shaped trend in odds of in-hospital mortality and MACE in men compared to women. Female sex appeared to be an independent protective factor for adverse hospital outcomes among patients <55 years of age but not among older patients, suggesting a protective role of premenopausal sex hormones.

6.
Circulation Conference: American Heart Association's ; 146(Supplement 1), 2022.
Article in English | EMBASE | ID: covidwho-2194355

ABSTRACT

Introduction: Timely treatment of ST elevation myocardial infarction [STEMI] requires ongoing coordinated care between emergency departments, paramedics, and primary percutaneous coronary (PCI) intervention facilities. Method(s): To provide a current view and a national benchmark, we examined 121,576 patient records submitted by 648 hospitals participating the GWTG-CAD registry from Q2 2018 through Q3 2021 [median age 63, women 29%, Black 11%, Hispanic 8%, admission cardiac arrest 5%, shock 7%, heart failure 7%, Covid 0.2%, presentation EMS 47%, walk in 27%, transfer 22%] Results: Reperfusion method for all patients included primary PCI 87%, fibrinolysis 5%, and no reperfusion 8% [increasing from 7 to 9% during the study period]. Median time from symptom onset to reperfusion was shortest for EMS patients 148 minutes, followed by walk-in 195 minutes, ground transferred 238 minutes, and air transferred 247 minutes. Process times did not improve during the study period. First medical contact to device times increased by 5 minutes for EMS and ground transferred patients in Q2 2020 corresponding with the pandemic onset, and adjusted mortality was significantly higher in the final 3 quarters compared to Q2 2018 [OR, 95% CI 1.28(1.07-1.53);1.35(1.13-1.61);1.23(1.03-1.48)]. Patients treated within guideline goals had significantly lower mortality [Figure]. Conclusion(s): These data reaffirm the association between process times and lower mortality for STEMI patients. They also identify concerning trends and opportunities for improved care. Increasing delays in treatment, particularly for hospital transfer, greater numbers of untreated patients, and increased risk-adjusted in-hospital mortality all provide strong impetus for renewed focus on STEMI systems. Regional collaborative efforts led by coordinators and informed by a common data system have the potential to reverse these trends and improve survival.

7.
Critical Care Medicine ; 51(1 Supplement):608, 2023.
Article in English | EMBASE | ID: covidwho-2190687

ABSTRACT

INTRODUCTION: Thiamine (TH) is a co-factor for pyruvate dehydrogenase, an enzyme necessary for pyruvate entry into the Krebs cycle, and without this enzyme, pyruvate would be converted to lactate. Elevated lactate, which is often used as a marker of perfusion, is proportionally associated with increased mortality in septic shock. The few publications on TH in septic shock are inconclusive. This study aims to ascertain if there is benefit to adding TH to standard of care (SOC) in the management of septic shock. METHOD(S): IRB-approved, multicenter, retrospective review from 2016 to 2021. Adult patients admitted to the ICU for septic shock and receiving >= 400 mg a day of IV TH (in divided doses) were included. Patients < 18, pregnant, admitted for SARS-COV-2, or whom received < 400 mg of TH daily were excluded. Two matched cohorts were evaluated, SOC plus TH versus SOC alone. The primary endpoint is time to shock reversal, defined as off vasopressors for at least 12 hrs and alive. Secondary endpoints include time to lactate clearance (< 2 mmol/L), lactate trends at 6, 12, 24, 48 hrs, and end of therapy, hospital and ICU lengths of stay, new end organ dysfunction, and in-hospital mortality. RESULT(S): Data from 50 patients were analyzed: 25 in the SOC plus TH and 25 in the SOC arm. The TH arm had greater number of vasopressors (2 vs. 1, p=.019), and greater utilization of stress-dose steroids (72% vs. 8%, p<.001), however there was no difference in cumulative vasopressor dose in norepinephrine equivalents at baseline (BL) (30.1 vs. 25.8 mcg/min, p=.248). There was no difference in SOFA score at ICU admission (10 vs. 8.5, p=.106) or lactate level at ICU admission (5.9 vs. 3.9 mmol/L, p=.055). There was a longer time to shock reversal from vasopressor initiation time in the TH arm (93 vs. 37.1 hrs, p=.023). Lactate clearance was slower in the TH arm (44.75 vs. 15.8 hrs, p=.027), and there was increased in-hospital mortality in the TH arm (13 vs. 5, p=.018). CONCLUSION(S): Compared to SOC alone, TH treated patients had longer times to shock reversal. However, this outcome may have been confounded by differences at BL with regard to number of vasopressors, and stress-dose steroid utilization, which indicate these patients were sicker at BL. Larger, prospective studies are required to confirm these findings.

