Clinical characteristics and risk factors of patients with COVID-19 developing barotrauma

Background: At our hospital, people with COVID-19 (coronavirus disease 2019) had a high rate of pulmonary barotrauma. Therefore, the current study looked at barotrauma in COVID-19 patients getting invasive and non-invasive positive pressure ventilation to assess its prevalence, clinical results, and features. Methodology: Our retrospective cohort study comprised of adult COVID-19 pneumonia patients who visited our tertiary care hospital between April 2020 and September 2021 and developed barotrauma. Result(s): Sixty-eight patients were included in this study. Subcutaneous emphysema was the most frequent type of barotrauma, reported at 67.6%;pneumomediastinum, reported at 61.8%;pneumothorax, reported at 47.1%. The most frequent device associated with barotrauma was CPAP (51.5%). Among the 68 patients, 27.9% were discharged without supplemental oxygen, while 4.4% were discharged on oxygen. 76.5% of the patients expired because of COVID pneumonia and its complications. In addition, 38.2% of the patients required invasive mechanical breathing, and 77.9% of the patients were admitted to the ICU. Conclusion(s): Barotrauma in COVID-19 can pose a serious risk factor leading to mortality. Also, using CPAP was linked to a higher risk of barotrauma.Copyright © 2021 Muslim OT et al.

Ingestion of Alcohol-Based Hand Sanitizer: A case report

Introduction: Alcohol-based hand sanitizers containing ethanol or is opropanol are being used in order to prevent person-to-person transmission during the COVID-19. Early signs and symptoms of this ingestion include nausea, vomiting, headache, abdominal pain, blurred vision, loss of coordination, and decreased level of consciousness. After hand sanitizer ingestion we have to suspect about methanol poisoning, monitoring the start of anion-gap metabolic acidosis, seizures, and blindness is essential. Treatment includes supportive care, acidosis correction, and the administration of an alcohol dehydrogenase inhibitor. In servere cases hemodialysis may be required. Objective(s): To present a case of an 29-year-old woman who was taken to the emergency department after voluntary ingestion of alcohol-based hand sanitizer in a suicide attempt. To describe the most common side effects of hand sanitizer ingestion and the literature review. Method(s): Clinical case presentation and literature review of similar cases. Result(s): A 29-year-old woman, with diagnosis of borderline personality disorder and previous suicide attempts was taken to the emergency department after 3 hours of voluntary ingestion of an unknown quantity of alcohol-based hand sanitizer. Initial laboratory findings showed laboratory a blood methanol concentration of 66 mg/dL, with an anion gap of 30 mEq/L, arterial blood pH of 7.2, serum bicarbonate concentration of 12 mEq/L. Patient complained of abdominal pain and nervoussness. Conclusion(s): Most common signs and symptoms of alcohol-based hand sanitizer ingestion include nausea, vomiting, headache, abdominal pain, blurred vision, loss of coordination, and decreased level of consciousness. Treatment includes supportive care, acidosis correction, the administration of an alcohol dehydrogenase inhibitor and sometimes may be required.

Toxicokinetics of metformin overdose treated with CVVHDF

Background: Metformin is the most commonly used diabetes medication and at supratherapeutic levels can result in a severe type-A metabolic lactic acidosis known as metformin-associated lactic acidosis (MALA). Treatment of MALA includes aggressive fluid resuscitation, supporting blood pressure and correcting acidosis. Renal replacement therapy (RRT), usually hemodialysis (HD) is recommended in severe cases with refractory acidosis (with elevated lactate), altered mental status, or shock. To our knowledge, this is the second report of metformin half-life during treatment with continuous veno-venous hemodiafiltration (CVVHDF). Case report: A 53-year-old man died following a reported acute on chronic ingestion of 80 g of his metformin tablets resulting in severe, refractory shock and MALA. His peak serum metformin concentration was 53mcg/mL (therapeutic range 1-2mcg/mL), peak lactic acid concentration was 49.7 mmol/L, and arterial pH nadir was 7.06. Serial serum metformin concentrations were obtained while on RRT;both HD and CVVHDF. The switch from HD to CVVHDF was done due to staffing shortages during the COVID-19 pandemic. The patient died despite aggressive therapy with renal replacement therapy and multiple vasopressors on hospital day five. Serial metformin concentrations during CVVHDF suggested a half-life of 33-h. Discussion(s): Hemodialysis has been reported to clear metformin at a rate greater than 200mL/min and continuous venous-venous hemofiltration (CVVH) at greater than 50mL/min. In this case, metformin levels appear to follow first-order elimination kinetics during CVVHDF with an estimated half-life of 33 h. Comparatively, metformin has a half-life of 4.7-5.5 h during HD. To our knowledge, this is the second report of estimated metformin half-life while using the CVVHDF form of continuous renal replacement. The previous case report measured a half-life of 16.5 h on CVVHDF. This case report shows CVVHDF decreases half-life of metformin and provides first order elimination in the setting of overdose. Conclusion(s): The early initiation of HD appears warranted but prognostic indicators have not been well established. In the absence of HD availability, other forms of RRT (e.g., CCVHDF) can be used and may provide first-order elimination of metformin.

