Impact of the COVID-19 pandemic on the education and procedural volume of fellows in critical care medicine - a cross-sectional survey.

BACKGROUND: The COVID-19 pandemic has changed the way medical education is delivered. The purpose of this study was to assess the impact of the COVID-19 pandemic on the education and procedural volume of critical care and pulmonary critical care fellows. METHODS: We conducted a cross-sectional, internet-based, voluntary, anonymous, national survey of adult critical care fellows and academic attending physicians in critical care and pulmonary critical care fellowship programs in the United States between December 2020 and February 2021. Survey questions covered both didactic and non-didactic aspects of education and procedural volumes. Answers were ranked on a 5-point Likert scale. Survey responses were summarized by frequency with percentage. Differences between the responses of fellows and attendings were assessed with the Fisher's exact or Chi-Square test, using Stata 16 software (StataCorp LLC, College Station, TX). RESULTS: Seventy four individuals responded to the survey; the majority (70.3%) were male; less than one-third (28.4%) female. Respondents were evenly split among fellows (52.7%) and attendings (47.3%). 41.9% of survey respondents were from the authors' home institution, with a response rate of 32.6%. Almost two-thirds (62.2%) reported that fellows spend more time in the ICU since the onset of the pandemic. The majority noted that fellows insert more central venous catheters (52.7%) and arterial lines (58.1%), but perform fewer bronchoscopies (59.5%). The impact on endotracheal intubations was mixed: almost half of respondents (45.9%) reported fewer intubations, about one-third (35.1%) more intubations. Almost all respondents (93.0%) described fewer workshops; and one-third (36.1%) fewer didactic lectures. The majority (71.2%) noted less time available for research and quality improvement projects; half (50.7%) noted less bedside teaching by faculty and more than one-third (37.0%) less fellow interaction with faculty. Almost one-half of respondents (45.2%) reported an increase in fellows' weekly work hours. CONCLUSION: The pandemic has caused a decrease in scholarly and didactic activities of critical care and pulmonary critical care fellows. Fellows spend more time in ICU rotations, insert more central and arterial lines, but perform fewer intubations and bronchoscopies. This survey provides insights into changes that have occurred in the training of critical care and pulmonary critical care fellows since the onset of the COVID-19 pandemic.

The effect of limited healthcare access on poor outcomes among hospitalized COVID-19 patients in Honduras: A single center cohort study.

Background: The COVID-19 pandemic has had a severe impact on the Latin American subcontinent, particularly in areas with limited hospital resources and a restricted Intensive Care Unit (ICU) capacity. This study aimed to provide a comprehensive description of the clinical characteristics, outcomes, and factors associated with survival of COVID-19 hospitalized patients in Honduras. Research question: What were the characteristics and outcomes of COVID-19 patients in a large referral center in Honduras? Study design and methods: This study employed a retrospective cohort design conducted in a single center in San Pedro Sula, Honduras, between October 2020 to March 2021. All hospitalized cases of confirmed COVID-19 during this timeframe were included in the analysis. Univariable and multivariable survival analysis were performed using Kaplan-Meier curves and Cox proportional hazards model aiming to identify factors associated with decreased 30 day in-hospital survival, using a priori-selected factors. Results: A total of 929 confirmed cases were identified in this cohort, with males accounting for 55.4 % of cases. The case fatality rate among the hospitalized patients was found to be 50.1 % corresponding to 466 deaths. Patients with comorbidities such as hypertension, diabetes, obesity, chronic kidney disease, chronic obstructive pulmonary disease and cardiovascular disease had a higher likelihood of mortality. Additionally, non-survivors had a significantly longer time from illness onset to hospital admission compared to survivors (8.2 days vs 4.7 days). Among the cohort, 306 patients (32.9 %) met criteria for ICU admission. However, due to limited capacity, only 60 patients (19·6 %) were admitted to the ICU. Importantly, patients that were unable to receive level-appropriate care had lower likelihood of survival compared to those who received level-appropriate care (hazard ratio: 1.84). Interpretation: This study represents, the largest investigation of in-hospital COVID-19 cases in Honduras and Central America. The findings highlight a substantial case fatality rate among hospitalized patients. In this study, patients who couldn't receive level-appropriate care (ICU admission) had a significantly lower likelihood of survival when compared to those who did. These results underscore the significant impact of healthcare access during the pandemic, particularly in low- and middle-income countries.

