TP49. TP049 COVID: ARDS AND ICU MANAGEMENT最新文献

{"title":"Disparities in Access to Medical Care After Hospitalization for Severe COVID-19 Pneumonia","authors":"A. Cañas, L. Gómez, A. Wolf, D. Furfaro, J. Zelnick, Aby Watson, C. Rodriguez, J. Iyasere, R. Fullilove, K. M. Burkart, M. O’Donnell","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2543","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2543","url":null,"abstract":"RATIONALE: Communities of color are bearing a disproportionate burden of coronavirus disease 2019 (COVID-19) morbidity and mortality. Social determinants of health have resulted in higher prevalence and severity of COVID-19 among minority groups. Published work on COVID-19 disparities has focused on higher transmission, hospitalization, and mortality risk among people of color, but studies on disparities in the post-acute care setting are scarce. Our aim was to identify socioeconomic disparities in health resource utilization after hospital discharge. METHODS: This was a retrospective study. We identified adult patients who were hospitalized at CUIMC or the Allen Hospital from March 1st through April 30th 2020, had a positive RT-PCR for severe acute respiratory syndrome coronavirus 2 (SARS-COV-2), developed severe hypoxemic respiratory failure requiring invasive mechanical ventilation, and were successfully discharged from the hospital without need for ventilator support. Patients who received a tracheostomy and were weaned off the ventilator prior to discharge were included. Exclusion criteria included transfer from or to another institution, prior tracheostomy, in-hospital death, and discharge with a ventilator. RESULTS: We identified 195 patients meeting inclusion criteria. The median age was 59 (IQR 47-67), and 135 (66.5%) were men. There were 25 (12.8%) patients who were uninsured and 116 (59.5%) patients who had public insurance. There were 121 (62%) Hispanic, 34 (17%) Black, and 18 (9%) White patients. Uninsured patients within our cohort were more likely to be Hispanic and Spanish-speaking (p=0.027;p<0.001, respectively). Uninsured patients were also more likely to be discharged to home (p<0.001) than to a rehabilitation facility. 8.8% of patients were readmitted to CUIMC within 30 days and 41.5% saw a medical provider at CUIMC within 30 days of discharge. Insurance status did not predict 30-day re-hospitalization or completion of outpatient follow-up, although our study was underpowered to answer these questions. CONCLUSION: Our study demonstrated that race/ethnicity and primary language are associated with insurance status with Hispanic and Spanish-speaking patients being more likely to be uninsured. Uninsured patients were more likely to be discharged home after hospitalization, rather than to facility for further care and rehabilitation. We did not demonstrate any short-term differences in 30-day re-hospitalization rates or follow-up visits but we suspect socioeconomic disparities represent a significant barrier to adequate follow-up care in the long term. We plan to investigate this further with longitudinal follow-up and survey data.","PeriodicalId":111156,"journal":{"name":"TP49. TP049 COVID: ARDS AND ICU MANAGEMENT","volume":"51 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":"122199745","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}

{"title":"Outcomes of Hospitalized Patients with Coronavirus 19 Pneumonia and Respiratory Failure Based in D- Dimer Levels","authors":"A. Alapati, S. Venkatram, A. Reyes, R. Singhal, A. Dileep, L. Yapor, D. Ronderos, A. Jog, G. Díaz-Fuentes","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2540","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2540","url":null,"abstract":"Rationale: Corona virus disease 2019 (COVID-19) related pneumonia carries high morbidity and mortality, especially in patients with acute respiratory distress syndrome (ARDS). The goal of this study was to evaluate the outcomes of patients admitted with COVID-19 pneumonia who required additional oxygen supplementation for hypoxia. We compared patients with and without ARDS based in their initial D-Dimer levels. Methods: Retrospective study conducted at BronxCare Hospital. Included all adult patients admitted with COVID-19 pneumonia requiring supplemental oxygen for hypoxia during the period of March to May 2020. Patients were classified in two groups based in the presence or absence of ARDS;then they were sub-classified based in their initial D-dimer levels, D-dimer levels ≥ 4 times upper limit of normal (ULN) compared with patients with D-dimer levels ≤ 4 times ULN. Primary outcome was mortality and secondary outcomes were length of stay (LOS), mechanical ventilation, shock, acute renal failure and thrombotic complications. Results: We identified 1242 patients. There were no differences for age, gender, race or comorbidities among the groups except for BMI. Mean age was 62.8 with 61% been males. There were 254(20.4%) patients in the ARDS and 988(79.5%) in the non-ARDS group. Hospital