Pub Date : 2021-05-01DOI: 10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2539
S. Jesudasen, D. Okin, G. A. Alba, A. Gavralidis, N. Dandawate, L. L. Chang, E. Moin, A. Witkin, K. Hibbert, A. Kadar, P. Gordan, L. Bebell, P. Lai
Rationale: Early in the coronavirus disease 2019 (COVID-19) pandemic there was significant practice variation among hospitals regarding the choice and timing of treatments for acute respiratory failure. It is unknown whether this practice variation contributed to outcome differences. Methods: We performed a retrospective study of all adult patients with respiratory failure due to COVID-19 admitted between March 11 and May 31, 2020 to a medical or surgical ICU at three Massachusetts hospitals. Medical charts were manually reviewed by physicians and abstracted into a standardized REDCap database. Chi-square test for categorical variables and Kruskal-Wallis test for continuous variables were performed using R version 4.0.2. Results: Data from 429 patients were analyzed. Among the three institutions, there were significant differences in race, prevalence of hypertension and diabetes mellitus, duration of COVID-19 symptoms on presentation, and days between admission and intubation. Significant differences were observed in presentation acuity by sequential organ failure assessment (SOFA) score but not simplified acute physiology score (SAPS) or PaO2:FiO2 ratios. Hospital A intubated more patients on the day of admission and utilized more inhaled nitric oxide and less immunosuppression (steroids, anti-IL6 agents). Hospital B treated more patients with remdesivir, other experimental antivirals, and early paralysis (within 48 hours of intubation) but less awake prone positioning. Hospital C utilized more non-invasive positive pressure ventilation (NIPPV) and high flow oxygen in lieu of intubation;it also administered more statins and steroids for acute respiratory distress syndrome (ARDS) and used less early proning within 48 hours of intubation. No difference in hydroxychloroquine use was seen across institutions. There were no statistical differences across hospitals in reintubation, ventilator-free days at 28 days, or in-hospital mortality. Transition to comfort measures was more common at hospital C. There was a trend at hospital A toward lower 30-day (A=25.3%, B=32.1%, C=39.4%;p=0.054) and 90-day (A=28.5%, B=36.1%, C=41.4%;p=0.085) mortality. At hospital A there was significantly longer hospital length-of-stay (A=25.0, B=19.0, C=15.0;p=0.004) and ICU length-of-stay (A=18.0, B=15.0, C=12.0;p=0.001). Conclusions: Early in the COVID-19 pandemic in Massachusetts, there were significant differences in patient characteristics and treatments administered across three institutions. One institution demonstrated a trend toward lower 30-day and 90-day mortality despite later presentation from symptom onset, higher admission acuity, and less utilization of remdesivir or steroids. Practice variation across institutions may explain differences in outcomes, independent of baseline characteristics, and should be studied further as it may inform future management of COVID-19.
{"title":"Variations in Presentation and Management of Critically Ill Coronavirus Disease 2019 Patients: A Multi-Center Descriptive Analysis","authors":"S. Jesudasen, D. Okin, G. A. Alba, A. Gavralidis, N. Dandawate, L. L. Chang, E. Moin, A. Witkin, K. Hibbert, A. Kadar, P. Gordan, L. Bebell, P. Lai","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2539","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2539","url":null,"abstract":"Rationale: Early in the coronavirus disease 2019 (COVID-19) pandemic there was significant practice variation among hospitals regarding the choice and timing of treatments for acute respiratory failure. It is unknown whether this practice variation contributed to outcome differences. Methods: We performed a retrospective study of all adult patients with respiratory failure due to COVID-19 admitted between March 11 and May 31, 2020 to a medical or surgical ICU at three Massachusetts hospitals. Medical charts were manually reviewed by physicians and abstracted into a standardized REDCap database. Chi-square test for categorical variables and Kruskal-Wallis test for continuous variables were performed using R version 4.0.2. Results: Data from 429 patients were analyzed. Among the three institutions, there were significant differences in race, prevalence of hypertension and diabetes mellitus, duration of COVID-19 symptoms on presentation, and days between admission and intubation. Significant differences were observed in presentation acuity by sequential organ failure assessment (SOFA) score but not simplified acute physiology score (SAPS) or PaO2:FiO2 ratios. Hospital A intubated more patients on the day of admission and utilized more inhaled nitric oxide and less immunosuppression (steroids, anti-IL6 agents). Hospital B treated more patients with remdesivir, other experimental antivirals, and early paralysis (within 48 hours of intubation) but less awake prone positioning. Hospital C utilized more non-invasive positive pressure ventilation (NIPPV) and high flow oxygen in lieu of intubation;it also administered more statins and steroids for acute respiratory distress syndrome (ARDS) and used less early proning within 48 hours of intubation. No difference in hydroxychloroquine use was seen across institutions. There were no statistical differences across hospitals in reintubation, ventilator-free days at 28 days, or in-hospital mortality. Transition to comfort measures was more common at hospital C. There was a trend at hospital A toward lower 30-day (A=25.3%, B=32.1%, C=39.4%;p=0.054) and 90-day (A=28.5%, B=36.1%, C=41.4%;p=0.085) mortality. At hospital A there was significantly longer hospital length-of-stay (A=25.0, B=19.0, C=15.0;p=0.004) and ICU length-of-stay (A=18.0, B=15.0, C=12.0;p=0.001). Conclusions: Early in the COVID-19 pandemic in Massachusetts, there were significant differences in patient characteristics and treatments administered across three institutions. One institution demonstrated a trend toward lower 30-day and 90-day mortality despite later presentation from symptom onset, higher admission acuity, and less utilization of remdesivir or steroids. Practice variation across institutions may explain differences in outcomes, independent of baseline characteristics, and should be studied further as it may inform future management of COVID-19.","PeriodicalId":111156,"journal":{"name":"TP49. TP049 COVID: ARDS AND ICU MANAGEMENT","volume":"18 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"127916842","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-05-01DOI: 10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2560
M. Chaturvedi, S. N. Mahmood, A. Kohli, E. Oweis, C. Woods, A. Shorr
Rationale: Acute Kidney Injury (AKI) is common in critically ill patients. Patients in the intensive care unit (ICU) who develop AKI and multi organ failure face a high mortality rate and in those progressing to renal replacement therapy (RRT) mortality rates may exceed 50%. Coronavirus disease 2019 (COVID-19) is a global pandemic caused by severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV-2). Severe COVID-19 often results in multi system involvement and may particularly affect the kidneys. The incidence of AKI in this setting is unclear and has varied widely in reports based on population evaluated. There is limited data on the incidence and outcomes of severe AKI necessitating RRT in COVID-19 patients who progress to respiratory failure requiring mechanical ventilation (MV). We conducted a retrospective study in order to determine the incidence and outcomes associated with need for RRT in patients with COVID-19 that progressed to need MV. Methods: We reviewed the records of all COVID-19 patients who were intubated for respiratory failure in our hospital between March and May 2020. Our primary endpoint was the incidence of RRT while outcomes in these subjects (e.g. hospital mortality, length of stay and recovery of renal function) served as secondary endpoints. We examined the relationship between our endpoints and baseline demographics, pre-existing co-morbidities, severity of illness identified by vasopressor requirement, PaO2/FiO2 ratio, plateau pressure, fluid balance in the first three days, and treatment with full strength anticoagulation and/or tocilizumab. Results: Our final cohort consisted of 135 patients of which 46 (34.0%) required RRT. Patients who required RRT had similar baseline characteristics to those who did not. Patients treated with RRT had a higher fluid balance in the first 72 hours (+4761 vs +3076, p=0.040). The mortality rate was higher in those requiring RRT (69.6% vs 39.3%, p=0.001), while the median ICU and hospital stay was lower in this subgroup. Amongst hospital survivors evaluated by the end of our study, 43.0% continued to require RRT, 7.0% no longer required RRT but still had some degree of renal dysfunction, and 50.0% had complete recovery of renal function. Conclusion: There is high incidence of AKI in patients with COVID-19 who require MV and one third of these patients develop renal failure requiring RRT. The mortality in these patients is high and exceeds that reported in patients with Acute Respiratory Distress Syndrome from other causes who need RRT. Complete renal function recovery often occurs in survivors.