High-Dose vs. Low-Dose Dexamethasone in Patients With COVID-19: A Cohort Study in Rural Central America.

To compare the clinical outcomes of a low dose dexamethasone strategy vs. a high-dose dexamethasone strategy in hypoxemic COVID-19 patients. A retrospective observational study comparing low-dose (8 mg) and high-dose dexamethasone (24 mg) of COVID-19 patients admitted from September 1, 2020 to October 31, 2020 in a hospital in Honduras. We included 81 patients with confirmed COVID-19 who required oxygen therapy. The mean age was similar between groups (57.49 vs. 56.95 years). There were more male patients in the group of 24 mg ( p = 0.01). Besides, patients on the 24 mg dose had more prevalence of hypertension ( p = 0.052). More patients in the 24 mg group had a higher rate of invasive mechanical ventilation (15.00% vs. 2.56%, p = 0.058). When evaluating the association between the high dose group and outcomes, we find no significant association with mortality, nosocomial infections, high flow mask, invasive mechanical ventilation, or the need for vasopressors. We find no significant differences in the Kaplan-Meier analysis regarding the survival (log-rank p -value = 0.315). We did not find significant differences between the use of 24 mg and 8 mg of dexamethasone in hypoxemic COVID-19 patients.

Development of Compartment Syndrome after Radial Artery Puncture in a Patient with Acute Hypoxemic Respiratory Failure due to COVID-19.

A 71-year-old man who was recently hospitalized for COVID-19 pneumonia complicated by acute hypoxemic respiratory failure and severe ARDS requiring noninvasive ventilation was transferred to our hospital from a rehabilitation facility for new onset right wrist and hand pain and swelling which had been attributed to arterial thrombosis and empirically treated with therapeutic anticoagulation. He developed numbness and paralysis in his right hand and was diagnosed with right forearm compartment syndrome requiring emergent fasciotomy. After a prolonged hospital stay complicated by respiratory failure requiring mechanical ventilation, he was discharged with improved, but not resolved, sensorimotor deficits. Arterial blood gas sampling is commonly performed in patients with acute hypoxemic respiratory failure, for assessment of oxygenation and acid-base status. It is considered a benign procedure, but it can lead to serious complications, such as bleeding and compartment syndrome. Risks and benefits of any procedure need to be weighed carefully and less is often more. Compartment syndrome is characterized by the 5 P's-pain, pallor, paresthesia, pulselessness, and paralysis.

Management of Life-Threatening Asthma: Severe Asthma Series.

Asthma exacerbations can be life-threatening, with 25,000 to 50,000 such patients per year requiring admission to an ICU in the United States. Appropriate triage of life-threatening asthma is dependent on both static assessment of airway function and dynamic assessment of response to therapy. Treatment strategies focus on achieving effective bronchodilation with inhaled ß2-agonists, muscarinic antagonists, and magnesium sulphate while reducing inflammation with systemic corticosteroids. Correction of hypoxemia and hypercapnia, a key in managing life-threatening asthma, occasionally requires the incorporation of noninvasive mechanical ventilation to decrease the work of breathing. Endotracheal intubation and mechanical ventilation should not be delayed if clinical improvement is not achieved with conservative therapies. However, mechanical ventilation in these patients often requires controlled hypoventilation, adequate sedation, and occasional use of muscle relaxation to avoid dynamic hyperinflation, which can result in barotrauma or volutrauma. Sedation with ketamine or propofol is preferred because of their potential bronchodilation properties. In this review, we outline strategies for the assessment and management of patients with acute life-threatening asthma focusing on those requiring admission to the ICU.

Predictors of failure of high flow nasal cannula failure in acute hypoxemic respiratory failure due to COVID-19.