8.
Critical Care Medicine ; 51(1 Supplement):602, 2023.
Article in English | EMBASE | ID: covidwho-2190683

ABSTRACT

INTRODUCTION: The Surviving Sepsis Campaign guidelines recommend prompt intravenous antibiotic administration within one hour for patients with septic shock or a high likelihood of sepsis. To improve timeliness of antibiotic administration, piperacillin-tazobactam and cefepime were stocked in the automated dispensing cabinets (ADCs) in five intensive care units (ICU).The aim of this study was to evaluate the time from order entry of piperacillintazobactam or cefepime to administration in ICU patients before and after addition to the ADC. METHOD(S): This was a retrospective study of adult, presumed septic patients who received their first dose of piperacillin-tazobactam or cefepime in an ICU. Patients included from March 23, 2019 - March 23, 2020 received antibiotics from the inpatient pharmacy (Pre-ADC) and those from March 25, 2020 - March 25, 2021 received piperacillintazobactam and cefepime from the ICU ADCs (Post-ADC). The primary outcome was time from antibiotic order entry to administration. Secondary outcomes included time from order entry to pharmacy verification, in-hospital mortality, and hospital length of stay. RESULT(S): One thousand eight hundred and three patients were included with 903 patients in the Pre-ADC group and 900 in the Post-ADC group. Baseline characteristics were similar, and respiratory infection was the most common antibiotic indication (37% Pre-ADC vs. 36% Post-ADC). Additionally, more Post-ADC patients had isolation precautions at the time of antibiotic administration (15% Pre-ADC vs. 19% Post-ADC, p=0.04). The median (IQR) time (minutes) from order of antibiotics to administration was shorter in the Pre-ADC group at 57 (32-97) vs. 75 (43-126) Post-ADC (p < 0.001). Median (IQR) time (minutes) from pharmacy verification to nursing administration was 51 (28- 91) Pre-ADC vs. 75 (43-126) Post-ADC, p< 0.001. Hospital length of stay and mortality were similar between the groups. CONCLUSION(S): Adding piperacillin-tazobactam and cefepime to the ICU ADCs did not result in earlier antibiotic administration in presumed septic patients. Due to the timing of this study, the COVID-19 pandemic and isolation precautions likely confounded the results. Further investigation of antibiotic administration barriers is needed to optimize patient care and meet Surviving Sepsis Campaign recommendations.

9.
Critical Care Medicine ; 51(1 Supplement):599, 2023.
Article in English | EMBASE | ID: covidwho-2190680

ABSTRACT

INTRODUCTION: COVID-19-related organ dysfunction is increasingly recognized as sepsis of viral origin and is a common complication among those requiring hospitalization, with estimated prevalence of over 50% among the latter. However, the population-level association of COVID-19 with short-term mortality among septic patients is unknown. METHOD(S): We used a statewide dataset to identify hospitalizations aged >=18 years with sepsis in Texas during April 1-December 31, 2020. Sepsis was defined by "explicit" and ICD-10 codes for severe sepsis (R65.20) and septic shock (R65.21) and COVID-19 by ICD-10 code U07.1. A hierarchical, mixed-effects model was fit to estimate the association of COVID-19 with short-term mortality (defined as in-hospital death or discharge to hospice) among sepsis hospitalizations. Sensitivity analyses of the sepsis hospitalization subsets with septic shock and ICU admission were performed using a similar modeling approach. RESULT(S): Among 55,145 sepsis hospitalizations, 13,149 (23.8%) had COVID-19. Compared to those without COVID-19, sepsis hospitalizations with COVID-19 were younger (aged >=65 years 53.6% vs 55.0%), more commonly male (59.5% vs 50.4%) and racial/ethnic minority (66.1% vs. 46.2%), with lower burden of chronic illness (mean [SD] Charlson comorbidity index 1.8 [1.9] vs 2.8 [2.6]), but with higher mean [SD] number of organ dysfunctions (3.1 [1.4] vs 2.7 [1.6]) [p < 0.0001 for all comparisons]. Short-term mortality among sepsis hospitalizations with and without COVID-19 was 52.7% vs 30.2%, respectively. On adjusted analysis, COVID-19 remained associated with higher risk of short-term mortality (adjusted odds ratio [aOR] 2.54 [95% 2.39-2.70]), with findings on sensitivity analyses consistent with the primary model among sepsis hospitalization subsets with septic shock ([aOR] 2.70 [95% 2.51-2.91]) and ICU admission ([aOR] 2.67 [95% 2.30-3.10]). CONCLUSION(S): COVID-19 infection was associated with over 250% higher odds of short-term mortality among septic patients. Additional studies are needed to determine the mechanisms underlying these observations in order to inform future efforts to reduce the observed outcome disparities.

