Patients with COVID-19 Pneumonia Admitted to an Intensive Care Unit (ICU) at a Community Hospital in Flint, Michigan, in Early 2020: Characteristics and Mortality.

INTRODUCTION: Despite the many studies conducted on the factors affecting mortality in patients with COVID-19, there is ongoing debate about the role of race as a risk factor. Several studies have reported a geographic and racial disparity in COVID-19 cases in Michigan. This study aimed to examine the characteristics of the 2020 first cohort of Intensive Care Unit (ICU) COVID-19 patients admitted to a community teaching hospital in Flint, Michigan, and to determine the factors associated with ICU mortality, including race. METHODS: This cross-sectional study included adult patients (≥ 18 years) with severe COVID-19 pneumonia admitted to the ICU between March and May 2020. Potential risk factors associated with ICU mortality included demographic characteristics, comorbidities, treatments, and complications. RESULTS: The study sample consisted of N = 48 patients, aged 24-85 years, (mean 59.7; SD = 12.8); 56.2% (n=27) were male and 51.1% (n=24) were Black adults. The mortality rate was 51.1%. Age (aOR 1.1, 95% CI [1.01, 1.20]; p =0.03), type 2 diabetes (aOR 5.7, 95% CI [1.2, 29.1]; p =0.03), and essential hypertension (aOR 6.2, 95% CI [1.1, 34.5]; p =0.04) were all found to have statistically significant independent associations with increased risk of ICU mortality in this study sample. On the other hand, race was not found to be associated with ICU mortality. CONCLUSIONS: These findings support the literature regarding the association of comorbid conditions, including type 2 diabetes and hypertension, with poorer outcomes in ICU hospitalized patients with severe COVID-19 pneumonia. This study provides insight into mortality of an ICU patient cohort earlier on during the COVID-19 pandemic in Flint, Michigan.

Coagulopathy and Acute Respiratory Distress Syndrome: Dual Complications of E-Cigarette-Associated Lung Injury.

E-cigarette-associated lung injury (EVALI) is related to the usage of e-cigarettes or a related product (e.g., "vaping" or "dabbing"). It presents mainly with constitutional, respiratory, or gastrointestinal symptoms, and EVALI is currently a diagnosis of exclusion. EVALI patients are more prone to rapid clinical decline requiring close monitoring, with some requiring intensive care unit (ICU) level of care or intubation. Mortality occurs in rare cases. We are presenting an interesting case of a male in his mid-60s who presented to the emergency department with worsening dyspnea and cough for two weeks, preceded by a one-week history of fever, nausea, and diarrhea. He was diagnosed with bilateral pneumonia based on computed tomography (CT) findings. Subsequent CT of the chest showed worsening bilateral diffuse ground-glass opacities (GGOs) correlating with acute respiratory distress syndrome (ARDS). Laboratory workup showed leukocytosis and lactic acidosis. The rest of the laboratory workup was normal. The patient was intubated due to ARDS, developed multiorgan failure, and passed away subsequently.

Use of glucocorticoids in patients with acute respiratory distress syndrome: a meta-analysis and trial sequential analysis.

BACKGROUND: Acute respiratory distress syndrome (ARDS) is a common and disabling disease with high rates of mortality and morbidity. The role of steroids in treating ARDS remains controversial. We aim to examine the evidence behind using glucocorticoids in the management of ARDS from the available studies. METHODS: We performed a literature review of major electronic databases for randomized controlled trials (RCTs) comparing glucocorticoids versus placebo in treating patients with ARDS. Our primary outcome was hospital mortality. Other outcomes included ICU mortality, number of ventilator-free days at day 28, incidence of nosocomial infections, and hyperglycemia. We performed a meta-analysis using a random effects model to calculate risk ratios (RR) and mean difference (MD) with their corresponding 95% confidence intervals (CI). A subsequent trial sequential analysis was performed to examine the strength of evidence and to guard against statistical type I and type II errors for our results. RESULTS: Eight RCTs were included in the final analysis totaling of 1091 patients, with a mean age of 57 ± 16, and 56.2% were male. In our pooled analysis, use of glucocorticoids was associated with a significant reduction in hospital mortality (RR 0.79; 95% CI 0.64-0.98; P = 0.03) and ICU mortality (RR 0.64; 95% CI 0.42-0.97; P = 0.04). Furthermore, glucocorticoid use was associated with an increased number of ventilator-free days at day 28 (MD 4.06 days; 95% CI 2.66-5.45; P < 0.01). Regarding adverse events, glucocorticoids use was not associated with an increased risk for nosocomial infections (RR 0.82; 95% CI 0.68-1.00; P = 0.05); however, it was associated with an increased risk of hyperglycemia (RR 1.11; 95% CI 1.01-1.24; P = 0.04). In our trial sequential analysis, the required diversity-adjusted information size (sample size = 2692 patients) was not reached, and the evidence was insufficient from the available RCTs. CONCLUSION: Among patients with ARDS, use of glucocorticoids is associated with a significant reduction in mortality and duration of mechanical ventilation, without increased risk of hospital-acquired infections. However, based on a trial sequential analysis, these findings may be secondary to a false-positive (type I) error. Further studies are needed for a firm conclusion with guarding against possible statistical errors.

