OBJECTIVES: To determine the association between time period of hospitalization and hospital mortality among critically ill adults with coronavirus disease 2019. DESIGN: Observational cohort study from March 6, 2020, to January 31, 2021. SETTING: ICUs at four hospitals within an academic health center network in Atlanta, GA. PATIENTS: Adults greater than or equal to 18 years with coronavirus disease 2019 admitted to an ICU during the study period (i.e., Surge 1: March to April, Lull 1: May to June, Surge 2: July to August, Lull 2: September to November, Surge 3: December to January). MEASUREMENTS AND MAIN RESULTS: Among 1,686 patients with coronavirus disease 2019 admitted to an ICU during the study period, all-cause hospital mortality was 29.7%. Mortality differed significantly over time: 28.7% in Surge 1, 21.3% in Lull 1, 25.2% in Surge 2, 30.2% in Lull 2, 34.7% in Surge 3 (p = 0.007). Mortality was significantly associated with 1) preexisting risk factors (older age, race, ethnicity, lower body mass index, higher Elixhauser Comorbidity Index, admission from a nursing home); 2) clinical status at ICU admission (higher Sequential Organ Failure Assessment score, higher d-dimer, higher C-reactive protein); and 3) ICU interventions (receipt of mechanical ventilation, vasopressors, renal replacement therapy, inhaled vasodilators). After adjusting for baseline and clinical variables, there was a significantly increased risk of mortality associated with admission during Lull 2 (relative risk, 1.37 [95% CI = 1.03–1.81]) and Surge 3 (relative risk, 1.35 [95% CI = 1.04–1.77]) as compared to Surge 1. CONCLUSIONS: Despite increased experience and evidence-based treatments, the risk of death for patients admitted to the ICU with coronavirus disease 2019 was highest during the fall and winter of 2020. Reasons for this increased mortality are not clear.
Purpose
Successful use of alteplase and argatroban to treat a patient with coronavirus disease 2019 (COVID-19)–associated massive pulmonary embolism with cardiac arrest is reported.
Summary
This case report describes a 42-year-old male with COVID-19 who developed a massive pulmonary embolism resulting in cardiac arrest after suspected failure of low-molecular-weight heparin therapy for a deep venous thrombosis. Administration of two 50-mg doses of intravenous alteplase resulted in return of spontaneous circulation, and low-dose argatroban was used as follow-up anticoagulation therapy without complications. This is the first case report of use of argatroban in a patient with COVID-19 with cardiac arrest–associated massive pulmonary embolism after failure of previous anticoagulation efforts.
Conclusion
Argatroban may be used as an alternate anticoagulation strategy in COVID-19 patients who fail low-molecular weight therapy. A risk versus benefit discussion should be had regarding appropriateness of therapy as well as dosing. More data is needed to understand the unique hypercoagulable condition in COVID-19 patients as well as research that further highlights the role of argatroban and bivalirudin therapy in this patient population.
Venovenous (VV) extracorporeal membrane oxygenation (ECMO) is a form of mechanical support used in respiratory failure refractory to conventional medical management. Because VV ECMO cannulation is an uncommonly performed, time-sensitive, and high-stakes procedure (1), simulation can be used to improve the procedural competency of trainees. Simulation-based training (SBT) has been shown to improve proficiency of vascular cannulation (2–5), yet there are few low-fidelity, low-cost, portable models that allow physicians-in-training to practice venous cannulation with an ECMO cannula. Most ECMO simulators are high-fidelity, software-based, interactive models (6–9). Because of the cost-prohibitive nature of such models, some nonhuman tissue models were developed for use in procedural skills laboratories for vascular access training, with promising improvements in procedural comfort and skill being shown (10). However, noncommercial simulators in the medical education literature are generally used to teach trainees management of intact ECMO circuits (11–13) or generally combine cannulation SBT with circuit management training (14, 15). Therefore, although these simulators may serve specific roles in ECMO SBT, they may not be as useful for the acquisition of skills related to venous cannula insertion. To address this educational need, we conducted an observational pilot study in which we developed a low-fidelity, low-cost, portable, gelatin-based model intended for use by trainees in preparation for VV ECMO initiation.
Ultrasound (US)-guided central venous catheter (CVC) insertion is a procedure that carries the risk of significant complications. Simulation provides a safe learning atmosphere, but most CVC simulators are not available outside of simulation centers. To explore longitudinal trends in US-guided CVC insertion competency in internal medicine (IM) interns, we studied the use of a low-fidelity, gelatin-based, US-guided CVC insertion simulation model combined with a simulation curriculum. This prospective observational study of IM interns was performed over the course of one academic year. Interns (n = 56) underwent model-based, US-guided procedure simulation training program and a repeated training course prior to their intensive care unit (ICU) rotation. CVC insertion competency at different timepoints was recorded. Survey data about intern experience and attitudes were also collected. Out of the 56 interns initially trained, 40 were included in the final analysis. Across all outcomes, interns experienced skill atrophy between initial training and the beginning of their ICU month. However, by the end of the month, there was a significant improvement in competency as compared to initial procedural training, which then waned by the end of the intern year. Attitudes toward the model were generally positive and self-reported confidence improved throughout the course of the year and correlated with objective measures of competency. Over the course of their intern year, which included simulation training using a gelatin-based model, interns demonstrated consistent competency trends. The use of a gelatin-based CVC insertion simulation model warrants further study as an adjunctive aid to existing simulation training.