{"title":"The Incidence and Outcomes of Renal Replacement Therapy in Patients with Severe COVID-19 Infection Requiring Mechanical Ventilation","authors":"M. Chaturvedi, S. N. Mahmood, A. Kohli, E. Oweis, C. Woods, A. Shorr","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2560","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2560","url":null,"abstract":"Rationale: Acute Kidney Injury (AKI) is common in critically ill patients. Patients in the intensive care unit (ICU) who develop AKI and multi organ failure face a high mortality rate and in those progressing to renal replacement therapy (RRT) mortality rates may exceed 50%. Coronavirus disease 2019 (COVID-19) is a global pandemic caused by severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV-2). Severe COVID-19 often results in multi system involvement and may particularly affect the kidneys. The incidence of AKI in this setting is unclear and has varied widely in reports based on population evaluated. There is limited data on the incidence and outcomes of severe AKI necessitating RRT in COVID-19 patients who progress to respiratory failure requiring mechanical ventilation (MV). We conducted a retrospective study in order to determine the incidence and outcomes associated with need for RRT in patients with COVID-19 that progressed to need MV. Methods: We reviewed the records of all COVID-19 patients who were intubated for respiratory failure in our hospital between March and May 2020. Our primary endpoint was the incidence of RRT while outcomes in these subjects (e.g. hospital mortality, length of stay and recovery of renal function) served as secondary endpoints. We examined the relationship between our endpoints and baseline demographics, pre-existing co-morbidities, severity of illness identified by vasopressor requirement, PaO2/FiO2 ratio, plateau pressure, fluid balance in the first three days, and treatment with full strength anticoagulation and/or tocilizumab. Results: Our final cohort consisted of 135 patients of which 46 (34.0%) required RRT. Patients who required RRT had similar baseline characteristics to those who did not. Patients treated with RRT had a higher fluid balance in the first 72 hours (+4761 vs +3076, p=0.040). The mortality rate was higher in those requiring RRT (69.6% vs 39.3%, p=0.001), while the median ICU and hospital stay was lower in this subgroup. Amongst hospital survivors evaluated by the end of our study, 43.0% continued to require RRT, 7.0% no longer required RRT but still had some degree of renal dysfunction, and 50.0% had complete recovery of renal function. Conclusion: There is high incidence of AKI in patients with COVID-19 who require MV and one third of these patients develop renal failure requiring RRT. The mortality in these patients is high and exceeds that reported in patients with Acute Respiratory Distress Syndrome from other causes who need RRT. Complete renal function recovery often occurs in survivors.","PeriodicalId":111156,"journal":{"name":"TP49. TP049 COVID: ARDS AND ICU MANAGEMENT","volume":"344 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"134207925","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-05-01DOI: 10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2531
B. Nezami, H. Tran, K. Zamora, P. Lowery, S. Kantrow, M. Lammi, B. deBoisblanc
Rationale: Acute respiratory failure (ARF) in COVID-19 (C19) is associated with high morbidity and mortality. To date, physiologic descriptions have largely focused on gas exchange and respiratory system compliance, however our anecdotal observations suggested that increased airways resistance also commonly contributed to ARF in C19. Normal inspiratory airways resistance (iRaw) has been reported to be 1 cm H2O/L/sec, while unselected patients with ARDS have been reported to have values closer to 5 cm H2O/L/sec (https://doi.org/10.1164/ajrccm/139.5.1169). Methods: We measured iRaw in a prospective convenience sample of 55 mechanically ventilated patients with C19 in 3 adult ICUs between March and September 2020. There were no exclusion criteria. We collected baseline demographics, date of first positive C19 test, days from intubation until the first captured waveform (see below), gas exchange parameters, inflammatory biomarkers, and 90-day mortality. All C19 medical care including sedation and neuromuscular blockade was determined by the primary team. During measurements of ventilatory mechanics, patients were placed on volume control ventilation 6 ml/kg/PBW, square flow at 60 L/min, and an end-inspiratory hold time of 0.3 seconds. Screen shots of flow-time and pressure-time scalars were captured for later review. iRaw was calculated as peak airway pressure-plateau airway pressure/flow. Results: Patient characteristics are shown in the table. The median iRaw was 12 cm H2O/L/sec (IQR 10-16). iRaw was not significantly different among patients with asthma or COPD compared to those without a history of obstructive airways disease (median 12.5 vs 12 cm H2O/L/sec, respectively, p=0.66). Survival to 90 days among patients with iRaw above 12 cm H2O/L/sec was 68% compared to 60% for patients below 12 cm H2O/L/sec (p=0.58). iRaw did not correlate with CRP, ferritin, PaO2/FiO2 ratio, or static compliance (Cstat). Conclusion: Waveform analysis using a convenience sample of mechanically ventilated patients with ARF due to C19 showed a significant increase in iRaw compared to prior studies done on unselected ARDS patients without C19. Increased iRaw was independent of a history of obstructive airways disease and did not correlate with biomarkers of disease severity nor did it predict mortality. Additional studies will be needed to determine if increased iRaw prolongs the duration of mechanical ventilation in C19.
