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Objectives The purpose of this study was to develop a severity rating scale for lung ultrasound pathology in lower respiratory tract infection based on multicenter expert consensus, and to test inter-rater reliability. Methods Ten point-of-care ultrasound experts from three academic institutions developed the scale iteratively through literature review, expert opinion, and pilot testing. Clips were prospectively collected from adults suspected of COVID-19 using a 14-zone scanning protocol. Blinded reviewers independently rated four data subsets. The rating scale was refined through eight consensus-building discussions reviewing challenging cases from the first three subsets. The final scale consisted of a set of ordinal scores from 0 to 4, for five sonographic findings: B-lines, pleural line abnormalities, consolidations, pleural effusions, and overall lung aeration. Ratings from the fourth subset were analyzed to determine reliability based on intraclass correlation coefficient (ICC). A total of 11,126 cine clips from 220 patients were acquired. Discussion After excluding uninterpretable clips, the test dataset contained 81 clips and yielded an average ICC of 0.70 across the five sonographic findings (0.76 for B-lines, 0.52 for pleural line abnormalities, 0.71 for consolidations, 0.80 for pleural effusions, and 0.70 for overall lung aeration). Improvements in agreement were observed with each successive review session and dataset rating. Conclusion The lung ultrasound severity scale established by multicenter expert consensus achieved moderate to good inter-rater reliability. The scale could be used clinically to standardize assessment of lower respiratory tract infection and in future studies to develop methods for automated interpretation of lung ultrasound pathology.
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OBJECTIVE: Bleeding and thrombosis are common complications during Extracorporeal Membrane Oxygenation (ECMO) support for COVID-19 patients. We sought to examine the relationship between inflammatory status, coagulation effects, and observed bleeding and thrombosis in patients receiving venovenous (VV) ECMO for COVID-19 respiratory failure. STUDY DESIGN: Cross-sectional cohort study. SETTINGS: Quaternary care institution. PATIENTS: The study period from April 1, 2020, to January 1, 2021, we included all patients with confirmed COVID-19 who received VV ECMO support. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Thirty-two patients were supported with VV ECMO during the study period, and 17 patients (53%) survived to hospital discharge. The ECMO nonsurvivors mean lactate dehydrogenase (LDH) levels were markedly elevated in comparison to survivors (1046 u/L [IQR = 509, 1305] vs 489 u/L [385 658], p = 0.003). Platelet/fibrinogen dysfunction, as reflected by the low Maximum Amplitude (MA) on viscoelastic testing, was worse in nonsurvivors (65.25 mm [60.68, 67.67] vs 74.80 mm [73.10, 78.40], p = 0.01). Time-group interaction for the first seven days of ECMO support, showed significantly lower platelet count in the nonsurvivors (140 k/ul [103, 170] vs 189.5 k/ul [ 146, 315], p < 0.001) and higher D-dimer in (21 µg/mL [13, 21] vs 14 µg/mL [3, 21], p < 0.001) in comparison to the survivors. Finally, we found profound statistically significant correlations between the clinical markers of inflammation and markers of coagulation in the nonsurvivors group. The ECMO nonsurvivors experienced higher rate of bleeding (73.3% vs 35.3%, p = 0.03), digital ischemia (46.7% vs 11.8%, p = 0.02), acute renal failure (60% vs 11.8%, p = 0.01) and bloodstream infection (60% vs 23.5%, p = 0.03). CONCLUSION: The correlation between inflammation and coagulation in the nonsurvivors supported with VV ECMO could indicate dysregulated inflammatory response and worse clinical outcomes.
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Introduction The emergence of SARS-CoV-2 and the subsequent COVID-19 pandemic has been a significant disruptor to traditional medical care. Burn patients are an interesting population in which to evaluate this disruption due to the complicated, multidisciplinary nature of injury management. Understanding the current landscape of burn care during the pandemic is a crucial first step in preparing for future pandemic impacts. The purpose of this study was to identify the current status of burn treatment during COVID by evaluating existing literature surrounding burns and COVID. Methods A literature review of articles published between March 2020 and August 2021 was conducted to determine trends in studies evaluating burn patients and burn center operation during this time frame. All ABA s published in 2020 containing the key words “burn,” “COVID,” and/or “coronavirus” were reviewed. Additionally, a Pubmed search was conducted using the same keywords. Each and article was sorted into one of four themes: Census/Etiology, Burn patients with COVID, Safe Practices/Protocols, and Telemedicine. Results A total of 23 ABA s and 126 articles were collected in the initial search. 63 articles were ultimately excluded because they did not report on burn patients. By theme, the following trends were seen: 1. Census/Etiology: Data on demographics of burn patients during this period was varied. Admissions for adult and/or pediatric burns increased for multiple burn centers, while others reported decreases. Consistently, the most common etiology of burn injury was scald, and an increased proportion of injuries were found to occur at home. Changes in the rates of first, second, and third-degree burns were also observed. 2. Burn patients with COVID: Overall, numerous reports indicated decreases in patient length of stay. However, several groups found no differences in length of stay, surgery rate, and length of follow-up. 3. Safe Practices: A recurring trend was observed of numerous burn centers having to implement increased safety protocols due to COVID-19. Select burn centers updated prevention guidelines for burn surgeons and patient care. 4. Telemedicine: The implementation of telemedicine helped minimize risk and maximize resources, However, much remains to be standardized, including the quality of images used. Conclusions This analysis of the current literature identified several overarching themes in the care of burn patients. Continued evaluation can identify innovations from the past year that should become best practices, as well as optimize preparation efforts for future disruptions in care.