Noninvasive Oxygenation Strategies in Immunocompromised Patients With Acute Hypoxemic Respiratory Failure: A Pairwise and Network Meta-Analysis of Randomized Controlled Trials.

INTRODUCTION: Acute hypoxemic respiratory failure (AHRF) is a leading cause of intensive care unit (ICU) admission among immunocompromised patients. Invasive mechanical ventilation is associated with increased morbidity and mortality. OBJECTIVE: To evaluate the efficacy of various oxygenation strategies including noninvasive ventilation (NIV), high-flow nasal cannula (HFNC), and conventional oxygen therapy in immunocompromised patients with AHRF. METHODS: Electronic databases including PubMed, Embase, and the Cochrane Library were reviewed from inception to December 2018. We included all randomized controlled trials (RCTs) comparing different modalities of initial oxygenation strategies in immunocompromised patients with AHRF. Our primary outcome was the need for intubation and invasive mechanical ventilation while secondary outcomes were ICU acquired infections and short- and long-term mortality. Data were extracted separately and independently by 2 reviewers. We performed a Bayesian network meta-analysis to calculate odds ratio (OR) and Bayesian 95% credible intervals (CrIs). RESULTS: Nine RCTs were included (1570 patients, mean age 61.1 ± 13.8 years with 64% male). Noninvasive ventilation was associated with a significantly reduced intubation rate compared with standard oxygen therapy (OR: 0.53; 95% CrI: 0.26-0.91). There were no significant reductions of intubation between NIV versus HFNC (OR: 0.83; 95% CrI: 0.35-2.11) or HFNC versus standard oxygen therapy (OR: 0.65; 95% CrI: 0.26-1.24). There were no significant differences between all groups regarding short-term (28-day or ICU) mortality or long-term (90-day or hospital) mortality or ICU-acquired infections (P > 0.05). CONCLUSION: Among immunocompromised patients with AHRF, NIV was associated with a significant reduction of intubation compared with standard oxygen therapy. There were no significant differences among all oxygenation strategies regarding mortality and ICU-acquired infections.

A 21-year-old woman with mediastinal mass and cardiac arrest.

Mediastinal mass syndrome (MMS) is a devastating respiratory and haemodynamic condition that might be encountered postintubation if special precautions are not carefully undertaken. We describe a case of MMS in a 21-year-old woman with a fatal outcome following emergency intubation for acute respiratory failure.

A young patient with massive haematemesis.

Aortoesophageal fistula (AEF) is a rare and life-threatening cause of gastrointestinal haemorrhage which requires emergency surgical intervention. We report a case of aortoesophageal fistula due to previous endovascular stent grafting to the ascending thoracic aorta after previous traumatic injury. The patient presented with catastrophic haematemesis which was managed by repeated deployment of endovascular stent graft and aortic bypass surgery; however, the patient ultimately died due to massive haemoptysis.

Critical care aspects of alcohol abuse.

The authors reviewed MEDLINE and references of major articles in the published literature over the last 30 years regarding the complications of alcohol abuse and discuss the critical care aspects of alcohol abuse. This article discusses the severe medical conditions associated with alcohol abuse that lead to admission to the medical intensive care unit. The clinical manifestations, pathophysiology, diagnostic studies, and management of these conditions are discussed in detail.