理由:COVID-19患者急性呼吸衰竭(ARF)与高发病率和死亡率相关。迄今为止，生理学描述主要集中在气体交换和呼吸系统顺应性上，然而我们的轶事观察表明，气道阻力增加也通常导致C19的ARF。据报道，正常吸气气道阻力(iRaw)为1 cm H2O/L/sec，而未入选的ARDS患者的数值接近5 cm H2O/L/sec (https://doi.org/10.1164/ajrccm/139.5.1169)。方法:我们在2020年3月至9月期间对3个成人icu中55名C19机械通气患者的前瞻性方便样本进行了iRaw测量。没有排除标准。我们收集了基线人口统计数据、首次C19检测阳性的日期、从插管到首次捕获波形的天数(见下)、气体交换参数、炎症生物标志物和90天死亡率。所有C19的医疗护理包括镇静和神经肌肉阻断均由初级团队确定。在通气力学测量中，患者被置于容量控制通气6 ml/kg/PBW，方流量为60 L/min，吸气末保持时间为0.3秒。捕获了流量时间和压力时间标量的屏幕截图，以便稍后查看。iRaw计算为气道峰值压力-平台气道压力/流量。结果:患者特征见表。平均iRaw为12 cm H2O/L/sec (IQR 10-16)。与没有阻塞性气道疾病史的患者相比，哮喘或COPD患者的iRaw无显著差异(中位数分别为12.5 vs 12 cm H2O/L/sec, p=0.66)。iRaw高于12 cm H2O/L/sec的患者90天生存率为68%，低于12 cm H2O/L/sec的患者为60% (p=0.58)。iRaw与CRP、铁蛋白、PaO2/FiO2比值或静态顺应性(Cstat)无关。结论:与之前对未选择的无C19的ARDS患者进行的研究相比，使用方便样本进行机械通气的C19所致ARF患者的波形分析显示，iRaw显著增加。iRaw升高与阻塞性气道疾病史无关，与疾病严重程度的生物标志物无关，也不能预测死亡率。需要进一步的研究来确定iRaw的增加是否会延长C19患者的机械通气时间。
{"title":"Inspiratory Airways Resistance in Respiratory Failure Due to COVID-19","authors":"B. Nezami, H. Tran, K. Zamora, P. Lowery, S. Kantrow, M. Lammi, B. deBoisblanc","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2531","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2531","url":null,"abstract":"Rationale: Acute respiratory failure (ARF) in COVID-19 (C19) is associated with high morbidity and mortality. To date, physiologic descriptions have largely focused on gas exchange and respiratory system compliance, however our anecdotal observations suggested that increased airways resistance also commonly contributed to ARF in C19. Normal inspiratory airways resistance (iRaw) has been reported to be 1 cm H2O/L/sec, while unselected patients with ARDS have been reported to have values closer to 5 cm H2O/L/sec (https://doi.org/10.1164/ajrccm/139.5.1169). Methods: We measured iRaw in a prospective convenience sample of 55 mechanically ventilated patients with C19 in 3 adult ICUs between March and September 2020. There were no exclusion criteria. We collected baseline demographics, date of first positive C19 test, days from intubation until the first captured waveform (see below), gas exchange parameters, inflammatory biomarkers, and 90-day mortality. All C19 medical care including sedation and neuromuscular blockade was determined by the primary team. During measurements of ventilatory mechanics, patients were placed on volume control ventilation 6 ml/kg/PBW, square flow at 60 L/min, and an end-inspiratory hold time of 0.3 seconds. Screen shots of flow-time and pressure-time scalars were captured for later review. iRaw was calculated as peak airway pressure-plateau airway pressure/flow. Results: Patient characteristics are shown in the table. The median iRaw was 12 cm H2O/L/sec (IQR 10-16). iRaw was not significantly different among patients with asthma or COPD compared to those without a history of obstructive airways disease (median 12.5 vs 12 cm H2O/L/sec, respectively, p=0.66). Survival to 90 days among patients with iRaw above 12 cm H2O/L/sec was 68% compared to 60% for patients below 12 cm H2O/L/sec (p=0.58). iRaw did not correlate with CRP, ferritin, PaO2/FiO2 ratio, or static compliance (Cstat). Conclusion: Waveform analysis using a convenience sample of mechanically ventilated patients with ARF due to C19 showed a significant increase in iRaw compared to prior studies done on unselected ARDS patients without C19. Increased iRaw was independent of a history of obstructive airways disease and did not correlate with biomarkers of disease severity nor did it predict mortality. Additional studies will be needed to determine if increased iRaw prolongs the duration of mechanical ventilation in C19.","PeriodicalId":111156,"journal":{"name":"TP49. TP049 COVID: ARDS AND ICU MANAGEMENT","volume":"24 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"134256035","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-05-01DOI: 10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2559
J. Chicoine, M. González, A. Meyers, J. A. Cárdenas, D. Mor, G. Russo, E. Yates, A. Duvvi, K. Ceilim, G. Pashmforoosh, H. Kalantari, J. Singh, N. Dua, A. Frosso, R. Jaiswal, E. Saadeh, G. Hassen
RATIONAL: Coronaviruses are RNA viruses that primarily affect the respiratory system. Patients with Coronavirus Disease-19 (COVID-19) pneumonia and respiratory distress often require hospitalization, ICU admission, intubation and/or non-invasive ventilation, and circulatory support. Some experts suggest that the pathophysiology of traditional ARDS and that of the lung disease associated with COVID-19 are different. It is proposed that the severe hypoxemia in COVID-19 patients is the result of hypoxia-induced vasoconstriction and a large burden of microthrombi which result in intrapulmonary shunting. Therefore, COVID-related ARDS-like patterns of disease may not respond to World Health Organization (WHO) recommendations for early intubation and ARDS Network (ARDSNet) recommendations for FiO2-titrated Positive End-Expiratory Pressure (PEEP) administration and ventilator support. Given the distinct pathophysiology of COVID-19-related ARDS, higher PEEP may indicate mechanical over-inflation of the alveoli resulting in volume trauma in addition to compromising preload and decreasing cardiac output, worsening the pulmonary hypoperfusion. The aim of this study was to examine the rate of death associated with initial and subsequent (48-hour) PEEP settings of 10cmH2O and higher in COVID-19 patients. We hypothesized that higher PEEP settings may lead to increased mortality. METHODS: We conducted a retrospective chart review of patients who presented or were transferred to our facility with COVID-19 and were subsequently intubated from March 1st until April 30th, 2020. Charts were reviewed for initial and 48-hour PEEP settings. Mortality, SARS CoV2 results, clinical data and demographics were also recorded. RESULTS: A total of 74 patients were included in the review. Of these, 53 patients had initial PEEP setting of >10cmH2O and 46 patients had PEEP settings >10cmH2O 48 hours after intubation. Thirty-seven patients had PEEP settings >10cmH2O both initially and 48 hours later. Thirty-seven patients who had an initial PEEP setting of >10 cmH220 died, (70%). Forty patients who had PEEP settings >10cmH2O at 48hrs died (87%). Twenty-seven patients who had both a PEEP setting >10 cmH2O initially and at 48 hours died (73%). CONCLUSIONS: There appears to be an association in COVID-19 patients between high mortality rates and high PEEP settings. The marked association is strong enough, in our view, to suggest that conventional ventilator settings recommended by ARDSNet may not apply to patients experiencing COVID-19-associated ARDS and in fact, may be leading to worse patient outcomes.