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Introduction The emergence of SARS-COV-2 and the COVID-19 pandemic has complicated the presentation, treatment, and prognosis of all types of patients. Further characterization and analysis of how concomitant COVID-19 infection impacts different patient populations is important for improving treatment strategies. Patients with burn injures often require ICU-level care, mechanical ventilation, and extensive surgical intervention. Concomitant COVID-19 infection in this population presents a new challenge to clinical teams. The purpose of this project is to compare COVID-19 positive burn patients treated at a regional burn center with those that are not. Methods Following IRB approval, our institution’s burn registry was queried from March 2020-June 2021. Data on demographics, injury circumstances, COVID-19 status, and outcomes were collected. Continuous variables were nonparametric and\compared using Mann-Whitney U test. Categorical variables were compared using Chi-squared with Fischer’s Exact test, where appropriate. Results Of the 622 patients admitted at our institution, 19 tested positive for COVID-19 during their hospitalization. Demographic and injury information is reported in Table 1. There were statistically significant differences between the COVID-19 positive and negative groups in regard to race and presence of inhalation injury (p=0.0002, p=0.0002). The TBSA burned was slightly higher in the COVID-19 positive group (9.1 vs 6.7%). COVID-19 positive patients spent more time ventilated (48±32.5 vs.12.2 ± 16.2 days, p=0.0035**) and had both longer ICU (42.71±37.41 vs 11.1±15.4 days, p=0.0175*) and hospital (26.32±32.14 vs 8.177±11.95 days, p< 0.0001***) lengths of stay (LOS). No COVID-19 positive patients died while 5% of the COVID-19 negative patients did. All outcomes were statistically significant. Conclusions Despite similar TBSA injury burden and age breakdown, patients at our institution who tested positive for COVID-19 required more time on the ventilator and were hospitalized longer. People of color had a higher percentage of positive tests than their Caucasian counterparts. While mortality rates were higher in the COVID-19 negative cohort, morbidities associated with longer LOS must be considered.
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Introduction The effects of the ongoing COVID19 pandemic are wide-reaching and still emerging. Fear of the virus, public health messaging, and government-instituted lockdowns have altered how Americans live, work, and use the healthcare system. There is minimal data that assesses how the COVID-19 pandemic and associated stay at home orders have influenced the etiology of burn injuries. With the majority of burns occurring in the home, it is possible lock down orders have significantly impacted etiology of major burn injuries. This project aims to characterize the demographics and injury characteristics of burn patients seen at a regional burn center during the COVID-19 pandemic. Methods Following IRB approval, our institution queried it’s burn registry from March 2020-June 2021. Data on demographics, injury circumstance and details, interventions, COVID-19 status, and outcomes were collected. Descriptive statistics were obtained for the population. Results There were 622 inpatient admissions during the study timeframe. Patients were primarily Black (44.4%) or Caucasian (32.6%) males (65.6%) identifying as Non-Hispanic (81.8%). The mean age was 46.73±18.6 years. Mean total TBSA burned was 6.7±10.7%, 2nd and 3rd degree percentages were 2.11±4.64 and 0.62±5.2 respectively with 47 total inhalation injuries. Top burn etiologies were 244 (39.2%) scald and 175 (28.1%) flame with 249 (40%) coded etiology associated with food prep or consumption. The majority of the burns occurred at home (93%). Time from injury to admission was 616.98±2199.42 minutes and time to first excision from admission was 4314.3 ± 5657.3 minutes. ICU and hospital length of stay were 12.7±18.3 and 8.73±13.3 days. In-hospital mortality was 31 (5%). Nineteen patients tested positive for COVID-19 during this time. Conclusions Nearly half of all burn center admissions were for cooking related etiologies during this time. Time to admission was over 10 hours in a population dense area. More information of site specific pre-pandemic etiology and treatment data are needed to fully understand these initial findings. Further sub-analyses may also elucidate the influence of pandemic related behavioral changes as public health mandates evolved over time.
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Wound infections and sepsis are significant causes of morbidity after burn injury and can be alleviated by early excision and grafting. In situations that preclude early surgery, topical agents allow for a safer delay. Cerium nitrate compounded with silver sulfadiazine (Ce-SSD) is a burn cream that provides broad antibacterial activity, forms a temporary barrier, and promotes re-epithelialization. Methemoglobinemia is a rare, but oft-cited, systemic complication of Ce-SSD. In this retrospective review, 157 patients treated with Ce-SSD between July 2014 and July 2018 were identified, and the monitoring protocol for methemoglobinemia during Ce-SSD treatment was evaluated. The median age was 59 years (interquartile range [IQR], 47-70.5 years), with TBSA of 8.5% (IQR, 3-27), adjusted Baux score of 76 (IQR, 59-94), and inhalation injury present in 9.9% of patients. Primary endpoints included incidence of symptomatic and asymptomatic methemoglobinemia. Of the 9.6% (n = 15) of patients with methemoglobinemia, 73.3% (n = 11) had maximum methemoglobin levels ≥72 hours from the time of the first application. One patient developed clinically significant methemoglobinemia. Patients with TBSA ≥20% were more likely to develop methemoglobinemia (odds ratio 9.318, 95% confidence interval 2.078-65.73, P = .0078); however, neither Ce-SSD doses nor days of exposure were significant predictors. Ce-SSD application to temporize burn wounds until excision and grafting is safe, effective, and, in asymptomatic patients with TBSA <20%, can be used without serial blood gas monitoring. Vigilant monitoring for symptoms should be performed in patients with TBSA ≥20%, but routine blood gases are not necessary.