Ultrasound-guided Axillary Artery Catheter Placement and Associated Complications in Critically Ill Patients.

BACKGROUND: Arterial catheter placement for hemodynamic monitoring is commonly performed in critically ill patients. The radial and femoral arteries are the two sites most frequently used; there is limited data on the use of the axillary artery for this purpose. The aim of this study was to investigate the rate of complications from ultrasound-guided axillary artery catheter placement in critically ill patients. METHODS: A retrospective study at a tertiary care center of patients admitted to an intensive care unit who had ultrasound-guided axillary artery catheter placement during admission. Primary outcome of interest was catheter related complications, including bleeding, vascular complications, compartment syndrome, stroke or air embolism, catheter malfunction, and need for surgical intervention. RESULTS: This study identified 88 patients who had an ultrasound-guided axillary artery catheter placed during their admission. Of these 88, nine patients required multiple catheters placed, for a total of 99 axillary artery catheter placement events. The median age was 64 [IQR 48, 71], 41 (47%) were female, and median body mass index (BMI) was 26 [IQR 22, 30]. The most common complication was minor bleeding (11%), followed by catheter malfunction (2%), and vascular complications (2%). Univariate analyses did not show any association between demographics and clinical variables, and complications related to axillary arterial catheter. CONCLUSION: The most common complication found with ultrasound-guided axillary artery catheter placement was minor bleeding, followed by catheter malfunction, and vascular complications. Ultrasound-guided axillary arterial catheters are an alternative in patients in whom radial or femoral arterial access is difficult or not possible to achieve.

First case of rapidly fatal mpox from secondary (household) transmission in a kidney transplant recipient.

In 2022, a global outbreak of mpox (formerly known as monkeypox) was reported outside of areas considered endemic for the disease, predominantly in persons identifying as men who have sex with men, gay, or bisexual. To date, 3 cases of mpox in solid organ transplant recipients have been published; however, no instances of secondary transmission among solid organ transplant recipients have been reported. Here, we report a case of a 53-year-old male kidney transplant recipient who contracted mpox while caring for a household contact with the disease. The patient's clinical and laboratory findings during his rapidly fatal course, autopsy findings, and genomics analysis are presented, emphasizing the need for expanded pre-exposure prophylaxis efforts in patient populations without the risk factors prioritized by public health authorities for vaccination.

Family experience survey in the surgical intensive care unit.

The experience of critical care is stressful for both patients and their families. This is especially true when patients are not able to make their own care decisions. This article details the creation of a Family Experience Survey in a surgical intensive care unit (SICU) to capture and improve overall experience. Kolcaba's "Enhanced Comfort Theory" provided the theoretical basis for question formation, specifically in regards to the four aspects of comfort: "physical," "psycho-spiritual," "sociocultural" and "environmental." Survey results were analyzed in real-time to identify and implement interventions needed for issues raised. Overall, there was a high level of satisfaction reported especially with quality of care provided to patients, communication and availability of nurses and doctors, explanations from staff, inclusion in decision making, the needs of patients being met, quality of care provided to patients and cleanliness of the unit. It was noted that 'N/A' was indicated for cultural needs and spiritual needs, a chaplain now rounds on all patients daily to ensure these services are more consistently offered. In addition, protocols for doctor communication with families, palliative care consults, daily bleach cleaning of high touch areas in patient rooms and nurse-led progressive mobility have been implemented. Enhanced comfort theory enabled the opportunity to identify and provide a more 'broad' approach to care for patients and families.

The COVID-19 Tracheostomy Experience at a Large Academic Medical Center in New York during the First Year.