and ICU LOS was higher in patients with ARDS with D-dimer levels ≤ 4 times ULN. 33% of patients received mechanical ventilation, mainly in the ARDS group. Overall mortality was 36.6%. Mortality rate was higher in ARDS with D-dimer levels ≥ 4 ULN (81.4%) followed by patients with ARDS with D-dimer levels ≤ 4 times ULN (70.1%), non ARDS with D-dimer levels ≥ 4 ULN (35.7%) and non ARDS with D-dimer levels ≤ 4 times ULN (21.1%) (p< 0.0001). On logistic regression analysis, higher mortality was seen in patients with ARDS irrespective of D-dimer levels, older age, history of asthma and presence of acute renal failure. Female sex and use of ascorbic acid showed decrease in mortality. Conclusions: Our study confirms prior findings in COVID-19 pneumonia. Patient with non-ARDS requiring supplemental oxygen despite lower levels of D-dimer have a significant mortality. Use of readily available data on admission can assist the clinicians for admission triage decisions and have implications on discharge planning and follow up. Closely monitor patients with Covid-19 associated acute respiratory failure for the need for mechanical ventilation, shock, acute renal failure and thrombotic complications. (Table Presented).","PeriodicalId":111156,"journal":{"name":"TP49. TP049 COVID: ARDS AND ICU MANAGEMENT","volume":"120 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":"127154580","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}

{"title":"Use of Prone Positioning for the Acute Respiratory Distress Syndrome Increased During the Coronavirus Disease 19 Pandemic","authors":"C. Hochberg, M. Eakin, D. Hager","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2541","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2541","url":null,"abstract":"Rationale: Prone positioning in acute respiratory distress syndrome (ARDS) improves patient outcomes but has been underutilized. In this study, we hypothesize that prone positioning use has increased during the COVID-19 pandemic. Methods: We conducted a retrospective study of patients treated in the medical ICU of a large academic tertiary care hospital in Baltimore, Maryland. Use of prone positioning among patients with COVID-19 ARDS treated from March 20th, 2020 to June 16th, 2020 were compared to patients with ARDS in 2019. Potential participants were identified from a registry of patients admitted with acute hypoxemic respiratory failure. Inclusion criteria required use of mechanical ventilation, the presence of ARDS, and a PaO2/FiO2 of < 150 during the first 72 hours following intubation. The primary outcome was use of prone positioning within 48 hours of the first qualifying PaO2/FiO2. Secondary outcomes were time to prone positioning and in-hospital mortality. The proportions of patients placed in the prone position in 2019 versus 2020 was compared using Fisher's exact test. Logistic regression was used to examine the association of early prone position (within 6 hours) with inhospital mortality in univariate models and models adjusted for age, sex and sequential organ failure assessment (SOFA) score. Results: Of 43 patients with COVID-19 that met inclusion criteria, 35 (81%) were proned within 48 hours of meeting oxygen criteria compared to 5 (25%) of 20 qualifying ARDS cases in 2019 (p<0.001) (Figure 1). Among those patients in whom it was used, prone positioning was used within 6 hours of meeting in oxygen criteria in 37% vs. 10% of patients in the COVID-19 vs. pre-COVID-19 ARDS patients (p=0.04). Overall, 37% of COVID-19 participants and 50% of non-COVID-19 ARDS patients died. Those proned within 6 hours of meeting oxygen criteria had numerically lower mortality compared to those not proned or proned later (33 vs. 44%), but this was not statistically significantly associated with in-hospital mortality in univariate or adjusted logistic regression models (adjusted odds ratio=0.43, 95% CI 0.12-1.57). Conclusions: Use of prone positioning for patients with moderate to severe ARDS markedly increased during the COVID-19 pandemic. Larger studies are needed to define the changes in prone positioning frequency in different settings and to understand why and how this rapid change in practice occurred. This understanding may inform interventions to more broadly implement evidence based ARDS care in a sustained fashion.","PeriodicalId":111156,"journal":{"name":"TP49. TP049 COVID: ARDS AND ICU MANAGEMENT","volume":"256 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":"122818656","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}