10.
Critical Care Medicine ; 51(1 Supplement):586, 2023.
Article in English | EMBASE | ID: covidwho-2190678

ABSTRACT

INTRODUCTION: Decreasing case fatality among septic patients has been documented in the United States (US). The strain on healthcare resources brought by the COVID-19 pandemic has been associated with a rise in adverse health outcomes in non-COVID patients. However, the populationlevel impact of the COVID-19 pandemic on the case fatality in sepsis among non-COVID patients is unknown. METHOD(S): We used a statewide dataset to identify hospitalizations aged >=18 years in Texas during April 1-December 31, for each year of 2016-2020 (to align each year with the date of introduction of COVID-19-specific ICD-10 code [U071] in the US). Sepsis was defined by "explicit" ICD-10 codes for severe sepsis (R65.20) and septic shock (R65.21). COVID-19 hospitalizations were excluded. Hierarchical models were fit to estimate the changes in shortterm mortality (defined as in-hospital death or discharge to hospice) of sepsis hospitalizations using 2 approaches: 1) using the 2016-2019 data to forecast risk-adjusted shortterm mortality in 2020 and then comparing the predicted and observed 2020 mortality 2) using the 2019-2020 data to estimate the change in short-term mortality in 2020. RESULT(S): There were 207,953 sepsis hospitalizations without a diagnosis of COVID-19 during the study period (45,826 in 2019 and 41,996 in 2020). Short-term mortality has decreased between 2016 and 2019 from 29.7% to 26.6% (adjusted odds ratio [aOR]/year 0.93 [95% CI 0.92-0.94]). The predicted and observed short-term mortality among sepsis hospitalizations in 2020 was 25.8% (95% CI 25.6-26.0) vs 30.8%, respectively (p < 0.0001). Following adjustment for confounders, the risk of short-term mortality among sepsis hospitalizations was higher in 2020 than in 2019 (aOR 1.30 [95% CI 1.25-1.35]). CONCLUSION(S): The COVID-19 pandemic was associated with reversal of the progressive pre-pandemic downtrend in case fatality of septic patients, with 30% higher odds of short-term mortality in 2020 compared to the preceding year among sepsis hospitalizations without COVID-19. Further studies are needed to determine the patient-, health system-, and policy-related contributors to these findings in order to inform potential scalable strategies to reduce pandemicrelated adverse impact on outcomes of septic patients without COVID-19.

11.
Critical Care Medicine ; 51(1 Supplement):555, 2023.
Article in English | EMBASE | ID: covidwho-2190673

ABSTRACT

INTRODUCTION: Patients infected with the SARS-CoV-2 virus (COVID-19) may develop acute respiratory distress syndrome, requiring mechanical ventilation. Reports suggest that these patients may have increased sedation requirements due to intensive mechanical ventilation needs, necessitating the evaluation of additional sedation, with limited guidance available. Due to multiple drug shortages, ketamine became an attractive adjunctive option to meet sedation goals. The primary objective of this study was to compare sedation and analgesic requirements in mechanically ventilated patients with COVID-19 who received continuous ketamine infusions with those who did not. METHOD(S): A multi-center, retrospective cohort study was performed in adult patients with COVID-19 who were mechanically ventilated for at least 24 hours. Groups were allocated based on whether or not adjunctive continuous infusion ketamine was used. The primary outcome was a comparison of the sedation and analgesic agents and the median morphine equivalents (ME) required. Secondary outcomes included intensive care unit (ICU) and hospital length of stay (LOS), duration of mechanical ventilation, and in-hospital mortality. RESULT(S): A total of 1,757 patients were screened for inclusion. After exclusions, 40 patients in each group were included for analysis. More patients in the ketamine group received intravenous opiates (100% vs 80%, p < 0.01) and also had higher ME than the non-ketamine group (357 [276-440] vs 222 [141-294] mg ME daily, p < 0.01). There was also a greater LOS in the ketamine group in both the hospital (24 vs 16.5 days, p=0.01) and ICU (18.8 [12.6- 27.9] vs 14.9 [7.1-18.7] days, p=0.04). The ketamine group also experienced longer intubation durations (14.5 [9.0-23.5] vs 8.0 [4.0-13.5] days, p=0.01). There were no significant differences in in-hospital mortality or average doses of propofol, midazolam, dexmedetomidine, or vasopressors between groups. CONCLUSION(S): Ketamine use was not associated with a decrease in opioid or sedation use in patients with COVID-19 who were mechanically ventilated. Additional studies are needed to assess the role of ketamine and its impact on sedation and analgesia requirements in COVID-19 positive patients.