Background: New York City was the epicenter of the initial surge of the COVID-19 pandemic in the United States. Tracheostomy is a critical procedure in the care of patients with COVID-19. We hypothesized that early tracheostomy would decrease the length of time on sedation, time on mechanical ventilation, intensive care unit length of stay, and mortality. Methods: A retrospective analysis of outcomes for all patients with COVID-19 who underwent tracheostomy during the first year of the COVID-19 pandemic at the Mount Sinai Hospital in New York City, New York. All adult intensive care units at the Mount Sinai Hospital, New York. Patients/subjects: 888 patients admitted to intensive care with COVID-19. Results: All patients admitted to the intensive care unit with COVID-19 (888) from 1 March 2020 to 1 March 2021 were analyzed and separated further into those intubated (544) and those requiring tracheostomy (177). Of those receiving tracheostomy, outcomes were analyzed for early (≤12 days) or late (>12 days) tracheostomy. Demographics, medical history, laboratory values, type of oxygen and ventilatory support, and clinical outcomes were recorded and analyzed. Conclusions: Early tracheostomy resulted in reduced duration of mechanical ventilation, reduced hospital length of stay, and reduced intensive care unit length of stay in patients admitted to the intensive care unit with COVID-19. There was no effect on overall mortality.

Prolonged Anaphylaxis to Pfizer Coronavirus Disease 2019 Vaccine: A Case Report and Mechanism of Action.

BACKGROUND: In response to the devastating effects of the coronavirus disease 2019 pandemic, several vaccine prototypes have been developed, with the Pfizer/BioNTech (BNT162b2) platform being the first to receive emergency use authorization. Although taken to market on an unprecedented timeline, the safety profile of the drug during clinical trials was shown to be favorable. Shortly after release, reports from the Centers for Disease Control and Prevention demonstrated a higher-than-average rate of anaphylaxis to the vaccine that has been the cause for concern for safety officials and the general public alike. Here, we present a unique case of protracted anaphylaxis in a recipient of the BNT162b2. CASE SUMMARY: The patient is a 55-year-old female with a history of multiple allergic reactions who presented with respiratory distress and hives after receiving the first dose of the BNT162b2, despite premedication with IV steroids and diphenhydramine. The refractory nature of her reaction was demonstrated by edema of her tongue (visualized on nasolaryngoscopy), requiring an epinephrine infusion for nearly 3 days. She was discharged from the hospital with instructions not to receive the second dose of the vaccine. CONCLUSION: Although the exact etiology of anaphylaxis secondary to this messenger RNA-based vaccine is not completely clear, our literature search and review of the patient's course support either polyethylene glycol versus other excipient-related allergy as a possible cause. Based on the protracted nature to our patient's anaphylaxis, critical care management for patients with a true anaphylactic reaction to BNT162b2 may require monitoring for an extended period of time.

Prognostic Value of Electrocardiographic QRS Diminution in Patients Hospitalized With COVID-19 or Influenza.

During the clinical care of hospitalized patients with COVID-19, diminished QRS amplitude on the surface electrocardiogram (ECG) was observed to precede clinical decompensation, culminating in death. This prompted investigation into the prognostic utility and specificity of low QRS complex amplitude (LoQRS) in COVID-19. We retrospectively analyzed consecutive adults admitted to a telemetry service with SARS-CoV-2 (n = 140) or influenza (n = 281) infection with a final disposition-death or discharge. LoQRS was defined as a composite of QRS amplitude <5 mm or <10 mm in the limb or precordial leads, respectively, or a ≥50% decrease in QRS amplitude on follow-up ECG during hospitalization. LoQRS was more prevalent in patients with COVID-19 than influenza (24.3% vs 11.7%, p = 0.001), and in patients who died than survived with either COVID-19 (48.1% vs 10.2%, p <0.001) or influenza (38.9% vs 9.9%, p <0.001). LoQRS was independently associated with mortality in patients with COVID-19 when adjusted for baseline clinical variables (odds ratio [OR] 11.5, 95% confidence interval [CI] 3.9 to 33.8, p <0.001), presenting and peak troponin, D-dimer, C-reactive protein, albumin, intubation, and vasopressor requirement (OR 13.8, 95% CI 1.3 to 145.5, p = 0.029). The median time to death in COVID-19 from the first ECG with LoQRS was 52 hours (interquartile range 18 to 130). Dynamic QRS amplitude diminution is a strong independent predictor of death over not only the course of COVID-19 infection, but also influenza infection. In conclusion, this finding may serve as a pragmatic prognostication tool reflecting evolving clinical changes during hospitalization, over a potentially actionable time interval for clinical reassessment.