{"title":"COVID-19 Ventilator Management Strategies: What We Have Learned and Future Management Options?","authors":"J. Chicoine, M. González, A. Meyers, J. A. Cárdenas, D. Mor, G. Russo, E. Yates, A. Duvvi, K. Ceilim, G. Pashmforoosh, H. Kalantari, J. Singh, N. Dua, A. Frosso, R. Jaiswal, E. Saadeh, G. Hassen","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2559","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2559","url":null,"abstract":"RATIONAL: Coronaviruses are RNA viruses that primarily affect the respiratory system. Patients with Coronavirus Disease-19 (COVID-19) pneumonia and respiratory distress often require hospitalization, ICU admission, intubation and/or non-invasive ventilation, and circulatory support. Some experts suggest that the pathophysiology of traditional ARDS and that of the lung disease associated with COVID-19 are different. It is proposed that the severe hypoxemia in COVID-19 patients is the result of hypoxia-induced vasoconstriction and a large burden of microthrombi which result in intrapulmonary shunting. Therefore, COVID-related ARDS-like patterns of disease may not respond to World Health Organization (WHO) recommendations for early intubation and ARDS Network (ARDSNet) recommendations for FiO2-titrated Positive End-Expiratory Pressure (PEEP) administration and ventilator support. Given the distinct pathophysiology of COVID-19-related ARDS, higher PEEP may indicate mechanical over-inflation of the alveoli resulting in volume trauma in addition to compromising preload and decreasing cardiac output, worsening the pulmonary hypoperfusion. The aim of this study was to examine the rate of death associated with initial and subsequent (48-hour) PEEP settings of 10cmH2O and higher in COVID-19 patients. We hypothesized that higher PEEP settings may lead to increased mortality. METHODS: We conducted a retrospective chart review of patients who presented or were transferred to our facility with COVID-19 and were subsequently intubated from March 1st until April 30th, 2020. Charts were reviewed for initial and 48-hour PEEP settings. Mortality, SARS CoV2 results, clinical data and demographics were also recorded. RESULTS: A total of 74 patients were included in the review. Of these, 53 patients had initial PEEP setting of >10cmH2O and 46 patients had PEEP settings >10cmH2O 48 hours after intubation. Thirty-seven patients had PEEP settings >10cmH2O both initially and 48 hours later. Thirty-seven patients who had an initial PEEP setting of >10 cmH220 died, (70%). Forty patients who had PEEP settings >10cmH2O at 48hrs died (87%). Twenty-seven patients who had both a PEEP setting >10 cmH2O initially and at 48 hours died (73%). CONCLUSIONS: There appears to be an association in COVID-19 patients between high mortality rates and high PEEP settings. The marked association is strong enough, in our view, to suggest that conventional ventilator settings recommended by ARDSNet may not apply to patients experiencing COVID-19-associated ARDS and in fact, may be leading to worse patient outcomes.","PeriodicalId":111156,"journal":{"name":"TP49. TP049 COVID: ARDS AND ICU MANAGEMENT","volume":"42 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"116091979","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-05-01DOI: 10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2564
G. Crowley, S. Kwon, L. Mengling, A. Nolan
RATIONALE. Coronavirus Disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), emerged in Wuhan, China in late 2019 and has expanded into a global pandemic. This mass casualty triage, while requiring tremendous resources, also required early decision-making and ultimately allocation of critical care resources. Primary Objective was to ascertain risk factors of COVID-19 patients requiring ICU admission. Identify biomarkers, clinical risk factors, and comorbid conditions that can predict clinical outcome. METHODS. Setting and Study Design. We performed a natural history/retrospective chart review of patient admissions (n=5,568) at our facility for patients admitted between March 1-May 1, 2020, over 18 years of age, with a positive test less than 15 days before admission. We examined their inflammatory biomarker profile and clinical phenotype collected as part of their standard of care (n=90 variables). Analysis. Random forests used as a variable selector were assessed via a modified hamming distance between variable importance rankings of models with identical hyperparameters. The top 10% of variables (n=9) by mean decrease accuracy (MDA) were then included in a gradient-boosted tree model (xgboost package, R-Project) to build classifiers of ICU admissions and mortality. A random hyperparameter space search determined a final model that maximized 5-fold cross-validated AUCROC. All data was collected in compliance with the Code of Federal Regulations, Title 21, Part 11 and approved by the NYU IRB#20-00473. RESULTS. The classifiers of ICU admission and mortality had AUCROC = 0.93 and 0.90, and classification error = 15.6% and 20.2% based on the Youden's index-optimal probability threshold, respectively. Variables in the final predictive models of ICU admission and mortality are shown by rank (by MDA) in each model, with rank of 1 being the most important, Figure 1. In predicting ICU admission, the three most important variables were triglycerides, procalcitonin, and c-reactive protein;age, initial O2 flow (L/min), and blood O2 saturation were the three most important predictors of mortality. Procalcitonin, blood O2 saturation, lactate, and initial O2 flow (L/min) were predicted both ICU admission and mortality. CONCLUSION. Our models will be included in an online calculator that will be made available and can be used at point of care by providers to assist risk assessment and triage. Our analysis suggests that novel biomarker combinations may be important in assessment of COVID-19 severity. Future work will include validation of these models in other populations.