{"title":"Impact of FEMA on Rapid Response System During the COVID-19 Surge","authors":"K. Johnson, R. Durrance, U. Dhamrah, N. Sheth, R. Payal, D. Papademetriou, A. Astua","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2570","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2570","url":null,"abstract":"RATIONALE The first confirmed case of COVID-19 in New York was on March 1, 2020.(1) A nationwide emergency declared on March 13 made New York immediately eligible for FEMA public assistance.(2) At the peak of this pandemic, over 50,094 FEMA employees, Public Health Service Commissioned Corps officers from HHS and the National Guard were deployed across the US(2) to care for suspected or confirmed COVID-19 cases, including 10,437 NYC H+H cases, many of which required ICU level care. Elmhurst Hospital Center (EHC) experienced an unprecedented surge, resulting in resource strain. At EHC 2,409 patients (1501, COVID-19 positive) were newly admitted between March 1st to May 29, 2020, drastically surpassing hospital capacity. Herein, we compare patient outcomes before and after assistance. METHODS A retrospective review of cardiopulmonary resuscitation code team data was carried out for admitted adults requiring code response team between March 11 to May 25. A total of 145 cases were analyzed with respect to different grades of FEMA assistance to determine impacts of ancillary staff to patient ratios on survival. RESULTS Prior to FEMA support (3/11-3/25), code survival was 47% (8/17) and survival to discharge was 0% (0/17). The first wave of FEMA support (3/26-4/8) brought 221 Critical Care providers. Code survival was 39% (24/62) and survival to discharge was 5% (3/62). The second wave (4/9-4/23) included both 86 providers and volunteers, after which code survival was 56% (28/50) and survival to discharge was 2% (1/50). A third wave of 79 additional providers (4/24-5/10) resulted in decreased number of codes, code survival to 38% (3/8) and improved survival to discharge 38% (3/8). During the subsequent weeks while FEMA support staff remained at EHC (5/11-5/25), code survival was 50% (4/8), and the improved survival to discharge of 38% (3/8) was maintained. Overall, while the probability of code survival remained relatively constant (38-56%), survival to discharge showed significant and sustained improvement with additional provider support. CONCLUSION Given the exponential rise in COVID-19 admissions, hospitals are likely to become overwhelmed and medical practice is forced to adapt.(3) Swift action from FEMA and optimal ancillary staff deployment was critical to improving survival to discharge in critically ill patients requiring cardiopulmonary resuscitation.(4) Flexibility in step-up planning with timely high acuity capacity and appropriately trained provider staffing is vital to ensuring proper care during a pandemic surge.","PeriodicalId":111156,"journal":{"name":"TP49. TP049 COVID: ARDS AND ICU MANAGEMENT","volume":"13 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":"131954620","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}

{"title":"ICU Telehealth Use and Concern for Workforce Shortages Among Rural Hospitals in Michigan at the Onset of the COVID-19 Pandemic","authors":"K. Epler, A. Schutz, T. Valley","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2568","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2568","url":null,"abstract":"Rationale: Though the United States has the highest number of ICU beds per capita in the world, the regional distribution of these beds is variable. Rural areas have 1% of American ICU beds despite having 16% of the country's population. Telehealth is frequently promoted as a tool that can augment care for the critically ill in rural communities. Yet, ICU telehealth still requires clinicians at the bedside who are able to provide critical care. We sought to examine telemedicine within rural ICUs in the context of potential workforce shortages related to the COVID-19 pandemic. Methods: We identified all hospitals with ICUs in Michigan using the 2018 American Hospital Association annual survey database and internet searches. Within each hospital, an ICU physician or nurse leader was surveyed between April 6, 2020 and May 8, 2020. At that time, the state of Michigan had the fifth highest total of COVID-19 hospitalizations within the country. Participants were asked about current telehealth utilization in the ICU. Participants were also asked to rate their concern on a 4-point Likert scale regarding exceeding existing ICU capacity and ICU staffing capabilities due to the pandemic. Results: Of the 28 rural hospitals in Michigan, 14 were surveyed (response rate 50%). Among responding hospitals, 12 (86%) had fewer than 11 ICU beds and an average pre-COVID-19 census of fewer than 4 patients. At the time of the survey, ten hospitals (71%) reported using ICU telehealth support, of which two used telehealth providers exclusively overnight. Of the four hospitals without telehealth, two planned to add telehealth in response to the pandemic. In the context of the COVID-19 pandemic, 11 hospitals (79%) reported concern about exceeding their ICU capacity, and 12 hospitals (86%) planned to create more ICU beds. The majority of rural hospitals worried about impending ICU workforce shortages, with 78% of hospitals concerned about having enough nurses, 64% about having enough respiratory therapists, and 50% about having enough physicians as a result of the pandemic. Conclusions: At the onset of the COVID-19 pandemic, most rural hospitals in Michigan utilized ICU telehealth support in some capacity. Despite broad use of telemedicine, rural hospitals remained concerned about exceeding ICU capacity and a lack of ICU nurses, respiratory therapists, and physicians. Expansion of existing telehealth infrastructures within rural hospitals may improve access to critical care clinicians virtually but would not ease concerns related to capacity and workforce shortages, particularly among ICU-trained nurses.","PeriodicalId":111156,"journal":{"name":"TP49. TP049 COVID: ARDS AND ICU MANAGEMENT","volume":"106 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":"128117937","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}

{"title":"Associations Among Patient Race, Sedation Practices, and Mortality in a Large Multi-Center Registry of COVID-19 Patients","authors":"T. Valley, T. Iwashyna, S. Cook, C. Hough, M. Armstrong-Hough","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2567","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2567","url":null,"abstract":"Introduction: Racial and ethnic minorities have accounted for the majority of intensive care unit (ICU) hospitalizations for COVID-19. At the same time, ICUs were forced to deviate from long-established care processes in response to a steep increase in admissions and to prevent healthcare worker infections. These shifts may have resulted in changes to sedation practices, such as level of sedation or sedation holidays, that differed by patient race or ethnicity. We aimed to examine associations among patient race and ethnicity, sedation practices, and mortality in a large, national sample of patients receiving mechanical ventilation for COVID-19. Methods: We analyzed granular daily data from the Viral Infection and Respiratory Illness Universal Study (VIRUS) Registry for COVID-19 patients admitted to ICUs between February and November 2020. We included patients over 18 years of age, who were mechanically ventilated following clinical or PCR-confirmed COVID-19 diagnosis. We will calculate descriptive statistics for mortality at discharge and 28 days by patient race/ethnicity, sex, and two care processes associated with mechanical ventilation: sedation level and sedation holidays. We will estimate risk-adjusted, hospital-level mortality differentials by race. We will use mixed effects logistic regression and causal mediation analysis to test associations among patient race/ethnicity, sedation practices for mechanical ventilation, and mortality at 28 days, controlling for comorbidities, markers of severity, and time to admission, and adjusting for clustering by ICU. Results: Among 19,626 patients hospitalized for COVID-19, 8,668 (14.6%) received mechanical ventilation at 238 hospitals. The median age was 62 (IQR 40-72) and 45.1% were female. Among hospitalized patients, 23.3% self-identified as Hispanic, 26.6% as non-Hispanic Black, 35.6% as non-Hispanic White, and 14.5% as non-Hispanic and another racial group. Approximately 1% (n=236) of patients were missing race/ethnicity. At 28 days, 20.7% (n=4,076) of hospitalized patients were deceased. Use of benzodiazepines was highly clustered by hospital (intraclass correlation coefficient of 0.63). In cluster-adjusted analyses, Hispanic patients were more likely to receive benzodiazepines at least once during hospitalization than either non-Hispanic White (Odds Ratio (OR) 0.76, p=0.013) or non-Hispanic Black (OR 0.70, p=0.003) patients. Multivariable mixed effects and causal mediation analyses are ongoing. Conclusions: Sedation practices, such as level of sedation and sedation holidays, are associated with mortality;yet these practices may differ based on a patient's race or ethnicity. We will leverage a unique, multi-center database with granular clinical information to understand how these differences may influence racial and ethnic disparities in respiratory failure.","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":"132105550","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}

{"title":"Predictors of ICU Admission and Mortality in Patients with Coronavirus Disease - 2019 (COVID 19) in Community Hospitals","authors":"V. Pathak, C. Conklin","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2551","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2551","url":null,"abstract":"Introduction: Coronavirus Disease 2019 (COVID-19) is caused by novel coronavirus Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). It was initially identified as the cause of pneumonia cases in Wuhan, China and has now rapidly spread throughout the world causing a pandemic. Although, 81% of patients have mild disease (pneumonia), 14% could have severe disease leading to hospitalization and 5% end up in intensive care unit. The mortality of patients in ICU is variable and has been reported to be as high as 80%, particularly the patient who require intubation. Not much is known about the factors leading to progression of