Retrospective Analysis of Arterial Carbon Dioxide Level and Arterial pH Level at the Time of Initiation of Respiratory ECMO and Outcome

Introduction Respiratory extracorporeal membrane oxygenation (ECMO) is well established and its popularity has increased during coronavirus disease 2019 (COVID-19) time. The efficacy of ECMO has been proved in refractory respiratory failure with varied etiology. More than 85,000 respiratory ECMO cases (neonatal, pediatric, adult) registered as per Extracorporeal Life support Organization (ELSO) statistics April 2022 report, with survived to discharge or transfer ranging from 58 to 73%. Early initiation of ECMO is usually associated with shorter ECMO run and better outcome. Many patient factors have been associated with mortality while on ECMO. Pre-ECMO patient pH and arterial partial pressure of carbon dioxide (paCO2) have been associated with poor outcome. We designed a retrospective study from a single tertiary care center and analyzed our data of all respiratory ECMO (neonatal, pediatric, and adult) to understand the effect of pre ECMO, paCO2, and arterial pH to ECMO outcome. Methods It is a retrospective analysis of data collected of patients with acute respiratory failure managed on ECMO from January 2010 to December 2021. Pre-ECMO (1-6 hours before initiation), paCO2, and arterial pH level were noted and analyzed with primary and secondary outcome. Primary outcome goal was survivor and discharged home versus nonsurvivor, while secondary goal was the number of ECMO days and incidence of neurological complications. The statistical analysis was done for primary outcome and incidences of neurological complications and p-value obtained by using chi-squared method. Meta-analysis was done by classifying the respiratory ECMO cases in three major category-COVID-19, H1N1 non-COVID-19, and H1N1 respiratory failure. Results The total 256 patients of respiratory failure were treated with ECMO during specified period by Riddhi Vinayak Multispecialty Hospital ECMO team. Data analysis of 251 patients (5 patients were transferred for lung transplant, hence been not included in study) done. Patients were divided on the basis of pH level less than 7.2 and more than 7.2 and analyzed for primary and secondary outcome. Similarly, patients were divided on the basis of paCO2 level of less than 45 and more than 45. Patient with pre-ECMO pH level more than 7.2 has statistically better survived extracorporeal life support (ECLS) (p-value: 0.008) and survival to discharge home (p-value: 0.038) chances. Pre-ECMO paCO2 level of less than 45 also showed better survival chance of survived ECLS (46.67 vs. 36.02) and survived to discharge home (42.22 vs. 31.06) but not statistically significant (p-value: 0.15 and 0.18, respectively). There was no significant difference in average number of ECMO days in patient survived to discharge home with paCO2 less than 45 and more than 45 (15.7 vs. 11.1 days), and also in pH more than 7.2 and pH less than 7.2 (15.8 vs. 11.6). The incidence of neurological complications was also found lower in patient with pH more than 7.2 (7.5 vs. 17.3%, p-value: 0.034) and in paCO2 level of less than 45 (4.4 vs. 12.65, p-value: 0.15). Conclusion Pre-ECMO arterial pH of more than 7.2 (statistically significant) and paCO2 of less than 45 (statistically not significant) have definitely better survival chances and have lesser incidences of neurological complications. There was no significance difference in the number of ECMO days in either group. Authors recommends early initiation of ECMO for mortality and morbidity benefits.

An Unusual Case of Autoantibody-Negative KetosisProne Diabetes (KPD) Secondary to Marked Insulin Resistance