Atrial Fibrillation in Patients Hospitalized With COVID-19: Incidence, Predictors, Outcomes, and Comparison to Influenza.

OBJECTIVES: The goal of this study is to determine the incidence, predictors, and outcomes of atrial fibrillation (AF) or atrial flutter (AFL) in patients hospitalized with coronavirus disease-2019 (COVID-19). BACKGROUND: COVID-19 results in increased inflammatory markers previously associated with atrial arrhythmias. However, little is known about their incidence or specificity in COVID-19 or their association with outcomes. METHODS: This is a retrospective analysis of 3,970 patients admitted with polymerase chain reaction-positive COVID-19 between February 4 and April 22, 2020, with manual review performed of 1,110. The comparator arm included 1,420 patients with influenza hospitalized between January 1, 2017, and January 1, 2020. RESULTS: Among 3,970 inpatients with COVID-19, the incidence of AF/AFL was 10% (n = 375) and in patients without a history of atrial arrhythmias it was 4% (n = 146). Patients with new-onset AF/AFL were older with increased inflammatory markers including interleukin 6 (93 vs. 68 pg/ml; p < 0.01), and more myocardial injury (troponin-I: 0.2 vs. 0.06 ng/ml; p < 0.01). AF and AFL were associated with increased mortality (46% vs. 26%; p < 0.01). Manual review captured a somewhat higher incidence of AF/AFL (13%, n = 140). Compared to inpatients with COVID-19, patients with influenza (n = 1,420) had similar rates of AF/AFL (12%, n = 163) but lower mortality. The presence of AF/AFL correlated with similarly increased mortality in both COVID-19 (relative risk: 1.77) and influenza (relative risk: 1.78). CONCLUSIONS: AF/AFL occurs in a subset of patients hospitalized with either COVID-19 or influenza and is associated with inflammation and disease severity in both infections. The incidence and associated increase in mortality in both cohorts suggests that AF/AFL is not specific to COVID-19, but is rather a generalized response to the systemic inflammation of severe viral illnesses.

Use of echocardiography and modalities of patient monitoring of trauma patients.

PURPOSE OF REVIEW: Trauma patients require evaluation of the anatomic structure as well as the hemodynamic profile of the heart to improve effectiveness of resuscitation. They are prone to hemodynamic instability and must be monitored with various modalities to detect deterioration early. Newer, less invasive ultrasound technologies are replacing familiar 'gold standard' modalities of the past. This article reviews the indications, roles, imaging approaches, and limitations of modern echocardiography. A brief review of other ICU monitoring modalities is also presented. RECENT FINDINGS: Echocardiography has emerged as a first-line diagnostic tool for assessment of trauma patients, especially those with hemodynamic compromise. It yields crucial information about structural damage as well as the hemodynamic profile and can be performed through either the transesophageal or transthoracic route. Quick and systematic use of echocardiography for diagnosis and management of critically injured patients may lead to improved outcomes. SUMMARY: Echocardiography plays an important role in the trauma bay for diagnosis of thoracic injury and at the bedside in the ICU for evaluation of the hemodynamic profile.

Tracheostomy for Coronavirus Disease 2019 Patients: Maintaining the Standard of Care.

OBJECTIVES: To respond to the new recommendations for delaying tracheostomy for coronavirus disease 2019 patients to day 21 post-intubation to ensure viral clearance. DESIGN: Prospective observational cohort from April 1, 2020, to April 30, 2020, with 60 days follow-up. SETTING: Academic medical center with nine adult ICUs dedicated to caring for coronavirus disease 2019 patients requiring mechanical ventilation. PATIENTS: Mechanically ventilated patients with coronavirus disease 2019 pneumonia requiring tracheostomy for prolonged ventilatory support. INTERVENTIONS: Adherence to the standard of care for timing of tracheostomy as deemed necessary by the intensivist without delay and utilizing the existing tracheostomy team in performing the needed procedures within 1 day of the request. MEASUREMENTS AND MAIN RESULTS: One hundred eleven patients with coronavirus disease 2019 received tracheostomy in the month of April 2020. Median time to tracheostomy was 11 days. All procedures were performed percutaneously at bedside under bronchoscopic guidance. Sixty-three percent of patients who received tracheostomy either weaned or discharged alive within 60 days of the procedure. Performing tracheostomy on these patients without delay did not lead to coronavirus disease 2019 viral transmission to the tracheostomy team as evident by lack of symptoms and negative antibody testing. CONCLUSIONS: Adherence to standard of care in timing of tracheostomy is safe. Recommending delaying the procedure may lead to harmful consequences from prolonging mechanical ventilation and sedation without apparent benefit.