12.
Critical Care Medicine ; 51(1 Supplement):535, 2023.
Article in English | EMBASE | ID: covidwho-2190657

ABSTRACT

INTRODUCTION: Acute kidney injury requiring renal replacement therapy (AKI-RRT) is associated with high mortality, especially in the setting of COVID-19. During the peak of the delta wave in New Mexico in late 2021, crisis standards of care were declared and strategies to ration care were explored. Our hypothesis is that a simplified SOFA score in patients with COVID-19 and AKI-RRT may predict short-term mortality. METHOD(S): We retrospectively analyzed all COVID-19 patients started on CRRT for AKI in the medical ICU at our center between April 2020 and July 2021. A 4-organ SOFA score (4OSS), with renal and neurologic sub-scores excluded, was calculated at the time of CRRT initiation. Neurologic sub-score was excluded because it is subjective, inconsistently documented, and confounded by the frequent use of sedation and paralysis in severe COVID-19. ECMO patients were included and assigned the maximum respiratory sub-score. Patients started on RRT at an outside hospital, found to be incidentally COVID-positive, or on chronic dialysis were excluded. P values were obtained using 1-sided Mann-Whitney U tests. RESULT(S): 63 total COVID-19 patients on CRRT were identified with 73% 30-day mortality and 83% in-hospital mortality. The median 4OSS was 8 in both in-hospital survivors and non-survivors with interquartile range [IQR] of 4-9 and 7-9.75, respectively (difference between groups non-significant, p = 0.075). The median 4OSS was 7 [5.5- 8.5] and 8 [7-10] in 30-day survivors and non-survivors, respectively (p = 0.018). Those with 4OSS of >=10 (n=13, 20.6%) had 100% in-hospital mortality. CONCLUSION(S): Similar to other analyses of SOFA score in COVID-19, 4OSS at CRRT initiation in patients with COVID-19 and AKI-RRT appears to have limited prognostic ability, with substantial overlap in scores between survivors and non-survivors. However, while additional multicenter studies are needed, 4OSS of >=10 may identify a group of about 20% of COVID-19 patients with AKI-RRT and mortality approaching 100%. Given the absence of a superior validated metric, a 4OSS of >=10 may be a reasonable tool for triage of CRRT in the setting of crisis standards of care and CRRT machine or supply shortages. At a minimum, 4OSS could inform goals of care discussions prior to CRRT initiation in patients with COVID-19 complicated by AKI-RRT.