{"title":"ICU Admission and Mortality Prediction in Severe COVID-19: A Machine Learning Approach","authors":"G. Crowley, S. Kwon, L. Mengling, A. Nolan","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2564","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2564","url":null,"abstract":"RATIONALE. Coronavirus Disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), emerged in Wuhan, China in late 2019 and has expanded into a global pandemic. This mass casualty triage, while requiring tremendous resources, also required early decision-making and ultimately allocation of critical care resources. Primary Objective was to ascertain risk factors of COVID-19 patients requiring ICU admission. Identify biomarkers, clinical risk factors, and comorbid conditions that can predict clinical outcome. METHODS. Setting and Study Design. We performed a natural history/retrospective chart review of patient admissions (n=5,568) at our facility for patients admitted between March 1-May 1, 2020, over 18 years of age, with a positive test less than 15 days before admission. We examined their inflammatory biomarker profile and clinical phenotype collected as part of their standard of care (n=90 variables). Analysis. Random forests used as a variable selector were assessed via a modified hamming distance between variable importance rankings of models with identical hyperparameters. The top 10% of variables (n=9) by mean decrease accuracy (MDA) were then included in a gradient-boosted tree model (xgboost package, R-Project) to build classifiers of ICU admissions and mortality. A random hyperparameter space search determined a final model that maximized 5-fold cross-validated AUCROC. All data was collected in compliance with the Code of Federal Regulations, Title 21, Part 11 and approved by the NYU IRB#20-00473. RESULTS. The classifiers of ICU admission and mortality had AUCROC = 0.93 and 0.90, and classification error = 15.6% and 20.2% based on the Youden's index-optimal probability threshold, respectively. Variables in the final predictive models of ICU admission and mortality are shown by rank (by MDA) in each model, with rank of 1 being the most important, Figure 1. In predicting ICU admission, the three most important variables were triglycerides, procalcitonin, and c-reactive protein;age, initial O2 flow (L/min), and blood O2 saturation were the three most important predictors of mortality. Procalcitonin, blood O2 saturation, lactate, and initial O2 flow (L/min) were predicted both ICU admission and mortality. CONCLUSION. Our models will be included in an online calculator that will be made available and can be used at point of care by providers to assist risk assessment and triage. Our analysis suggests that novel biomarker combinations may be important in assessment of COVID-19 severity. Future work will include validation of these models in other populations.","PeriodicalId":111156,"journal":{"name":"TP49. TP049 COVID: ARDS AND ICU MANAGEMENT","volume":"5 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"114427965","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-05-01DOI: 10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2552
N. Wadud, Naim Ahmed, M. Shergill, Maida Khan, M. Krishna, A. Gilani, S. E. Zarif, Jodi L Galaydick, K. Linga, S. Koor, J. Galea, L. Stuczynski, M. Osundele
RATIONALE: With over 1.6 million deaths worldwide, COVID-19 was declared a global pandemic. Many counties facing second wave of infection, hence an urgent need for early identification and therapeutic modalities. Methods: Retrospective study, included 245 patients, over 18 years admitted to Garnet Health Medical Center with confirmed COVID-19 results from March 2020 to May 2020. Further classified into 3 groups;COVID-19 positive and intubated, COVID-19 negative and intubated and COVID-19 positive and non-intubated. Information collected included demographics: age, sex, race, comorbidities;inflammatory markers and treatment modalities. Primary outcome for mortality, ventilator duration, ICU and length of hospital stays were compared. Statistical analysis was done by one-way ANOVA;statistical significance defined by P less than 0 .05. Results: 245 patients were analyzed;105 COVID-19 positive and intubated, 115 COVID-19 negative and intubated and 25 COVID-19 positive and non-intubated groups. Mean age was 60.45, 63.22 and 65.96 with male predominance 72.38%, 53.04% and 60% respectively. Caucasians seemed more affected 53.33%, 73.91% and 40% followed by African Americans. Chronic medical conditions included hypertension (63.80%, 68.69% and 84%), diabetes mellitus (44.76%, 34.78% and 48%) and asthma (13.33%, 10.43% and 8%) respectively. Mortality was 45.71%, 34.23% and 16%. COVID-19 positive patients were intubated for a mean duration of 22.14 days compared to 8.69 days in COVID-19 negative patients. Mean ICU and hospital length of stay were 16.01 and 23.7 days in COVID-19 positive intubated patients, 8.83 and 11.25 days in COVID-19 negative intubated patients, while mean ICU and hospital durations were 2.84 and 12.12 days in COVID-19 positive non-intubated patients;P = 0.0001. Acute Respiratory Distress Syndrome (ARDS), in COVID-19 positive intubated patients (82.85%), acute kidney injury (AKI) (80%) with 32.38 % needing continuous renal replacement therapy (CRRT). While in COVID-19 negative intubated patients 66.95% developed AKI with 17.3 % needing CRRT and only 5.21% patient developed ARDS. COVID-19 positive non-intubated patients AKI was predominant in 64% with no CRRT and 28% developed ARDS. Inflammatory markers were also significantly elevated in COVID-19 positive intubated patients comparatively. In addition, 53 (50.47%) patients received Tocilizumab, 10 (9.52%) received Remdesivir in COVID-19 positive intubated group. While 6 (24%) and 1 (4%) received Tocilizumab and Remdesivir respectively, in COVID-19 positive non-intubated group. Conclusion: COVID-19 positive intubated patients had greater mortality, ventilator duration, length of ICU and hospital stays. This study identified risk factors and complications that may be associated in COVID-19. Early identification, supportive therapies and medications may improve outcome.
{"title":"Clinical Characteristics and Outcomes Comparison Amongst COVID-19 Positive Intubated, Non-Intubated and COVID-19 Negative Intubated Patients; Single Center, Retrospective Study","authors":"N. Wadud, Naim Ahmed, M. Shergill, Maida Khan, M. Krishna, A. Gilani, S. E. Zarif, Jodi L Galaydick, K. Linga, S. Koor, J. Galea, L. Stuczynski, M. Osundele","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2552","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2552","url":null,"abstract":"RATIONALE: With over 1.6 million deaths worldwide, COVID-19 was declared a global pandemic. Many counties facing second wave of infection, hence an urgent need for early identification and therapeutic modalities. Methods: Retrospective study, included 245 patients, over 18 years admitted to Garnet Health Medical Center with confirmed COVID-19 results from March 2020 to May 2020. Further classified into 3 groups;COVID-19 positive and intubated, COVID-19 negative and intubated and COVID-19 positive and non-intubated. Information collected included demographics: age, sex, race, comorbidities;inflammatory markers and treatment modalities. Primary outcome for mortality, ventilator duration, ICU and length of hospital stays were compared. Statistical analysis was done by one-way ANOVA;statistical significance defined by P less than 0 .05. Results: 245 patients were analyzed;105 COVID-19 positive and intubated, 115 COVID-19 negative and intubated and 25 COVID-19 positive and non-intubated groups. Mean age was 60.45, 63.22 and 65.96 with male predominance 72.38%, 53.04% and 60% respectively. Caucasians seemed more affected 53.33%, 73.91% and 40% followed by African Americans. Chronic medical conditions included hypertension (63.80%, 68.69% and 84%), diabetes mellitus (44.76%, 34.78% and 48%) and asthma (13.33%, 10.43% and 8%) respectively. Mortality was 45.71%, 34.23% and 16%. COVID-19 positive patients were intubated for a mean duration of 22.14 days compared to 8.69 days in COVID-19 negative patients. Mean ICU and hospital length of stay were 16.01 and 23.7 days in COVID-19 positive intubated patients, 8.83 and 11.25 days in COVID-19 negative intubated patients, while mean ICU and hospital durations were 2.84 and 12.12 days in COVID-19 positive non-intubated patients;P = 0.0001. Acute Respiratory Distress Syndrome (ARDS), in COVID-19 positive intubated patients (82.85%), acute kidney injury (AKI) (80%) with 32.38 % needing continuous renal replacement therapy (CRRT). While in COVID-19 negative intubated patients 66.95% developed AKI with 17.3 % needing CRRT and only 5.21% patient developed ARDS. COVID-19 positive non-intubated patients AKI was predominant in 64% with no CRRT and 28% developed ARDS. Inflammatory markers were also significantly elevated in COVID-19 positive intubated patients comparatively. In addition, 53 (50.47%) patients received Tocilizumab, 10 (9.52%) received Remdesivir in COVID-19 positive intubated group. While 6 (24%) and 1 (4%) received Tocilizumab and Remdesivir respectively, in COVID-19 positive non-intubated group. Conclusion: COVID-19 positive intubated patients had greater mortality, ventilator duration, length of ICU and hospital stays. This study identified risk factors and complications that may be associated in COVID-19. Early identification, supportive therapies and medications may improve outcome.","PeriodicalId":111156,"journal":{"name":"TP49. TP049 COVID: ARDS AND ICU MANAGEMENT","volume":"114 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"124123026","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-05-01DOI: 10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2557