hospitalized patient needing ICU care and the predictors of mortality among ICU patients. We did the univariate followed by multivariate logistic regression analysis to determine the predictors of mortality in ICU. Method: Retrospective data were collected from consecutive 101 patients admitted from March, 2020 to June, 2020. Data were collected from 5 different community hospitals in Eastern Virginia with varied demographics. Univariate and multivariate logistic regression was done to determine the factors associated with progression of hospitalized patient to ICU and the predictors of mortality in ICU. Result: Total 101 consecutive hospitalized patients in 5 community hospitals in Eastern Virginia were enrolled in the study. Total 52/101 patients were admitted into the ICU for respiratory failure. Of these, 40 patients required intubation and mechanical ventilation. Altogether, 32/52 patients died. Of these 32 patients, 25 had required intubation. Total 22/25 (88%) intubated patients passed away while 3 were successfully extubated. Of these 32 patients, one had mild ARDS, 6 had moderate ARDS and 18 had severe ARDS. Patients aged 60 years and above accounted for &gt;2/3rd of the cases in ICU;mortality rate was higher in this age group as well. The inflammatory markers (CRP, D-dimer, Ferritin) peaked on day 8. The medications like Hydroxychloroquine, Azithromycin, Tocilizumab and Remdesivir did not alter the outcomes. Logistic regression analysis (univariate and multivariate) were done in the patients to determine the predictors of ICU admission from floor or ED. Logistic regression analysis was also done in the patients admitted to the ICU to look for the predictors of mortality. Conclusion: Based on logistic regression, none of the demographics (age, sex, race), symptoms, laboratory findings, chest imaging, ventilator settings or treatment identified the predictors of mortality in ICU in patients with COVID 19.","PeriodicalId":111156,"journal":{"name":"TP49. TP049 COVID: ARDS AND ICU MANAGEMENT","volume":"59 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":"116563965","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}

{"title":"Safety and Efficacy of a Novel Percutaneous Tracheostomy Protocol Adapted to Patients with COVID-19","authors":"R. Bechara, S. Islam, E. Fountain, S. Allen","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2563","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2563","url":null,"abstract":"Introduction and rationale: Many patients with COVID-19 admitted to the intensive care units require prolonged mechanical ventilation. Tracheostomy has been avoided due to increased risk of aerosolization especially during tracheal dilation resulting in increased risk for personnel infection. We describe our novel protocol to prevent exposure during percutaneous tracheostomy.Methods: Patients with COVID-19, on mechanical ventilation requiring prolonged mechanical ventilation were evaluated for bed-side percutaneous tracheostomy. The procedure was performed under bronchoscopic guidance and using a disposable bronchoscope. The scope was secured in position 1 cm from the end of the endotracheal tube with tape at the insertion site to allow the bronchoscopist to withdraw the ETT/bronchoscope en-bloc to the appropriate location in the trachea for adequate visualization during the procedure. Once the puncture point was identified, an expiratory pause was performed during which the trachea was punctured, a guide wire was placed, the anterior wall was dilated, and a tracheostomy was advanced and placed in the trachea. The time of the expiratory pause, any desaturation, complication and personnel conversion were measured.Results: A total of 18 percutaneous tracheostomies were performed. The total time of the expiratory pause, tracheal puncture to tracheostomy placement was thirty seconds to sixty seconds. There was no evidence of desaturation during the procedure, and there were no cases of staff conversion to positive COVID-19 status up to 14 days post procedure.Conclusions: we conclude that expiratory pause during percutaneous tracheostomy is safe, and importantly, may play significant role in decreasing aerosolization and staff exposure in patients with COVID-19 respiratory failure.","PeriodicalId":111156,"journal":{"name":"TP49. TP049 COVID: ARDS AND ICU MANAGEMENT","volume":"36 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":"116566344","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}