13.
Critical Care Medicine ; 51(1 Supplement):496, 2023.
Article in English | EMBASE | ID: covidwho-2190652

ABSTRACT

INTRODUCTION: The medication regimen complexityintensive care unit (MRC-ICU) score was developed prior to the existence of COVID-19 and has demonstrated an association with increased mortality, ICU length of stay, fluid balance, drug interactions, and quantity and quality of pharmacist interventions. Previous reports have questioned the ability of traditional predictors of mortality in critically ill patients to predict death in patients with COVID-19. The purpose of this study was to assess if MRC-ICU could predict mortality patients with COVID-19. METHOD(S): A single-center, observational study was conducted from August 2020 to January 2021. The primary outcome of this study was the area under the receiver operating characteristic (AUROC) for mortality for the 48- hour MRC-ICU. Age, sequential organ failure assessment (SOFA), and World Health Organization (WHO) COVID-19 Severity Classification were also assessed. Logistic regression was also performed to predict mortality as well as WHO Severity Classification at 7 days. RESULT(S): A total of 149 patients were included. The median SOFA score was 8 (IQR 5 - 11) and median MRC-ICU score at 48 hours was 15 (IQR 7 - 21). The inhospital mortality rate was 36% (n = 54). The AUROC for MRC-ICU was 0.71 (95% Confidence Interval (CI), 0.62 - 0.78) compared to 0.66 for age, 0.81 SOFA, and 0.72 for the WHO Severity Classification. In univariate analysis, age, SOFA, MRC-ICU, and WHO Severity Classification all demonstrated significant association with mortality, while SOFA, MRC-ICU, and WHO Severity Classification demonstrated significant association with WHO Severity Classification at 7 days. A multiple logistic regression model for mortality was developed using these four predictors. CONCLUSION(S): In the first analysis of medication-related variables as a predictor of severity and mortality in COVID-19, MRC-ICU demonstrated acceptable predictive ability;however, SOFA was the strongest predictor in both AUROC and regression analysis.

14.
Critical Care Medicine ; 51(1 Supplement):208, 2023.
Article in English | EMBASE | ID: covidwho-2190542

ABSTRACT

INTRODUCTION: Tocilizumab is recognized as a safe and efficacious treatment option for critically ill patients with COVID-19. Controversy remains regarding appropriate criteria for use. This evaluation assessed tocilizumab use for COVID-19 treatment and clinical outcomes following implementation of an institutional guideline. METHOD(S): This was a 2-center (1 community;1 academic), retrospective review of adult patients admitted to the ICU that received tocilizumab for COVID-19. Baseline demographics, length of stay (LOS), mechanical ventilation (MV), morbidity, mortality, and drug cost were collected. C-reactive protein (CRP), ferritin, and lactate dehydrogenase (LDH) were reviewed and compared to institutional criteria for use. RESULT(S): Forty (26 community;14 academic) critically ill patient cases were reviewed. No differences were observed in baseline demographics, with a pool median age and weight of 58 (49-65) years and 102 (88-117) kg, respectively. No difference (community, 4 [15.4%] vs academic, 0 [0%];p=0.28) was seen in vaccination status. No differences were seen in time to tocilizumab administration, dose, hospital and ICU LOS, or progression to MV. Pooled median inflammatory markers included a CRP 131 (92-200) mg/L, ferritin 1074 (418-1936) ng/mL, and LDH 589 (414-803) IU/L with no differences between groups. Median ferritin values were noted as numerically higher, but non-significant in the community group (1331 [614-2306] ng/L vs 555 [341- 1851] ng/mL;p=0.16). Pooled all-cause in-hospital mortality was observed in 14 (35%) patients, with numerically higher, but non-significant rates in the community group (12 [46.2%] vs 2 [14.3%];p=0.08). Median charge per patient was $15,625.55. CONCLUSION(S): Critically ill patients receiving tocilizumab for COVID-19 treatment have high rates of mortality despite early use upon ICU admission. Baseline inflammatory markers were markedly above institutional criteria for use, leading to adjustments in the institutional guideline. Routine evaluation of tocilizumab use criteria may be warranted during strained supplies and COVID-19 surges.