KPD is classically regarded as an atypical form of diabetes caused by near-complete beta-cell failure. A 37-year-old Egyptian man (BMI: 27.7 Kg/m2) presented with hyperglycemia (362 mg/dL) and DKA (arterial pH 7.20, ketonemia 5.0 mmol/L, ketonuria 80 mg/dL) . He was afebrile, with recent polyuria, polydipsia and weight loss. HbA1c was 107 mmol/mol (11.9%) and blood tests excluded diabetes secondary to endocrinopathies. SARS-CoV-2 RT-PCR test was negative. IV insulin infusion (0.1 IU/kg/h) and IV fluid therapy were started. He was shortly transitioned to a sc basal-bolus insulin regimen (0.7 IU/kg/day) . Mixed-meal tolerance test (MMTT) revealed a peak 120-min stimulated C-peptide of 12.3 ng/mL, suggesting marked insulin resistance. Islet autoantibodies (ICA, IAA, GADA, IA-2A, ZnT8A) and insulin receptor autoantibodies (IgG/IgM) were negative. HLA genotyping detected the following haplotypes: DRB1∗01, ∗04;DQA1∗01:01P, ∗03:01P;DQB1∗03:02P, ∗05:01P. Insulin dose was gradually reduced and insulin therapy was discontinued after 4 months in favor of metformin (2550 mg/day) plus sc semaglutide (up to 1 mg/week) . After one year, MMTT revealed a peak 60-min stimulated C-peptide of 8.25 ng/mL. During the 18-month follow-up period, fasting capillary beta-hydroxybutyrate values were <0.2 mmol/L and HbA1c remained <48 mmol/mol (<6.5%) , indicating disease remission. This case suggests the existence of an autoantibody-negative KPD subtype driven by marked insulin resistance rather than by insulinopenia.

A Single Center Experience with Early Initiation of ECMO Prior to Mechanical Ventilation in COVID-19 Patients with Severe ARDS

Background: Coronavirus disease 2019 (COVID-19) is an ongoing global pandemic that results in a viral pneumonia caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Prognosis is poor among those that develop acute respiratory distress syndrome and progress to mechanical ventilation. Due to the high mortality associated with mechanical ventilation and the unique physiology associated with COVID-19, we compared outcomes in COVID-19 patients placed on ECMO prior to initiation of mechanical ventilation (early group) to patients treated with ECMO after mechanical ventilation (conventional group). Methods: This is a single center retrospective analysis of COVID-19 patients placed on veno-venous (VV) ECMO between 04/06/2020 and 01/15/2021 in a tertiary high-volume ECMO center. Patients between 18 - 70 years of age with a diagnosis of SARS-CoV-2 and diagnosed with ARDS. Patients were considered for ECMO if they had a P/F ratio of less than 50 mmHg for at least three hours, a P/F ratio of less than 80 mmHg for at least 6 hours or an arterial blood pH of less than 7.25 with a pCO2 greater than or equal to 60 mmHg for at least six hours despite optimized ventilator settings (RR> 35 breaths/minute, plateau pressure ≤ 32, tidal volume of 6ml/kg of predicted body weight, FiO2 ≥ 80% and PEEP ≥ 10 cm water). A subset of patients with a rapid deterioration (rapid escalation of O2 requirements, tachypnea RR > 30, tachycardia HR >100) or with clinical signs consistent with poor tolerance to positive pressure ventilation such as a pneumothorax or pneumomediastinum were considered for ECMO prior to mechanical ventilation if they had a P/F <80 despite selfproning with either HFNC 40L/100% in addition to a nonrebreather mask with 15L/100% or non-invasive positive pressure ventilation (NIPPV) with an FiO2 100%. The primary outcome was survival to discharge assessed as a binary outcome of survived or non-survived. Secondary outcomes evaluated included discharge location, length of stay, and incidence of adverse events such as bleeding events, infection, CVA, and pneumothorax requiring chest tube placement. Results: A total of 100 patients were reviewed, including 24 early ECMO patients and 76 conventional ECMO patients. The mean age of the cohort was 48.9 + 11.5 years, 28% were female, and 74% were Hispanic. At baseline, the mean BMI was 31.6 + 5.8, 55% had a history of hypertension, 36% were diabetic and 9% had a history of asthma. Overall, 57% of patients survived to discharge with a median of 23.3 (7.8-40.6) days on ECMO. There were no significant differences in age, gender, BMI, comorbidities, or APACHE scores between the two groups. Prior to ECMO, the early group had lower P/F ratios (52.7 + 11.5 vs. 71.1 + 20.7, p <0.0001), higher pH (7.4 + 0.0 vs. 7.3 + 0.1, p <0.0001), and lower CO2 (36.1 + 6.8 vs 50.9 + 19.1, p <0.0001) than the conventional cohort. Though not significant, there was a trend towards survival in the early ECMO group compared to the conventional group (71% survival vs. 53%, p= .12). Of the early cohort, 15 patients required intubation at some point after cannulation for a median time of 2.5 days (0- 27.0 days). Of the nine patients never intubated, two patients expired, two received a lung transplant, three were discharged home, one discharged to rehab and one to an LTAC facility. There was no difference in adverse events between the two groups. Conclusions: Certain patients with severe ARDS due to COVID-19 may benefit from VV-ECMO cannulation prior to mechanical ventilation with similar outcomes and a trend towards improved mortality.