OBJECTIVES: Increasing time to mechanical ventilation and high-flow nasal cannula use may be associated with mortality in coronavirus disease 2019. We examined the impact of time to intubation and use of high-flow nasal cannula on clinical outcomes in patients with coronavirus disease 2019. DESIGN: Retrospective cohort study. SETTING: Six coronavirus disease 2019-specific ICUs across four university-affiliated hospitals in Atlanta, Georgia. PATIENTS: Adults with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection who received high-flow nasal cannula or mechanical ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among 231 patients admitted to the ICU, 109 (47.2%) were treated with high-flow nasal cannula and 97 (42.0%) were intubated without preceding high-flow nasal cannula use. Of those managed with high-flow nasal cannula, 78 (71.6%) ultimately received mechanical ventilation. In total, 175 patients received mechanical ventilation; 44.6% were female, 66.3% were Black, and the median age was 66 years (interquartile range, 56-75 yr). Seventy-six patients (43.4%) were intubated within 8 hours of ICU admission, 57 (32.6%) between 8 and 24 hours of admission, and 42 (24.0%) greater than or equal to 24 hours after admission. Patients intubated within 8 hours were more likely to have diabetes, chronic comorbidities, and higher admission Sequential Organ Failure Assessment scores. Mortality did not differ by time to intubation (≤ 8 hr: 38.2%; 8-24 hr: 31.6%; ≥ 24 hr: 38.1%; p = 0.7), and there was no association between time to intubation and mortality in adjusted analysis. Similarly, there was no difference in initial static compliance, duration of mechanical ventilation, or ICU length of stay by timing of intubation. High-flow nasal cannula use prior to intubation was not associated with mortality. CONCLUSIONS: In this cohort of critically ill patients with coronavirus disease 2019, neither time from ICU admission to intubation nor high-flow nasal cannula use were associated with increased mortality. This study provides evidence that coronavirus disease 2019 respiratory failure can be managed similarly to hypoxic respiratory failure of other etiologies.
On March 6, 2020, the first patient diagnosed with COVID-19 at our institution was admitted to the Emory Serious Communicable Disease Unit (SCDU), which was initially established for the care of patients with Ebola and other special pathogens. The demand for ICU beds quickly outstripped the SCDU capacity: within days we converted ordinary ICUs to receive the influx of COVID patients. Our teams struggled with fear, anxiety, and uncertainty about our safety and that of our families. We struggled much more wondering about the best care for our patients.
ABSTRACT: The coronavirus disease (COVID-19) pandemic has threatened millions of lives worldwide with severe systemic inflammation, organ dysfunction, and thromboembolic disease. Within our institution, many critically ill COVID-19-positive patients suffered major thrombotic events, prompting our clinicians to evaluate hypercoagulability outside of traditional coagulation testing.We determined the prevalence of fibrinolysis shutdown via rotational thromboelastometry (ROTEM, Instrumentation Laboratories, Bedford, Mass) in patients admitted to the intensive care unit over a period of 3 weeks. In 25 patients who had a ROTEM test, we found that 11 (44%) met criteria for fibrinolysis shutdown. Eight of 9 (73%) of the VTE patients met criteria for fibrinolysis shutdown.Given the high rate of fibrinolysis shutdown in these patients, our data support using viscoelastic testing to evaluate for the presence of impaired fibrinolysis. This may help identify patient subsets who might benefit from the administration of fibrinolytics.
Raising public awareness of sepsis, a potentially life-threatening dysregulated host response to infection, to hasten its recognition has become a major focus of physicians, investigators, and both non-governmental and governmental agencies. While the internet is a common means by which to seek out healthcare information, little is understood about patterns and drivers of these behaviors. We sought to examine traffic to Wikipedia, a popular and publicly available online encyclopedia, to better understand how, when, and why users access information about sepsis. Utilizing pageview traffic data for all available language localizations of the sepsis and septic shock pages between July 1, 2015 and June 30, 2018, significantly outlying daily pageview totals were identified using a seasonal hybrid extreme studentized deviate approach. Consecutive outlying days were aggregated, and a qualitative analysis was undertaken of print and online news media coverage to identify potential correlates. Traffic patterns were further characterized using paired referrer to resource (i.e. clickstream) data, which were available for a temporal subset of the pageviews. Of the 20,557,055 pageviews across 65 linguistic localizations, 47 of the 1,096 total daily pageview counts were identified as upward outliers. After aggregating sequential outlying days, 25 epochs were examined. Qualitative analysis identified at least one major news media correlate for each, which were typically related to high-profile deaths from sepsis and, less commonly, awareness promotion efforts. Clickstream analysis suggests that most sepsis and septic shock Wikipedia pageviews originate from external referrals, namely search engines. Owing to its granular and publicly available traffic data, Wikipedia holds promise as a means by which to better understand global drivers of online sepsis information seeking. Further characterization of user engagement with this information may help to elucidate means by which to optimize the visibility, content, and delivery of awareness promotion efforts.
We report preliminary data from a cohort of adults admitted to COVID-designated intensive care units from March 6 through April 17, 2020 across an academic healthcare system. Among 217 critically ill patients, mortality for those who required mechanical ventilation was 29.7% (49/165), with 8.5% (14/165) of patients still on the ventilator at the time of this report. Overall mortality to date in this critically ill cohort is 25.8% (56/217), and 40.1% (87/217) patients have survived to hospital discharge. Despite multiple reports of mortality rates exceeding 50% among critically ill adults with COVID-19, particularly among those requiring mechanical ventilation, our early experience indicates that many patients survive their critical illness.
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.
We present a case of rare congenital obstruction of the inferior vena cava (IVC) outlet detected intraoperatively on transesophageal echocardiography (TEE). Lacking a better explanation, hepatic dysfunction had been attributed to primary presentation of hypertrophic cardiomyopathy with presumed diastolic heart failure. However, the intraoperative finding of IVC obstruction better explained hepatic disease, and concurrent repair was successful in resolving the hepatic dysfunction.
Background: Methylene blue (MB) has been used to treat refractory hypotension in a variety of settings. Aims: We sought to determine whether MB improved blood pressure in postcardiopulmonary bypass (CPB) vasoplegic syndrome (VS) in a complex cardiac surgery population. Furthermore, to determine variables that predicted response to MB.
Setting and Design: This was conducted in a tertiary care medical center; this study was a retrospective cohort study. Materials and
Methods: Adult cardiac surgery patients who received MB for post-CPB VS over a 2-year period were studied. Mean arterial blood pressure (MAP) and vasopressor doses were compared before and after MB, and logistic regression was used to model which variables predicted response.
Results: Eighty-eight patients received MB for post-CPB VS during the study period. MB administration was associated with an 8 mmHg increase in MAP (P = 0.004), and peak response occurred at 2 h. Variables that were associated with a positive drug response were deep hypothermic circulatory arrest during surgery and higher MAP at the time of drug administration (P = 0.006 and 0.02). A positive response had no correlation with in-hospital mortality (P = 0.09).
Conclusions: MB modestly increases MAP in cardiac surgery patients with VS. Higher MAP at the time of drug administration and surgery with deep hypothermic circulatory arrest predict a greater drug response.