15.
Critical Care Medicine ; 51(1 Supplement):191, 2023.
Article in English | EMBASE | ID: covidwho-2190534

ABSTRACT

INTRODUCTION: The dysregulated inflammatory response to SARS-CoV-2 plays a crucial role in the pathogenesis of Coronavirus Disease 2019 (COVID-19). The National Institutes of Health (NIH) guidelines recommend adding a second immunomodulatory agent, tocilizumab (TCZ) or baricitinib (BARI), to dexamethasone in patients with rapidly increasing oxygen requirements and systemic inflammation. As of July 2022, these guidelines do not recommend one agent over the other. This study aims to compare the progression rates to mechanical ventilation and in-hospital mortality for TCZ vs. BARI in patients with moderate to severe COVID-19. METHOD(S): This was a single-center, retrospective, cohort study of patients treated with TCZ or BARI for COVID-19 between August 24, 2021, and December 31, 2021. The primary endpoint was a composite outcome of progression to mechanical ventilation or in-hospital mortality. Secondary endpoints included components of the composite outcome, progression to a higher level of care, duration of mechanical ventilation, hospital length of stay (LOS), and intensive care unit (ICU) LOS. Safety endpoints included the incidence of infection and thrombosis. RESULT(S): One-hundred-seventy-six patients were included, of which 61 (34.7%) received TCZ and 115 (65.3%) received BARI. The primary outcome was not significant between groups (52.5% TCZ vs. 44.3% BARI, p=0.305). There were no statistically significant differences noted between TCZ and BARI in regards to progression to mechanical ventilation (36.1% vs 28.7%, p=0.315), inhospital mortality (50.8% vs 41.7%, p=0.249), progression to higher level of care (18% vs 17.4%, p=0.926), duration of mechanical ventilation (median 9 days vs 6 days, p=0.311), hospital LOS (median 8 days vs 14 days, p=0.193), or ICU LOS (median 7 days vs 8 days, p=0.964). For safety outcomes, there was no difference in the infection rate (36.1% vs. 26.1%, p=0.167), but the rate of thrombosis was higher in the TCZ group (11.5% vs. 3.5%, p=0.042). CONCLUSION(S): There was no significant difference in the composite outcome of progression to mechanical ventilation or in-hospital mortality in patients who received TCZ of BARI for the treatment of COVID-19. However, this primary outcome occurred more frequently in the TCZ group, and a larger study may be able to detect this difference.

16.
Critical Care Medicine ; 51(1 Supplement):174, 2023.
Article in English | EMBASE | ID: covidwho-2190518

ABSTRACT

INTRODUCTION: Corticosteroids have shown to decrease mortality and increase ventilator-free days in the treatment of COVID-19. The incidence of and risk factors for secondary infections (SI) associated with corticosteroid use in COVID-19 patients are not well defined. The purpose of this study was to assess the incidence and impact of dose and duration of corticosteroids on the rate of secondary infections (SI) in critically-ill COVID-19 patients. METHOD(S): This multi-center, single health-system, retrospective cohort study evaluated adults (>=18 years) admitted to an intensive care unit (ICU) who received corticosteroid(s) for the treatment of COVID-19 between March 2020 and August 2021. Patients were excluded for ICU stay < 24 hours or if the patient transferred from another hospital. The primary endpoint was rate of SI defined as a positive microbiological result after initial corticosteroid administration and at least 48 hours after admission. Secondary endpoints were compared in those who did and did not develop SI and included but not limited to: cumulative corticosteroid dose, duration of corticosteroid, receipt of recommended corticosteroid regimen(s), ICU length of stay (LOS), hospital LOS, in-hospital mortality, 90-day mortality, and ventilator-free days. Secondary outcomes were adjusted for pre-specified variables. RESULT(S): Of the 910 patients included in analyses, 300 patients (32%) experienced SI. Patients who developed SI had higher use of prolonged corticosteroid courses (79.3% vs 44.9%, p< 0.001) and higher cumulative steroid doses (238 vs 124 mg dexamethasone equivalents;aOR 1.008;95% CI, 1.006-1.009;p< 0.001) and longer median (IQR) corticosteroid duration 16 days (11-25) vs 11 days (9-17);aOR 1.12, 1.09-1.14;p< 0.001). The use of recommended corticosteroid regimen was lower in patients with SI 11.7% vs. 39.3% (p< 0.001). Patients with SI had more ventilator days, longer ICU and hospital LOS and increased in-hospital and 90-day mortality (p< 0.001). CONCLUSION(S): In patients who received corticosteroids for COVID-19, exceeding recommended dosing strategies by either prolonging treatment or receiving higher cumulative doses was associated with increased rates of SI. Patients with SI were more likely to experience increased ICU LOS, ventilator days and mortality.

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Critical Care Medicine ; 51(1 Supplement):102, 2023.
Article in English | EMBASE | ID: covidwho-2190491