A. Rai, M. Malviya, A. Jacobs, V. Nadile, M. Ahmad, S. Thomas
Introduction: Extracorporeal membrane oxygenation (ECMO) therapy is indicated for acute respiratory distress syndromes (ARDS) with refractory hypoxia1. ARDS associated with Severe Acute Respiratory Syndrome-Coronavirus-2 infection has been shown to have 45% mortality, secondary to elevated inflammatory cytokines2. Prolonged duration of ECMO leads to poor short term neurological function 3. However there is lack of data regarding long term quality of life among patients who undergo ECMO for ARDS. We plan to conduct a retrospective study among patients undergoing ECMO to assess their quality of life. Methods: Retrospectives chart review and phone interviews conducted approximately 6 months after receiving ECMO at New York University-Long Island Hospital. 22 patients have received veno-venous or veno-arterial ECMO since March 2020. Phone interviews of 10 patients have been conducted. Welch two sample t test will be used to detect differences between activities of daily living (ADL) between prolonged ECMO (more than 20 days) and routine ECMO (less than 20 days) groups. Association between ECMO parameters, laboratory values and ADL will be evaluated by using a multivariable logistic regression analysis. Result will be considered statistically significant if p<0.05 Results:11 out of 22 patients have been discharged from hospital, 1 patient continues to receive ECMO. Initial analysis of our data shows that patients undergoing prolonged ECMO have a low mean score of 14 for activities of daily living (bathing, independent use of toilet, cooking and eating meals, shopping, driving, and use of supplemental oxygen) when compared to a mean score of 30 among routine ECMO. Mean Interleukin-6 (IL-6) and D Dimer levels 24 hours prior to undergoing cannulation for ECMO among prolonged ECMO group was higher when compared to routine ECMO group. (table 1) Conclusion:Patients undergoing prolonged ECMO have reduced activities of daily living 6 months post hospital discharge. Immune and coagulation markers prior to receiving ECMO were elevated among prolonged ECMO group suggesting severe cytokine storm and immunothrombosis resulting in poor prognosis.
{"title":"Extra Corporeal Membrane Oxygenation and Long Term Neurological Function Among COVID-19 Patients","authors":"A. Rai, M. Malviya, A. Jacobs, V. Nadile, M. Ahmad, S. Thomas","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2557","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2557","url":null,"abstract":"Introduction: Extracorporeal membrane oxygenation (ECMO) therapy is indicated for acute respiratory distress syndromes (ARDS) with refractory hypoxia1. ARDS associated with Severe Acute Respiratory Syndrome-Coronavirus-2 infection has been shown to have 45% mortality, secondary to elevated inflammatory cytokines2. Prolonged duration of ECMO leads to poor short term neurological function 3. However there is lack of data regarding long term quality of life among patients who undergo ECMO for ARDS. We plan to conduct a retrospective study among patients undergoing ECMO to assess their quality of life. Methods: Retrospectives chart review and phone interviews conducted approximately 6 months after receiving ECMO at New York University-Long Island Hospital. 22 patients have received veno-venous or veno-arterial ECMO since March 2020. Phone interviews of 10 patients have been conducted. Welch two sample t test will be used to detect differences between activities of daily living (ADL) between prolonged ECMO (more than 20 days) and routine ECMO (less than 20 days) groups. Association between ECMO parameters, laboratory values and ADL will be evaluated by using a multivariable logistic regression analysis. Result will be considered statistically significant if p<0.05 Results:11 out of 22 patients have been discharged from hospital, 1 patient continues to receive ECMO. Initial analysis of our data shows that patients undergoing prolonged ECMO have a low mean score of 14 for activities of daily living (bathing, independent use of toilet, cooking and eating meals, shopping, driving, and use of supplemental oxygen) when compared to a mean score of 30 among routine ECMO. Mean Interleukin-6 (IL-6) and D Dimer levels 24 hours prior to undergoing cannulation for ECMO among prolonged ECMO group was higher when compared to routine ECMO group. (table 1) Conclusion:Patients undergoing prolonged ECMO have reduced activities of daily living 6 months post hospital discharge. Immune and coagulation markers prior to receiving ECMO were elevated among prolonged ECMO group suggesting severe cytokine storm and immunothrombosis resulting in poor prognosis.","PeriodicalId":111156,"journal":{"name":"TP49. TP049 COVID: ARDS AND ICU MANAGEMENT","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115077801","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-05-01DOI: 10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2561
T. Marvi, William B. Stubblefield, B. Tillman, W. Self, T. Rice
RATIONALE: Coronavirus disease 2019 (COVID-19) is associated with high rates of venous thromboembolism despite prophylactic anticoagulation. Thromboelastography (TEG) has been suggested as a tool for identifying patients at increased risk of VTE. This study aims to determine if serial TEG evaluation predicts the development of VTE in patients with COVID-19 and respiratory failure admitted to the intensive care unit (ICU). METHODS: We conducted a prospective cohort study of patients admitted to the ICU with COVID-19 and respiratory failure without a prior diagnosis of acute VTE. Patients underwent TEG on days 1, 4, and 6 of ICU admission. The number of hypercoagulable days, defined as elevated TEG maximum amplitude, were recorded. The outcome was time from ICU admission to VTE during the hospital admission. Patients were censored at death and discharge. A Cox proportional hazards model was fit for time to first VTE controlling for patient age, sex, and exposure to antiplatelet agents. RESULTS: A total of 56 patients were enrolled in the study (11 females/45 males);41.1% had a hypercoagulable TEG (MA above the upper limit of normal) on ICU day 1, 55.4% on day 4, and 48.2% on day 6. The primary outcome of VTE occurred in 17 patients (30.4%). The median time from ICU admission to VTE was 7 days (IQR 3-12). Of the 14 patients with hypercoagulable MA on all 3 measured days, 1 patient (7.1%) developed a VTE compared to 15.4% of those with hypercoagulable MA for 2 days (N=13), 30.8% of those hypercoagulable for 1 day (N=13), and 62.5% of patients not hypercoagulable any of the 3 days (N=16). Multivariable Cox-proportional hazards model found that increasing number of hypercoagulable days by MA was associated with a decreased risk of VTE (OR 0.48, CI 0.27-0.85, p=0.01). A Cox proportional hazards regression curve for the number of hypercoagulable days by MA holding all other covariates at their medians is shown in Figure 1. CONCLUSION: In this study, more hypercoagulable days on TEG MA measurement was counterintuitively associated with a decreased risk of VTE in patients with COVID-19 respiratory failure. The normal response to inflammation and infection is upregulation of pro-coagulant acute phase reactants suggesting that increased TEG MA may be physiologic. TEG MA measures below the upper limit of normal are associated with an increased risk of VTE and may mark the development of a consumptive coagulopathy.
