Influence of ICU Surge and Capacity on COVID Mortality Across U.S. States and Regions During the COVID-19 Pandemic.

BACKGROUND: To describe the influence of COVID-19 caseload surges and overall capacity in the intensive care unit (ICU) on mortality among US population and census divisions. METHODS: A retrospective analysis of the national COVID ActNow database between January 1, 2021 until March 1, 2022. The main outcome used was COVID-19 weekly mortality rates, which were calculated and incorporated into several generalized estimation of effects models with predictor variables that included ICU bed capacity, as well as ICU capacity used by COVID cases while adjusting for ratios of vaccinations in populations, case density, and percentage of the population over the age of 65. RESULTS: Each 1% increase in general ICU capacity is correlated with approximately 5 more weekly deaths from COVID-19 per 100,000 population and each percentage increase in the number of patients with COVID-19 admitted to the ICU resulted in approximately 10 more COVID-19 deaths per week per 100,000 population. Significant differences in ability to handle caseload surges were observed across US census divisions. CONCLUSIONS: A strong association was observed between COVID-19 ICU surges, overall ICU surge, and increased mortality. Further research is needed to reveal best practices and public health measures to prevent ICU overcrowding amidst future pandemics and disaster responses.

Complex Management of AV Nodal Agent Toxicity in Patients with Cardiac Devices: Massive Calcium Channel Antagonist Overdose in a Patient with a Permanent Pacemaker.

We present a unique case of a massive calcium channel antagonist overdose in a patient with a permanent pacemaker. Upon presentation after the acute overdose, the patient's cardiac device was found to be pacing to an adequate rate (75 beats per minute) and she was admitted to the cardiac intensive care unit. Approximately 24 hours after her ingestion, she acutely decompensated and became hypotensive. The patient was started on infusions of norepinephrine, epinephrine, phenylephrine, and vasopressin. Her mean arterial pressure was unresponsive to multi-vasopressor therapy. She was then given a bolus of methylene blue and high-dose insulin euglycemic therapy. Despite these treatments, the patient remained hypotensive Therefore, intralipid emulsion therapy and IV epinephrine pushes were also administered. As a result of her shock and hemodynamic instability, her course was further complicated by hypoxemic respiratory failure for which she required ventilatory support and developed oliguric renal failure for which she was initiated on continuous veno-venous hemofiltration. This case emphasizes the challenges in managing complex physiology associated with nodal agent toxicity and is the first, to our knowledge, to describe management in a patient who already had a pacemaker, though it was ultimately ineffective in avoiding the patient's profound decompensation.

A pilot study evaluating a simple cardiac dysfunction score to predict complications and survival among critically-ill patients with traumatic brain injury.

PURPOSE: To describe the frequency of cardiovascular complications and cardiac dysfunction in critically-ill patients with moderate-severe traumatic brain injury (msTBI) and cardiac factors associated with in-hospital survival. METHODS: Retrospective analysis of a prospective cohort study at a single Level-1 trauma center with a dedicated neuro-trauma intensive care unit (ICU). Adult patients admitted to the ICU with msTBI were consecutively enrolled in the prospective OPTIMISM study between November 2009 and January 2017. Cardiac dysfunction was measured using a combination of EKG parameters, echocardiography abnormalities, and peak serum troponin-I levels during the index hospitalization. These items were combined into a cardiac dysfunction index (CDI), ranging from 0 to 3 points and modeled in a Cox regression analysis. RESULTS: A total of 326 patients with msTBI were included. For every one-point increase in the CDI, the multivariable adjusted risk of dying during the patient's acute hospitalization more than doubled (adjusted HR 2.41; 95% CI 1.29-4.53). CONCLUSION: Cardiac dysfunction was common in patients with msTBI and independently associated with more severe brain injury and a reduction in hospital survival in this population. Further research is needed to validate the CDI and create more precise scoring tools.