ABSTRACT

INTRODUCTION: Rural residence has been associated with increased risk of COVID-19-related mortality. However, the population-level prognostic implications of rural residence among critically ill patients with COVID-19 are lacking, and the impact of inter-hospital transfer and hospitals' location on the outcomes of these patients is unknown. METHOD(S): We used a statewide dataset to identify ICU admissions aged >=18 years with a diagnosis of COVID-19 in Texas during April 1-December 31, 2020. COVID-19 was defined by ICD-10 code U07.1. We used dichotomized (rural vs urban) ZIP Code-level Rural-Urban Commuting Area categories, linked to hospitalization data, to identify rural residence. Hierarchical, mixed-effects models were fit to estimate the association of rural residence with shortterm mortality (defined as in-hospital death or discharge to hospice) for the whole cohort and among hospitalizations with and without transfer from another hospital. Similar modeling was used to examine the association of care in rural hospitals among rural residents without transfer to another facility with short-term mortality. RESULT(S): Among 58,485 ICU admissions with COVID-19, 9,495 (16.2%) were rural residents. Among rural residents, 8,607 (90.6%) were managed in non-rural hospitals, and 1,827 (19.2%) were transferred from another hospital. The unadjusted short-term mortality among rural and urban residents was 25.9% vs 23.9%, respectively. Following adjustment for confounders, rural residence was associated with higher short-term mortality for the whole cohort (adjusted odds ratio [aOR] 1.093 [95% CI 1.003-1.191]) and among those transferred from another hospital (aOR 1.349 [95% CI 1.106-1.646]), but not among those without inter-hospital transfer (aOR 1.052 [95% CI 0.955-1.159]). Management of critically ill rural residents with COVID-19 in rural hospitals, without inter-hospital transfers was not associated with shortterm mortality on adjusted analyses (aOR 0.672 [95% CI 0.393-1.149]). CONCLUSION(S): The observed increased short-term mortality among critically ill patients with COVID-19 residing in rural areas is confounded by inter-hospital transfers and the geographic location of hospitals, with no adverse prognostic impact of rural residence in non-transferred patients and those managed in rural facilities.

18.
Critical Care Medicine ; 51(1 Supplement):101, 2023.
Article in English | EMBASE | ID: covidwho-2190489

ABSTRACT

INTRODUCTION: The adverse impact of comorbid conditions on the development of severe illness and risk of death among hospitalized patients with COVID-19 has been well-documented. However, the population-level epidemiology and outcomes of previously healthy [PH] adults compared to those with prior comorbidities [PC] among COVID-19 patients requiring ICU admission are unknown. METHOD(S): We used a statewide dataset to identify hospitalizations aged >=18 years with ICU admission and a diagnosis of COVID-19 in Texas during April 1-December 31, 2020. COVID-19 was defined by ICD-10 code U07.1. PH was defined as absence of the comorbidities included in the Charlson Comorbidity Index, and of obesity, malnutrition, mental disorders, and substance and alcohol use disorders. A hierarchical, mixed-effects model was fit to estimate the association of PH with short-term mortality (defined as in-hospital death or discharge to hospice) among ICU admissions. A similar approach was used to identify predictors of short-term mortality among the PH group. RESULT(S): Among 58,845 ICU admissions with COVID-19, 6,760 (11.6%) were PH. Compared to those with PC, those with PH were younger (aged >=65 years 36.1% vs 49.4%), more commonly racial/ethnic minority (63.8% vs 61.5%), and with lower mean [SD] number of organ dysfunctions (1.2 [1.1] vs 1.8 [1.4]) [p< 0.001 for all comparisons]. Short-term mortality was lower among PH than among PC (16.4% vs 25.0%). However, following adjustment for confounders, the risk of short-term mortality was higher among PH (adjusted odds ratio [aOR] 1.37 [95% CI 1.25-1.51]). Among PH ICU admissions, short-term mortality increased with age ([aOR] 35.20 [95% CI 22.09-56.09];>=65 vs 18-44 years) and management at facilities with >=50 ICU beds ([aOR] 4.43 [95% CI 1.07-18.32] vs < 10 ICU beds). CONCLUSION(S): PH was uncommon among critically ill adults with COVID-19 and PH patients had substantially lower short-term mortality than those with PC. However, once risk-adjusted, the odds of short-term mortality were, unexpectedly, 37% higher among PH, with the latter facing higher risk of death when managed at hospitals with higher number of ICU beds. Additional studies are needed to identify the patient-, care process-, and health system-related contributors to these findings.