{"title":"Maximum Amplitude Measurement on Thromboelastography Is Inversely Associated with Development of Venous Thromboembolism in Critically Ill Patients with COVID-19 Pneumonia","authors":"T. Marvi, William B. Stubblefield, B. Tillman, W. Self, T. Rice","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2561","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2561","url":null,"abstract":"RATIONALE: Coronavirus disease 2019 (COVID-19) is associated with high rates of venous thromboembolism despite prophylactic anticoagulation. Thromboelastography (TEG) has been suggested as a tool for identifying patients at increased risk of VTE. This study aims to determine if serial TEG evaluation predicts the development of VTE in patients with COVID-19 and respiratory failure admitted to the intensive care unit (ICU). METHODS: We conducted a prospective cohort study of patients admitted to the ICU with COVID-19 and respiratory failure without a prior diagnosis of acute VTE. Patients underwent TEG on days 1, 4, and 6 of ICU admission. The number of hypercoagulable days, defined as elevated TEG maximum amplitude, were recorded. The outcome was time from ICU admission to VTE during the hospital admission. Patients were censored at death and discharge. A Cox proportional hazards model was fit for time to first VTE controlling for patient age, sex, and exposure to antiplatelet agents. RESULTS: A total of 56 patients were enrolled in the study (11 females/45 males);41.1% had a hypercoagulable TEG (MA above the upper limit of normal) on ICU day 1, 55.4% on day 4, and 48.2% on day 6. The primary outcome of VTE occurred in 17 patients (30.4%). The median time from ICU admission to VTE was 7 days (IQR 3-12). Of the 14 patients with hypercoagulable MA on all 3 measured days, 1 patient (7.1%) developed a VTE compared to 15.4% of those with hypercoagulable MA for 2 days (N=13), 30.8% of those hypercoagulable for 1 day (N=13), and 62.5% of patients not hypercoagulable any of the 3 days (N=16). Multivariable Cox-proportional hazards model found that increasing number of hypercoagulable days by MA was associated with a decreased risk of VTE (OR 0.48, CI 0.27-0.85, p=0.01). A Cox proportional hazards regression curve for the number of hypercoagulable days by MA holding all other covariates at their medians is shown in Figure 1. CONCLUSION: In this study, more hypercoagulable days on TEG MA measurement was counterintuitively associated with a decreased risk of VTE in patients with COVID-19 respiratory failure. The normal response to inflammation and infection is upregulation of pro-coagulant acute phase reactants suggesting that increased TEG MA may be physiologic. TEG MA measures below the upper limit of normal are associated with an increased risk of VTE and may mark the development of a consumptive coagulopathy.","PeriodicalId":111156,"journal":{"name":"TP49. TP049 COVID: ARDS AND ICU MANAGEMENT","volume":"23 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"132892230","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-05-01DOI: 10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2554
C. Vahdatpour, S. D. Young, J. Ayyoub, J. Jaber, Psom Data Investigators, O. Nwankwo, P. Kinniry
Introduction: Acute respiratory distress syndrome (ARDS) management in the intensive care unit (ICU) has been debated since the start of the Covid-19 pandemic. Our study aims to describe the outcomes and predictors of mortality of ARDS associated with Covid-19 within one university-based healthcare system. Methods: This was a retrospective study performed within one university-based healthcare system. An electronic medical record was used to identify 166 patients admitted to the ICU for ARDS in the setting of SARS-CoV-2 infection at three different hospitals. Baseline patient characteristics, ICU and hospital course information, ICU interventions, ventilator settings, and hospital complications were collected and analyzed using descriptive statistical techniques. Results: The 166 patients meeting inclusion criteria had an average age of 64.1 (± 14.8). No significant difference in mortality was identified with male vs. female gender (57.9% vs. 42.1%, p=0.852) or BMI (8.4 ± 0.9 vs. 12.1 ± 1.5, p=0.727). The majority of the patient cohort was identified as black (68.2%). The overall mortality of our cohort was 38.2%. Hyperlipidemia (p=0.011), coronary artery disease (0.034), and chronic obstructive pulmonary disease (p=0.006) were all associated with higher mortality. Prone positioning was utilized in 42.8% of all patients, and ECMO in 6.0%. There was a significant difference of mortality between those with higher observed ventilator plateau pressures at 24 hours (25.7 vs. 23.1, p=0.010) and driving pressures at 24 hours (13.4 vs. 11.7, p=0.036). Conclusion: Covid-19 associated ARDS is associated with significant mortality. Physicians should be aware of pre-existing conditions that are potentially associated with worse outcomes so that they receive appropriate level of care in a timely manner. Lower plateau and driving pressures were associated with improved outcomes. Prospective studies are needed to guide Covid-19 associated ARDS management.
