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SESSION TITLE: COVID-19 Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Malignant hyperthermia (MH) is a hypermetabolic crisis where an increase in carbon dioxide is seen despite an increased minute ventilation with a proposed mechanism as a disturbance in calcium homeostasis. Commonly seen in volatile anesthetic agents and depolarizing neuromuscular blockers, rarely with nondepolarizing agents. There has been one reported case of cisatracurium-induced MH in the setting of ARDS. There have been two cases reported of nondepolarizing neuromuscular agents causing MH in the setting of COVID-19. CASE PRESENTATION: A 34-year-old man with severe COVID-19 complicated by ARDS on ventilator day 16, due to refractory fevers, ventilatory dyssynchrony, high minute ventilation and auto-PEEP phenomena, the decision was made to attempt neuromuscular paralysis. After one dose of cisatracurium, the patient became hyperthermic and end-tidal carbon-dioxide increased from 58-98 with inability to oxygenate. The patient developed high peak pressures, bedside ultrasound revealed no evidence of pneumothorax also confirmed with chest x-ray. The patient then received a dose of dantrolene with end-tidal improving to 60 and tachycardia also resolved. A creatinine kinase level drawn was elevated at 571. DISCUSSION: A proposed mechanism of MH is calcium release from sarcoplasmic reticulum, a mutation in skeletal muscle ryanodine receptor calcium release channels that can release IL-6 when activated leading to excessive muscular contraction. Proinflammatory cytokine IL-6, dantrolene may block IL-6 release which results in its therapeutic effect in the treatment of MH. IL-6 has been used to predict deterioration from COVID-19. Dantrolene in this sense has been proposed as a potential therapeutic agent against COVID-19, inhibiting intracellular calcium influx thus preventing the pathological feedback of viral entry into cells via endocytosis, as this is a calcium dependent process. Given the possible link between IL-6 release, calcium and MH, SARS-CoV-2 viral entry into cells may place patients at higher risk of MH. Patients with COVID-19 may be at higher risk of MH, even in rare agents such as non-depolarizing agents as seen in this case. Awareness of this potentially increased complication from these agents in those patients with COVID-19 is key as we continue in the ongoing global pandemic. CONCLUSIONS: Given the possible link between IL-6 release, calcium and MH, SARS-CoV-2 viral entry into cells may place patients at higher risk of MH. Patients with COVID-19 may be at higher risk of malignant hyperthermia, even in rare agents such as non-depolarizing agents as seen in this case. Awareness of this potentially increased complication from these agents in those patients with COVID-19 is key as we continue in the ongoing global pandemic. Reference #1: Sathyanarayanan SP, Hamza M, Hamid K, Groskreutz D. Cisatracurium-Associated Malignant Hyperthermia During Severe Sars-CoV-2 Infection. Am J Ther. 2021 Aug 10;28(5):e590-e591. doi: 10.1097/MJT.0000000000001437. PMID: 34387563;PMCID: PMC8415506. Reference #2: Chiba N, Matsuzaki M, Mawatari T, Mizuochi M, Sakurai A, Kinoshita K. Beneficial effects of dantrolene in the treatment of rhabdomyolysis as a potential late complication associated with COVID-19: a case report. Eur J Med Res. 2021 Feb 8;26(1):18. doi: 10.1186/s40001-021-00489-8. PMID: 33557936;PMCID: PMC7868892. Reference #3: Han H, Ma Q, Li C, Liu R, Zhao L, Wang W, Zhang P, Liu X, Gao G, Liu F, Jiang Y, Cheng X, Zhu C, Xia Y. Profiling serum cytokines in COVID-19 patients reveals IL-6 and IL-10 are disease severity predictors. Emerg Microbes Infect. 2020 Dec;9(1):1123-1130. doi: 10.1080/22221751.2020.1770129. PMID: 32475230;PMCID: PMC7473317. DISCLOSURES: No relevant relationships by Hira Bakhtiar No relevant relationships by Timothy DAmico no disclosure on file for Sarah Margolskee;No relevant relationships by Carlos Merino No relevant relationships by Joanna Moore
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Introduction: The EXIT (ex-utero intrapartum treatment) procedure allows management of an abnormal fetal airway during operative delivery while they remain on utero-placental circulation. The vast majority of published cases were conducted under deep volatile anaesthesia [1] in order to provide uterine relaxation and a degree of fetal anaesthesia.10 cases have been reported under combined spinalepidural anaesthesia or intrathecal catheter, with supplemental GTN (glyceryl trinitrate) and remifentanil infusions. Recent research has improved the ability to predict the likelihood and complexity of surgical intervention. Regional anaesthesia cases all had a hysterotomy time of under 21 minutes. Here we present the first case report of an EXIT procedure conducted with simple spinal anaesthesia. Case Report: A 35-year-old woman with a BMI of 37 kg/m2, asthma and a recent COVID-19 pneumonia, had a history of post-dural puncture headache after a difficult epidural for labour, spinal anaesthetics requiring ultrasound and a lumbar puncture requiring x-ray guidance. Her fetal MRI had shown a 5.6 cm cystic neck mass, with a deviated but patent airway. The ENT team predicted surgical interventionwas unlikely or would be very short, but intubation likely. We advised a general anaesthetic as our centre did not yet have experience with EXIT under regional anaesthesia, but the patient adamantly wanted spinal anaesthesia until the baby was born, to be aware of their outcome on delivery. She preferred to avoid an epidural. An arterial line aided the challenging blood pressure management with intrathecal hyperbaric bupivacaine 13.5 mg and diamorphine 300 μg, remifentanil and GTN infusions. The uterus remained relaxed on 2.3 μg/kg/minute of GTN. Uterine tonewas later re-established with intravenous Syntocinon 10 U and intramuscular ergometrine 500 μg, with only 500 mL maternal blood loss. Despite remifentanil target controlled infusion (Minto model) at 3.5 ng/mL for 15 minutes before hysterotomy, the baby cried spontaneously. Hysterotomy timewas two minutes. Discussion: Our team were satisfied with this technique, allowing us to offer more choice to mothers with an expected short EXIT procedure. The utero-placental transfer of remifentanil has previously been found to be variable, but cases have described no fetal response to intubation from maternal remifentanil titrated to light sedation [2]. It is common for additional drugs to be given directly to the fetus even with volatile anaesthetic.