19.
Critical Care Medicine ; 51(1 Supplement):86, 2023.
Article in English | EMBASE | ID: covidwho-2190484

ABSTRACT

INTRODUCTION: COVID-19 can manifest in the lungs as acute respiratory distress syndrome leading to poor lung compliance and increasing susceptibility to barotrauma, which is hypothesized to cause an airleak resulting in pneumomediastinum (PM) and pneumothorax (PTX). Pneumopericardium (PP), a more rare complication, has been documented in relatively few cases to date. This study sought to review the relationship between positive pressure ventilation (PPV) and development of PP and to survey treatment options for COVID-19 patients with PP. METHOD(S): A systematic search was conducted on full text articles, including case reports and case series, for COVID-19 patients with comorbid PP from January 1st, 2019 to April 12th, 2022. Demographic data, presence of PM, PTX, PP and subcutaneous emphysema (SE), treatment information regarding respiratory support, use of steroids and other medications were recorded along with in-hospital mortality. RESULT(S): 51 articles met final inclusion criteria, reporting 76 cases of COVID-19 patients with PP. The average age was 54.5 years with a range of 17-82. Fifty-eight (76.3%) patients were male. 27 (35.5%) patients with PP died. PP occurred in isolation in 5 (6.6%) patients. PP was most comorbid with PM (n=65, 85.5%). SE occurred in 44 (57.9%) patients and PTX in 25 (32.9%) patients. 18 (23.7%) patients developed all of the sequalae of airleak. 64 (84.2%) patients received some degree of respiratory support: 35 (46.1%) patient's maximum support was supplemental oxygen, six (7.9%) were on non-invasive PPV, and 22 (28.9%) required mechanical ventilation. 29 (38.2%) patients with PP were given steroids. Only 1 patient received pericardiocentesis for presumed tamponade physiology. CONCLUSION(S): There was a high mortality in COVID-19 patients with PP. Previous reports hypothesized that PPV may be the etiology of PP in COVID-19 patients;however, only 36.8% of patients with PP in this review received PPV. It is unclear if the COVID-19 patients with PP not receiving PPV had tachypnea causing air trapping thus leading to self-induced barotrauma. Decompressive maneuvers have been studied in PTX and PM, however only one patient in this review received pericardiocentesis. Further research is needed to provide further etiology and treatment guidelines as this pandemic continues.

20.
Critical Care Medicine ; 51(1 Supplement):25, 2023.
Article in English | EMBASE | ID: covidwho-2190459

ABSTRACT

INTRODUCTION: Studies have shown early application of prone-positioning in ARDS significantly decreased mortality. Our goal is to evaluate the effect of early prone-positioning specifically on COVID ARDS patients. METHOD(S): We performed a multicenter, retrospective observational analysis with a total of 1,335 patients with COVID ARDS that underwent prone positioning. Data was obtained from all HCA facilities within the dates of 1/1/2020- 6/20/2021. ARDS was defined using the Berlin criteria. Logistic regression was used to predict the likelihood of in-hospital all-cause mortality early vs late prone-positioning. Secondary outcomes were the relationship between age of the patient, MAP, days on ventilator and ICU length of stay (ICULOS) likelihood of in-hospital mortality. RESULT(S): From 1/1/2020-6/20/2021, a total of 3,407 patients with COVID ARDS were admitted to the participating facilities. 1,335 patients were included in the final analysis. Patients were mostly between ages 51-80 years old (77%), male (61.5%), white (55.4%), all of them admitted to ICU on mechanical ventilation. In-hospital allcause mortality was significantly lower in the shorter time to prone group (< 16 hours) than the longer time to prone group (>16, >24 hours), (p < 0.001, Exp(B) = 1.119, 95% C.I. [1.088, 1.151]). Mortality rate < 16 hours (46.53%), >16 hours (55%) vs >24 hours (68.1%). Patients that were prone in < 16 hours were less likely to experience an in-hospital mortality than those prone >16 hours (X2 (1, N= 1513) = 19.051, p < 0.001). There was not any statistically significant difference between the 16- and 24-hours group. For each one-day increase in days on the ventilator the likelihood of mortality is 0.978 times as likely. (p < 0.01, Exp(B) = 0.978, 95% C.I. [0.968, 0.989]). Expired rate by time to prone < 16 hours (55.45%) vs >16 hours (79.69%). For each one-year increase in age, patients are 1.045 times as likely to experience an in-hospital mortality (p < 0.001, Exp(B) =1.045, 95% C.I. [1.033,1.056]). CONCLUSION(S): We concluded through logistic regression that the time to prone had a statistically significant relation to in-hospital all-cause mortality and patients with COVID ARDS can benefit from early prone treatment.

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