自Covid-19大流行开始以来，重症监护病房(ICU)的急性呼吸窘迫综合征(ARDS)管理一直存在争议。我们的研究旨在描述一所大学医疗系统中与Covid-19相关的ARDS死亡率的结果和预测因素。方法:这是一项在一所大学医疗保健系统中进行的回顾性研究。使用电子病历对3家不同医院因SARS-CoV-2感染而入住ICU的166例ARDS患者进行了鉴定。使用描述性统计技术收集和分析基线患者特征、ICU和医院病程信息、ICU干预措施、呼吸机设置和医院并发症。结果:符合入选标准的166例患者，平均年龄64.1岁(±14.8岁)。男女死亡率无显著差异(57.9%比42.1%，p=0.852)， BMI(8.4±0.9比12.1±1.5,p=0.727)。大多数患者队列为黑人(68.2%)。我们队列的总死亡率为38.2%。高脂血症(p=0.011)、冠状动脉疾病(0.034)和慢性阻塞性肺疾病(p=0.006)均与较高的死亡率相关。42.8%的患者采用俯卧位，6.0%采用ECMO。24小时呼吸机平台压力较高组(25.7 vs. 23.1, p=0.010)与24小时驾驶压力较高组(13.4 vs. 11.7, p=0.036)死亡率差异有统计学意义。结论:Covid-19相关ARDS与显著死亡率相关。医生应该意识到已有的疾病可能会导致更糟糕的结果，以便他们及时得到适当的护理。较低的平台压力和驱动压力与改善的结果相关。需要前瞻性研究来指导Covid-19相关的ARDS管理。
{"title":"ICU Outcomes in Patients with Covid-19 Associated ARDS: A Retrospective Analysis","authors":"C. Vahdatpour, S. D. Young, J. Ayyoub, J. Jaber, Psom Data Investigators, O. Nwankwo, P. Kinniry","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2554","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2554","url":null,"abstract":"Introduction: Acute respiratory distress syndrome (ARDS) management in the intensive care unit (ICU) has been debated since the start of the Covid-19 pandemic. Our study aims to describe the outcomes and predictors of mortality of ARDS associated with Covid-19 within one university-based healthcare system. Methods: This was a retrospective study performed within one university-based healthcare system. An electronic medical record was used to identify 166 patients admitted to the ICU for ARDS in the setting of SARS-CoV-2 infection at three different hospitals. Baseline patient characteristics, ICU and hospital course information, ICU interventions, ventilator settings, and hospital complications were collected and analyzed using descriptive statistical techniques. Results: The 166 patients meeting inclusion criteria had an average age of 64.1 (± 14.8). No significant difference in mortality was identified with male vs. female gender (57.9% vs. 42.1%, p=0.852) or BMI (8.4 ± 0.9 vs. 12.1 ± 1.5, p=0.727). The majority of the patient cohort was identified as black (68.2%). The overall mortality of our cohort was 38.2%. Hyperlipidemia (p=0.011), coronary artery disease (0.034), and chronic obstructive pulmonary disease (p=0.006) were all associated with higher mortality. Prone positioning was utilized in 42.8% of all patients, and ECMO in 6.0%. There was a significant difference of mortality between those with higher observed ventilator plateau pressures at 24 hours (25.7 vs. 23.1, p=0.010) and driving pressures at 24 hours (13.4 vs. 11.7, p=0.036). Conclusion: Covid-19 associated ARDS is associated with significant mortality. Physicians should be aware of pre-existing conditions that are potentially associated with worse outcomes so that they receive appropriate level of care in a timely manner. Lower plateau and driving pressures were associated with improved outcomes. Prospective studies are needed to guide Covid-19 associated ARDS management.","PeriodicalId":111156,"journal":{"name":"TP49. TP049 COVID: ARDS AND ICU MANAGEMENT","volume":"2015 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"114561693","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-05-01DOI: 10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2562
S. Mcgowan, E. Chen, T. Johnson, J. Longcoy, Elizabeth Avery, B. Lange-Maia, D. Ansell
RATIONALE: Many hospitals were unable to accommodate the rapid surge of critically ill patients with COVID-19 requiring intensive care unit (ICU) admission in the spring of 2020. As a result, some patients were transferred to tertiary referral centers with increased surge capacity and an ability to provide a higher level of care for patients in respiratory failure requiring mechanical ventilation. In general, interhospital transfers have higher disease severity, longer length of stay, and higher mortality. Our study investigated whether patients with COVID-19 who were transferred to a tertiary referral center had higher severity of illness and poorer health outcomes compared to patients who were directly admitted. METHODS: This was a single center, retrospective cohort study of adult patients with COVID-19 who received mechanical ventilation. Demographic and clinical variables were extracted from the electronic medical record for patients admitted and discharged between March 17, 2020 and September 30, 2020. Patients were classified as either directly admitted or admitted via interhospital transfer. Inverse probability weighted regression models were constructed to test the association between transfer status and outcomes, including in-hospital death versus survival to hospital discharge, and number of days from intubation to discharge, adjusting for patient demographic characteristics and severity of illness. RESULTS: Of 1,785 patients admitted to Rush University Medical Center with COIVD-19, 174 (10%) were transferred from another hospital and 1,611 were directly admitted through the emergency department. A total of 119 transfer patients and 183 direct admits required mechanical ventilation. Transfer patients differed from direct admits in being more likely to have English as a preferred language (71% vs 56%,), younger age (median 57 vs 60 years), higher BMI (median, 34 vs 31), and more likely to have received ECMO (12% vs 3%), p<0.01 for each. Overall,150 (42%) transferred patients and 78 (43%) directly admitted patients died prior to discharge, and there was no significant difference in in-hospital mortality after adjusting for patient sociodemographic factors and presentation severity. Additionally, there were no significant difference found between days from intubation to discharge between the two groups. CONCLUSION: Although transferred patients may have been sicker on arrival when compared to directly admitted patients, there were no differences in in-hospital mortality or length of stay in this study. These data suggest that interhospital transfer of critically ill patients with COVID-19 can be done safely and effectively.
{"title":"Interhospital Transfer for Patients with COVID-19 Admitted to an Urban Academic Medical Center in Chicago, IL","authors":"S. Mcgowan, E. Chen, T. Johnson, J. Longcoy, Elizabeth Avery, B. Lange-Maia, D. Ansell","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2562","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2562","url":null,"abstract":"RATIONALE: Many hospitals were unable to accommodate the rapid surge of critically ill patients with COVID-19 requiring intensive care unit (ICU) admission in the spring of 2020. As a result, some patients were transferred to tertiary referral centers with increased surge capacity and an ability to provide a higher level of care for patients in respiratory failure requiring mechanical ventilation. In general, interhospital transfers have higher disease severity, longer length of stay, and higher mortality. Our study investigated whether patients with COVID-19 who were transferred to a tertiary referral center had higher severity of illness and poorer health outcomes compared to patients who were directly admitted. METHODS: This was a single center, retrospective cohort study of adult patients with COVID-19 who received mechanical ventilation. Demographic and clinical variables were extracted from the electronic medical record for patients admitted and discharged between March 17, 2020 and September 30, 2020. Patients were classified as either directly admitted or admitted via interhospital transfer. Inverse probability weighted regression models were constructed to test the association between transfer status and outcomes, including in-hospital death versus survival to hospital discharge, and number of days from intubation to discharge, adjusting for patient demographic characteristics and severity of illness. RESULTS: Of 1,785 patients admitted to Rush University Medical Center with COIVD-19, 174 (10%) were transferred from another hospital and 1,611 were directly admitted through the emergency department. A total of 119 transfer patients and 183 direct admits required mechanical ventilation. Transfer patients differed from direct admits in being more likely to have English as a preferred language (71% vs 56%,), younger age (median 57 vs 60 years), higher BMI (median, 34 vs 31), and more likely to have received ECMO (12% vs 3%), p<0.01 for each. Overall,150 (42%) transferred patients and 78 (43%) directly admitted patients died prior to discharge, and there was no significant difference in in-hospital mortality after adjusting for patient sociodemographic factors and presentation severity. Additionally, there were no significant difference found between days from intubation to discharge between the two groups. CONCLUSION: Although transferred patients may have been sicker on arrival when compared to directly admitted patients, there were no differences in in-hospital mortality or length of stay in this study. These data suggest that interhospital transfer of critically ill patients with COVID-19 can be done safely and effectively.","PeriodicalId":111156,"journal":{"name":"TP49. TP049 COVID: ARDS AND ICU MANAGEMENT","volume":"50 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"132732494","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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