Hypoxemic respiratory failure is a common manifestation of COVID-19 pneumonia. Early in the COVID-19 pandemic, patients with hypoxemic respiratory failure were, at times, being intubated earlier than normal; in part because the options of heated humidified high flow nasal cannula (HFNC) and non-invasive ventilation (NIV) were considered potentially inadequate and to increase risk of virus aerosolization. To understand the benefits and factors that predict success and failure of HFNC in this population, we evaluated data from the first 30 sequential patients admitted with COVID-19 pneumonia to our center who were managed with HFNC. We conducted Cox Proportional Hazards regression models to evaluate the factors associated with high flow nasal cannula failure (outcome variable), using time to intubation (censoring variable), while adjusting for comorbidities and immunosuppression. In the majority of our patients (76.7%), the use of HFNC failed and the patients were ultimately placed on mechanical ventilation. Those at increased risk of failure had a higher sequential organ failure assessment score, and at least one comorbidity or history of immunosuppression. Our data suggest that high flow nasal cannula may have a role in some patients with COVID-19 presenting with hypoxemic respiratory failure, but careful patient selection is the likely key to its success.

Impact of ketamine as an adjunct sedative in acute respiratory distress syndrome due to COVID-19 Pneumonia.

PURPOSE: Deep sedation is sometimes needed in acute respiratory distress syndrome. Ketamine is a sedative that has been shown to have analgesic and sedating properties without having a detrimental impact on hemodynamics. This pharmacological profile makes ketamine an attractive sedative, potentially reducing the necessity for other sedatives and vasopressors, but there are no studies evaluating its effect on these medications in patients requiring deep sedation for acute respiratory distress syndrome. MATERIALS AND METHODS: This is a retrospective, observational study in a single center, quaternary care hospital in southeast Texas. We looked at adults with COVID-19 requiring mechanical ventilation from March 2020 to September 2020. RESULTS: We found that patients had less propofol requirements at 72 h after ketamine initiation when compared to 24 h (median 34.2 vs 54.7 mg/kg, p = 0.003). Norepinephrine equivalents were also significantly lower at 48 h than 24 h after ketamine initiation (median 38 vs 62.8 mcg/kg, p = 0.028). There was an increase in hydromorphone infusion rates at all three time points after ketamine was introduced. CONCLUSIONS: In this cohort of patients with COVID-19 ARDS who required mechanical ventilation receiving ketamine we found propofol sparing effects and vasopressor requirements were reduced, while opioid infusions were not.

Atypical Presentation of Acute Disseminated Encephalomyelitis (ADEM) in a Middle-Aged Adult.

BACKGROUND Acute disseminated encephalomyelitis (ADEM) is a demyelinating disease that usually presents in pediatric patients, usually following a viral or bacterial infection. The clinical findings in ADEM include acute neurologic decline that typically presents with encephalopathy, with some cases progressing to multiple sclerosis. An atypical case of ADEM is reported that presented in a middle-aged adult. CASE REPORT A 46-year-old Caucasian man, who had recently emigrated to the US from Ukraine, presented with gait abnormalities that began four days after he developed abdominal cramps. Magnetic resonance imaging (MRI) of the brain with contrast, fluid-attenuated inversion recovery (FLAIR), and T2-weighting showed contrast-enhancing, patchy, diffuse lesions in both cerebral hemispheres. Cerebrospinal fluid (CSF) was negative for oligoclonal bands. On hospital admission, the patient was treated with intravenous (IV) methylprednisolone, 500 mg twice daily. He responded well and was discharged from hospital after a week, with resolution of his presenting symptoms and signs. CONCLUSIONS This report is of an atypical presentation of ADEM in a middle-aged patient who presented with spastic paresis. Although there are no set guidelines for the diagnosis of ADEM in adults, this diagnosis should be considered in patients with acute onset of demyelinating lesions in cerebral MRI. As this case has shown, first-line treatment is with high-dose steroids, which can be rapidly effective.

A case of posterior reversible encephalopathy syndrome associated with sepsis.