{"title":"Outcomes of Extracorporeal Membrane Oxygenation in Influenza vs. COVID-19 During the First Wave of COVID-19","authors":"C. Blazoski, M. Baram, H. Hirose","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2542","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2542","url":null,"abstract":"Purpose: Extracorporeal membrane oxygenation (ECMO) is a refractory\u0000treatment for acute respiratory distress syndrome (ARDS) due to\u0000influenza and severe acute respiratory syndrome coronavirus 2\u0000(SARS-CoV-2, also referred to as COVID-19). We conducted this study to\u0000compare the outcomes of influenza patients treated with veno-venous-ECMO\u0000(VV-ECMO) to COVID-19 patients treated with VV-ECMO, during the first\u0000wave of COVID-19. Materials and Methods: Patients in our institution\u0000with ARDS due to COVID-19 or influenza who were placed on ECMO between\u0000August 1, 2010 and September 15, 2020 were included in this comparative,\u0000retrospective study. To improve homogeneity, only VV -ECMO patients were\u0000analyzed. The clinical characteristics and outcomes were extracted and\u0000analyzed. Results: 28 COVID-19 patients and 17 influenza patients were\u0000identified and included. ECMO survival rates were 68% (19/28) in\u0000COVID-19 patients and 94% (16/17) in influenza patients (p=0.04).\u000030-day survival rates after ECMO decannulation were 54% (15/28) in\u0000COVID-19 patients and 76% (13/17) in influenza patients (p=0.13).\u0000COVID-19 patients spent a longer time on ECMO compared to flu patients\u0000(21 days vs. 12 days, p=0.025), and more COVID-19 patients (26/28 vs.\u00002/17) were on immunomodulatory therapy prior to ECMO initiation\u0000(p<0.001). COVID-19 patients had higher rates of new\u0000infections during ECMO (50% vs. 18%, p=0.03) and bacterial pneumonia\u0000(36% vs 6%, p=0.024). Conclusions: COVID-19 patients who were treated\u0000in our institution with VV-ECMO had statistically lower ECMO survival\u0000rates than influenza patients. It is possible that COVID-19\u0000immunomodulation therapies may increase the risk of other superimposed\u0000infections.","PeriodicalId":111156,"journal":{"name":"TP49. TP049 COVID: ARDS AND ICU MANAGEMENT","volume":"11 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":"128662992","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}

{"title":"Modification and Application of the ProVent-14 Model to a Covid-19 Cohort to Predict Risk for In-Hospital Mortality","authors":"B. Sines, L. Chang, T. Reid, S. Carson, I. Douglas","doi":"10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2536","DOIUrl":"https://doi.org/10.1164/AJRCCM-CONFERENCE.2021.203.1_MEETINGABSTRACTS.A2536","url":null,"abstract":"Rationale: Deficiencies exist in the communication of prognosis for patients requiring prolonged mechanical ventilation (PMV) from COVID-19 pneumonia, in part because of clinician uncertainty about the natural history of disease and observational cohort studies with variable outcomes. In order to address this gap for PMV patients, we developed a modified clinical prediction model based on the ProVent-14 model to predict in-hospital mortality for patients receiving at least 14 days of mechanical ventilation for acute respiratory distress syndrome (ARDS) from COVID-19. Methods: We evaluated 107 patients with COVID-19 requiring PMV (at least 14 days of mechanical ventilation (MV)) at 2 tertiary care medical centers in the US in a retrospective observational cohort study. On day 14 of MV, we collected data for the original ProVent-14 variables (age, platelet count, requirement for vasopressors, non-trauma admission, and dialysis requirement). We also collected data for 2 other potential predictor variables (extra-corporeal membrane oxygenation (ECMO) on day 14 and neutrophil to lymphocyte ratio). Model Development: Logistic regression models were used to evaluate the performance of the ProVent-14 variables with the outcome inhospital mortality. We then assessed successive models adding variable combinations including requirement of ECMO and neutrophil to lymphocyte ratio on day 14 to predict inhospital mortality. We assessed discrimination of the models by measuring the area under the receiver operating characteristic curve (AUC). We assessed calibration by the Hosmer-Lemeshow goodness of fit statistic. Results: The AUC for the model using original Provent-14 variables was 0.78 (trauma omitted for N=1). The most parsimonious model using the additional variables includes risk factors age 50-64 and ≥65;platelet count <100, and requirement for vasopressors, renal replacement or ECMO on day 14 of MV. The area under the curve for this model is 0.83. Calibration for the modified parsimonious model is provided in the table below (Goodness-of-fit statistic p=0.80). Dichotomized neutrophil to lymphocyte ratio on day 14 (N:L>15) improves the model slightly AUC=0.83, Goodness-of-fit p=0.61, though this variable was available for only 60% of the cohort. Conclusion: A modified clinical prediction model based on the previously validated ProVent-14 model is a simple method to accurately identify patients with ARDS from COVID-19 requiring PMV who are at high risk of in-hospital mortality. Further validation of model performance in a larger population and including long-term survival is warranted.","PeriodicalId":111156,"journal":{"name":"TP49. TP049 COVID: ARDS AND ICU MANAGEMENT","volume":"11 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":"115476456","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}