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Rationale: The COVID-19 pandemic has renewed interest in the use of inhaled anesthetics for sedation of ventilated critically ill patients. Compared to intravenous sedatives, inhaled anesthetics reduce lung inflammation, time to extubation, and ICU length of stay. However, their impact on cognitive and psychiatric outcomes is less clear. In this systematic review we summarize the impact of inhaled sedatives on cognitive and psychiatric outcomes in ventilated critically ill patients. Methods: We searched MEDLINE, EMBASE, and PsychINFO for studies from 1970 - 2021 that assessed cognitive and psychiatric outcomes in critically ill adult patients sedated with inhaled anesthetics. We included case series, observational, cohort, and randomized controlled trials. Outcome(s) of interest included cognition, anxiety, depression, hallucinations, psychomotor recovery, and PTSD, as well as instruments for assessing these outcomes. Results: We identified a total of twelve studies that examined at least one of our outcomes of interest (16 total outcomes). Four studies were in post cardiac arrest survivors, three in post-operative (non-cardiac) patients, two in post-operative cardiac patients, and three more in mixed medical-surgical patients. Seven studies reported incidence of delirium, two assessed neurologic recovery post cardiac-arrest, and two examined ICU memories. One study reported on each of anxiety, depression, hallucinations, PTSD, psychomotor recovery, and long-term cognitive dysfunction more than 3 months following ICU discharge. Of the seven studies reporting on delirium, only one reported an increase in delirium for those sedated with intravenous sedation compared to volatile. The remaining studies did not report any difference in delirium incidence between modes of sedation. Similarly, no difference between sedation methods were observed for neurologic recovery following cardiac arrest, anxiety, depression, hallucinations, PTSD, psychomotor recovery, or long-term cognitive dysfunction. The most commonly used tool used was the CAM-ICU tool (delirium outcome;3 studies). Five studies used subjective chart review to assess their outcome of interest, or did not report their method of assessment. Conclusions: Few studies examined cognitive and psychiatric outcomes in critically ill adults sedated with volatile anesthetics. As volatile anesthetics offer a promising alternative mode of sedation in the ICU, future studies should incorporate assessment of these important patientcentered outcomes using validated objective tools during and following hospital stay.
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Volatile anaesthetic agents are potent greenhouse gases (GHGs), representing approximately 5% of the carbon footprint of acute NHS services [1]. Desflurane is an especially potent GHG, with a global warming potential of 1620 CO2 equivalents (CO2e), compared with 210 CO2e for sevoflurane [2]. Efforts to promote environmentally responsible anaesthesia continue, mostly through education and spreading the message through the Scottish Environmental Anaesthesia Group. We aimed to measure changing patterns of volatile anaesthetic use over 3 years, and snapshot nitrous oxide use, within NHS Scotland. Methods The project was registered with clinical governance in NHS Tayside. We quantified volatile use in Scotland from 2018 to 2021 using purchasing data for each territorial health board on a quarterly basis, from point of peak use to the third quarter (Q3) of the 2020/2021 financial year. This was calculated per head of catchment population, with CO2e calculated using the data published by Sulbaek Andersen et al. [1]. Additionally, a survey of anaesthetists within Scotland was carried out to determine patterns of fresh gas flow rates and nitrous oxide use nationally. Results Desflurane fell from a mean of 17.2% to 9.6% of volatile use across larger Scottish hospitals from 2018 to 2021. Between health boards, desflurane use varied from 64.7 to 0 ml per 1000 catchment population, per quarter, at the end of the study period (Fig. 1). A sustained downward trend in desflurane was noted in most health boards, and overall consumption steeply declined, even outwith the COVID-19 pandemic. One hundred and sixty-six anaesthetists responded to the survey. The most common flow rate during maintenance was 0.5-1.9 min-1. Of the anaesthetists, 86% 'rarely' or 'never' used nitrous oxide, with only two anaesthetists out of 166 using it 'always' or 'often'. Default fresh gas flow on anaesthetic machines varied between hospitals and sometimes within hospitals. Figure 1 Desflurane use per quarter per health board. Discussion Even once the effects of COVID-19 are considered, we demonstrate a sustained reduction in desflurane use over 3 years, across an NHS catchment population of 5.5 million. This represents substantial reductions in CO2e emissions. Further reductions in desflurane and nitrous oxide purchasing could offer large environmental and financial benefits. At least one major hospital in Scotland is now decommissioning its nitrous oxide manifold and switching to cylinders for occasional use. Reducing default fresh gas flow rates on anaesthetic machines may offer a means of further reducing unnecessary volatile expenditure.