Posterior reversible encephalopathy syndrome (PRES) is a neurological disorder characterised by parieto-occipital vasogenic oedema seen on MRI. Infection and sepsis has been reported as a possible cause for this disorder.We present a 19-year-old immunocompetent Caucasian man with known type 1 diabetes mellitus who presented to the emergency department with acute onset of bilateral visual loss, headaches and hypertension; he had been discharged 2 weeks ago for severe diabetic ketoacidosis and Staphylococcus aureus bacteraemia. Initial CT scan of the head was negative, but MRI showed findings suggestive of PRES. He was treated with nicardipine drip for strict blood pressure management and symptoms resolved within 4 days. PRES is a rare disease that has been increasingly reported as MRI becomes more commonplace. Usually associated with immunological disease, pre-eclampsia and cytotoxic therapies but an association with sepsis due to gram-positive bacteria.

Cardiomyopathy induced by anabolic-androgenic steroid abuse.

Bodybuilders use anabolic-androgenic steroids to increase muscle mass, but abuse of these hormones has been related to cardiomyopathy in the past. A 60-year-old Caucasian male bodybuilder with medical history of male hypogonadism and on testosterone replacement therapy, allegedly preparing for a weightlifting competition and receiving stem cell infusions from his trainer, is transferred to the intensive care unit for worsening shortness of breath after failing treatment for community-acquired pneumonia. Chest X-ray on transfer was suggestive of pulmonary oedema, and transthoracic echocardiography showed an ejection fraction of 25%-30%. The patient was taken for cardiac catheterisation, which yielded non-ischaemic cardiomyopathy. His testosterone levels were supratherapeutic. Anabolic-androgenic steroid abuse can be a cause of cardiomyopathy in patients who have no other risk factor for such disease.

Headache in an HIV-Positive Patient: Dangerous Interaction.

Ergotism is an ischaemic complication due to vasoconstriction throughout the body due to ingestion of ergotamine. A 34-year-old Hispanic man with HIV infection treated with saquinavir, ritonavir and abacavir/lamivudine presented to the emergency department complaining of left foot pain 1 week prior to admission. The affected extremity was cold with absence of pedal and tibial pulses. Arterial Doppler revealed absent arterial flow from the popliteal artery later confirmed by arteriography. Medication reconciliation revealed a recent prescription for migraine headache containing ergotamine. Drug was discontinued and the patient was started on cilostazol, enoxaparin and nitroglycerin patches on the affected limb. Complete resolution of symptoms and arteriography findings occurred 2 days after therapy began.

Disseminated Nocardiosis Associated with Treatment with Infliximab in a Patient with Ulcerative Colitis.

BACKGROUND Opportunistic infections may occur when patients with inflammatory bowel disease (IBD) are treated with tumor necrosis factor (TNF)-alpha inhibitors. With the increasing use of new immunosuppressant drugs, the incidence of opportunistic or atypical infections is also increasing, including with Nocardia spp. A high level of awareness of atypical infections is warranted in immunosuppressed patients. CASE REPORT A 57-year-old female African American, with a past medical history of ulcerative colitis (UC) and arthritis, was treated with infliximab and prednisone. She presented to the emergency department with acute onset of chest pain, shortness of breath, and a two-week history of a productive cough. Examination showed hypoxia, tachypnea, decreased and coarse bilateral breath sounds, and fluctuant, tender, erythematous masses on her trunk and groin. Laboratory investigations showed a leukocytosis with a left shift. She was initially treated for presumed community-acquired pneumonia (CAP). However, blood cultures grew Nocardia farcinica and treatment with trimethoprim-sulfamethoxazole (TMP-SMX) was begun, which was complicated by severe symptomatic hyponatremia. Following recovery from infection and resolution of the hyponatremia, the patient was discharged to a senior care facility, but with continued treatment with TMP-SMX. CONCLUSIONS To our knowledge, this is the first case of disseminated nocardiosis associated with infliximab treatment in a patient with ulcerative colitis. As with other forms of immunosuppressive therapy, patients who are treated with infliximab should be followed closely due to the increased risk of atypical infections. When initiating antibiotic therapy, careful monitoring of possible side effects should be done.