Timing of Intubation and In-Hospital Mortality in Patients With Coronavirus Disease 2019.

OBJECTIVES: To examine whether increasing time between admission and intubation was associated with mortality in patients with coronavirus disease 2019 who underwent mechanical ventilation. DESIGN: Retrospective cohort study of patients with severe acute respiratory syndrome coronavirus 2 infection who were admitted between January 30, 2020, and April 30, 2020, and underwent intubation and mechanical ventilation prior to May 1, 2020. Patients were followed up through August 15, 2020. SETTING: Five hospitals within the Mount Sinai Health System in New York City, NY. PATIENTS: Adult patients with severe acute respiratory syndrome coronavirus 2 infection who underwent intubation and mechanical ventilation. INTERVENTIONS: Tracheal intubation and mechanical ventilation. MEASUREMENTS AND MAIN RESULTS: The primary outcome was in-hospital mortality. A hospital-stratified time-varying Cox model was used to evaluate the effect of time from admission to intubation on in-hospital death. A total of 755 adult patients out of 5,843 admitted with confirmed severe acute respiratory syndrome coronavirus 2 infection underwent tracheal intubation and mechanical ventilation during the study period. The median age of patients was 65 years (interquartile range, 56-72 yr) and 64% were male. As of the time of follow-up, 121 patients (16%) who were intubated and mechanically ventilated had been discharged home, 512 (68%) had died, 113 (15%) had been discharged to a skilled nursing facility, and 9 (1%) remained in the hospital. The median time from admission to intubation was 2.3 days (interquartile range, 0.6-6.3 d). Each additional day between hospital admission and intubation was significantly associated with higher in-hospital death (adjusted hazard ratio, 1.03; 95% CI, 1.01-1.05). CONCLUSIONS: Among patients with coronavirus disease 2019 who were intubated and mechanically ventilated, intubation earlier in the course of hospital admission may be associated with improved survival.

Convalescent plasma treatment of severe COVID-19: a propensity score-matched control study.

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a new human disease with few effective treatments1. Convalescent plasma, donated by persons who have recovered from COVID-19, is the acellular component of blood that contains antibodies, including those that specifically recognize SARS-CoV-2. These antibodies, when transfused into patients infected with SARS-CoV-2, are thought to exert an antiviral effect, suppressing virus replication before patients have mounted their own humoral immune responses2,3. Virus-specific antibodies from recovered persons are often the first available therapy for an emerging infectious disease, a stopgap treatment while new antivirals and vaccines are being developed1,2. This retrospective, propensity score-matched case-control study assessed the effectiveness of convalescent plasma therapy in 39 patients with severe or life-threatening COVID-19 at The Mount Sinai Hospital in New York City. Oxygen requirements on day 14 after transfusion worsened in 17.9% of plasma recipients versus 28.2% of propensity score-matched controls who were hospitalized with COVID-19 (adjusted odds ratio (OR), 0.86; 95% confidence interval (CI), 0.75-0.98; chi-square test P value = 0.025). Survival also improved in plasma recipients (adjusted hazard ratio (HR), 0.34; 95% CI, 0.13-0.89; chi-square test P = 0.027). Convalescent plasma is potentially effective against COVID-19, but adequately powered, randomized controlled trials are needed.

Malignant Arrhythmias in Patients With COVID-19: Incidence, Mechanisms, and Outcomes.

BACKGROUND: Patients with coronavirus disease 2019 (COVID-19) who develop cardiac injury are reported to experience higher rates of malignant cardiac arrhythmias. However, little is known about these arrhythmias-their frequency, the underlying mechanisms, and their impact on mortality. METHODS: We extracted data from a registry (NCT04358029) regarding consecutive inpatients with confirmed COVID-19 who were receiving continuous telemetric ECG monitoring and had a definitive disposition of hospital discharge or death. Between patients who died versus discharged, we compared a primary composite end point of cardiac arrest from ventricular tachycardia/fibrillation or bradyarrhythmias such as atrioventricular block. RESULTS: Among 800 patients with COVID-19 at Mount Sinai Hospital with definitive dispositions, 140 patients had telemetric monitoring, and either died (52) or were discharged (88). The median (interquartile range) age was 61 years (48-74); 73% men; and ethnicity was White in 34%. Comorbidities included hypertension in 61%, coronary artery disease in 25%, ventricular arrhythmia history in 1.4%, and no significant comorbidities in 16%. Compared with discharged patients, those who died had elevated peak troponin I levels (0.27 versus 0.02 ng/mL) and more primary end point events (17% versus 4%, P=0.01)-a difference driven by tachyarrhythmias. Fatal tachyarrhythmias invariably occurred in the presence of severe metabolic imbalance, while atrioventricular block was largely an independent primary event. CONCLUSIONS: Hospitalized patients with COVID-19 who die experience malignant cardiac arrhythmias more often than those surviving to discharge. However, these events represent a minority of cardiovascular deaths, and ventricular tachyarrhythmias are mainly associated with severe metabolic derangement. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04358029.

Characterization of Myocardial Injury in Patients With COVID-19.

BACKGROUND: Myocardial injury is frequent among patients hospitalized with coronavirus disease-2019 (COVID-19) and is associated with a poor prognosis. However, the mechanisms of myocardial injury remain unclear and prior studies have not reported cardiovascular imaging data. OBJECTIVES: This study sought to characterize the echocardiographic abnormalities associated with myocardial injury and their prognostic impact in patients with COVID-19. METHODS: We conducted an international, multicenter cohort study including 7 hospitals in New York City and Milan of hospitalized patients with laboratory-confirmed COVID-19 who had undergone transthoracic echocardiographic (TTE) and electrocardiographic evaluation during their index hospitalization. Myocardial injury was defined as any elevation in cardiac troponin at the time of clinical presentation or during the hospitalization. RESULTS: A total of 305 patients were included. Mean age was 63 years and 205 patients (67.2%) were male. Overall, myocardial injury was observed in 190 patients (62.3%). Compared with patients without myocardial injury, those with myocardial injury had more electrocardiographic abnormalities, higher inflammatory biomarkers and an increased prevalence of major echocardiographic abnormalities that included left ventricular wall motion abnormalities, global left ventricular dysfunction, left ventricular diastolic dysfunction grade II or III, right ventricular dysfunction and pericardial effusions. Rates of in-hospital mortality were 5.2%, 18.6%, and 31.7% in patients without myocardial injury, with myocardial injury without TTE abnormalities, and with myocardial injury and TTE abnormalities. Following multivariable adjustment, myocardial injury with TTE abnormalities was associated with higher risk of death but not myocardial injury without TTE abnormalities. CONCLUSIONS: Among patients with COVID-19 who underwent TTE, cardiac structural abnormalities were present in nearly two-thirds of patients with myocardial injury. Myocardial injury was associated with increased in-hospital mortality particularly if echocardiographic abnormalities were present.

Successful placement of a right ventricular assist device for treatment of a presumed amniotic fluid embolism.

Amniotic fluid embolism is a rare and often fatal complication of pregnancy. We report the successful multidisciplinary management of a woman who developed a coagulopathy from a presumed amniotic fluid embolism after forceps-assisted vaginal delivery requiring recombinant factor VIIa, and pulmonary arterial hypertension requiring a right ventricular assist device.

Sinus bradycardia associated with daclizumab in liver transplant recipients: report of 3 cases.

Daclizumab is a commonly used immunosuppressive agent for prophylaxis of solid organ rejection. Although rare, the cardiovascular adverse effects of daclizumab include sinus tachycardia, hypotension, and hypertension. Here, we report 3 patients who developed significant and prolonged sinus bradycardia after receiving daclizumab following orthotopic liver transplant. Daclizumab should be considered a possible cause of bradycardia following its administration in orthotopic liver transplant.

Critical care management and intensive care unit outcomes following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy.

AIM: To study the early postoperative intensive care unit (ICU) management and complications in the first 2 wk of patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS: Our study is a retrospective, observational study performed at Icahn School of Medicine at Mount Sinai, quaternary care hospital in New York City. All adult patients who underwent CRS and HIPEC between January 1, 2007 and December 31, 2012 and admitted to ICU postoperatively were studied. Fifty-one patients came to the ICU postoperatively out of 170 who underwent CRS and HIPEC therapy during the study period. Data analysis was performed using descriptive statistics. RESULTS: Of the 170 patients who underwent CRS and HIPEC therapy, 51 (30%) came to the ICU postoperatively. Mean ICU length of stay was 4 d (range 1-60 d) and mean APACHE II score was 15 (range 7-23). Thirty-one/fifty-one (62%) patients developed postoperative complications. Aggressive intraoperative and postoperative fluid resuscitation is required in most patients. Hypovolemia was seen in all patients and median amount of fluids required in the first 48 h was 6 L (range 1-14 L). Thirteen patients (25%) developed postoperative hypotension with seven requiring vasopressor support. The major cause of sepsis was intraabdominal, with 8 (15%) developing anastomotic leaks and 5 (10%) developing intraabdominal abscess. The median survival was 14 mo with 30 d mortality of 4% (2/51) and 90 d mortality of 16% (8/51). One year survival was 56.4% (28/51). Preoperative medical co morbidities, extent of surgical debulking, intraoperative blood losses, amount of intra op blood products required and total operative time are the factors to be considered while deciding ICU vs non ICU admission. CONCLUSION: Overall, ICU outcomes of this study population are excellent. Triage of these patients should consider preoperative and intraoperative factors. Intensivists should be vigilant to aggressive postop fluid resuscitation, pain control and early detection and management of surgical complications.

Enteral nutrition administration in a surgical intensive care unit: Achieving goals with better strategies.

AIM: To evaluate the impact of an enteral feeding protocol on administration of nutrition to surgical intensive care unit (SICU) patients. METHODS: A retrospective chart review was conducted on patients initiated on enteral nutrition (EN) support during their stay in a 14 bed SICU. Data collected over a seven-day period included date of tube feed initiation, rate initiated, subsequent hourly rates, volume provided daily, and the nature and length of interruptions. The six months prior to implementation of the feeding protocol (pre-intervention) and six months after implementation (post-intervention) were compared. One hundred and four patients met criteria for inclusion; 53 were pre-intervention and 51 post-intervention. RESULTS: Of the 624 patients who received nutrition support during the review period, 104 met the criteria for inclusion in the study. Of the 104 patients who met criteria outlined for inclusion, 64 reached the calculated goal rate (pre = 28 and post = 36). The median time to achieve the goal rate was significantly shorter in the post-intervention phase (3 d vs 6 d; P = 0.01). The time to achieve the total recommended daily volume showed a non-significant decline in the post-intervention phase (P = 0.24) and the overall volume administered daily was higher in the post-intervention phase (61.6% vs 53.5%; P = 0.07). While the overall interruptions data did not reach statistical significance, undocumented interruptions (interruptions for unknown reasons) were lower in the post-intervention phase (pre = 23/124, post = 9/96; P = 0.06). CONCLUSION: A protocol delineating the initiation and advancement of EN support coupled with ongoing education can improve administration of nutrition to SICU patients.

Getting to zero: Reduction in the incidence of multidrug-resistant organism infections using an integrated infection control protocol in an intensive care unit.

Environmental cleaning is a vital component of infection control. We describe the use of an integrated infection control protocol in an intensive care unit and its influence on multidrug-resistant organism infection rates. Sustained reductions in multidrug-resistant organism infections can be achieved if individual processes and weaknesses in intensive care unit environments are identified and addressed in a systematic and comprehensive manner.