Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 795
Filtrar
1.
Interventional Neuroradiology ; 28(1 Supplement):293-294, 2022.
Artigo em Inglês | EMBASE | ID: covidwho-2195327

RESUMO

Purpose: Increased anticoagulant use in the context of COVID-19 related thrombotic events, endothelial damage that may predispose arteries to rupture, and COVID-19-related cerebral sinus thrombosis may predispose COVID-19 patients to a greater rate of intracranial hemorrhage. We aim to describe the prevalence of ICH among hospitalized patients with COVID-19 and compare the clinical characteristics and outcomes of COVID-19 patients with and without ICH. Method(s): Between May 1 and June 1, 2021, this singlecenter prospective trial enrolled 265 individuals with severe acuterespiratory syndrome coronavirus-2 (SARS-CoV-2). 18 patients with neurological signs were evaluated using anon-contrast brain computed tomography scan out of 265 patients infected with SARS-CoV-2. Study included 12individuals with spontaneous intraparenchymal hemorrhage. Patient information from electronic health records was evaluated, including demographic data, medical history, hospital course, laboratory values, andmedications. Result(s): 5 patients were male, and 7 patients were female out of 12 patients with an average age of 55.6 years. 8patients (2 female and3male) (66.7%) had justmild COVID-19 symptoms without experiencing considerablerespiratory distress. 7 patients (58.4 percent) had a Glasgow Coma Scale score of fewer than eight (GCS). Themost prevalent risk factor in their prior medical history (76.4 percent) was hypertension. Hematoma had an average volume of 56cc. Four patients died during admission, while the remaining patients were dischargedafter an average of 25 days in the hospital. None of the patients with a GCS of less than 11 survived. Conclusion(s): While mortality in ICH is normally high, it may be worse than predicted in COVID-19infected ICH patients.More research is needed to establish the risk, predictors, and consequences of ICH during COVID-19, particularly among anticoagulated patients.

2.
Journal of the Royal College of Physicians of Edinburgh ; 52(4):281, 2022.
Artigo em Inglês | EMBASE | ID: covidwho-2195271
3.
Vascular Medicine ; 27(6):NP6-NP7, 2022.
Artigo em Inglês | EMBASE | ID: covidwho-2194543

RESUMO

Background: Coronavirus disease-19 (COVID-19) is an emerging threat because of its significant damage to the lungs and its risk of thrombosis in microvascular, venous, and arterial beds. Moreover, thrombosis in patients with the COVID-19 infection may also be more extensive, leading to limb loss and death. One of the thrombotic complications reported in COVID-19 is acute limb ischemia (ALI), which is characterized with an abrupt decrease in the arterial perfusion of a limb, threatening its viability and integrity. In this report, we describe an unusual case of an unvaccinated patient who presented with acute unilateral upper extremity ischemia as the initial manifestation of COVID-19. Case presentation: A 49-year-old man, unvaccinated for COVID-19, presented to the emergency room due to worsening left hand and forearm pain of one week duration. The brachial, radial, and ulnar pulses were absent. Emergency arterial duplex scan of the left arm showed acute thrombi totally occluding the lumen of axillary artery and extending to the proximal to distal brachial, proximal to distal radial and ulnar arteries. Anticoagulant infusion in the form of heparin was immediately started was titrated accordingly depending on aPTT. Surgical embolectomy was offered but could not be immediately done within 6 hours of presentation due to positive result for SARSCoV2. Patient denied history of respiratory symptoms and was also noted to have normal lung findings. During surgical embolectomy, a significant amount of large, elongated acute thrombi were retrieved. Anticoagulation was resumed post-operatively and no signs and symptoms of compartment syndrome were noted. Patient slowly recovered his sensory and motor functions within a month from onset of ALI. Conclusion(s): Thrombotic events such as acute limb ischemia may be the initial manifestation of COVID-19 infection. In this patient, what we found particularly peculiar was that he had no respiratory symptoms despite being unvaccinated during the time that the Delta variant was the prevailing strain of coronavirus. This case underscores the fact that clinicians should have high index of suspicion of COVID-19 infection as a cause of thrombotic events, especially in patients with no or very few risk factors.

4.
Vascular Medicine ; 27(6):651, 2022.
Artigo em Inglês | EMBASE | ID: covidwho-2194540

RESUMO

Background: COVID-19 infection can cause an array of symptoms including arterial thrombosis with an incidence of 4.4% however isolated large vessel thrombosis is even rarer. We present a review of the literature regarding large vessel (Iliac and aortic) thrombosis associated with COVID-19 infection and discuss the outcomes. In addition, we present a case that was infected with COVID-19 with presentation of isolated aortic thrombosis. Method(s): We performed a literature review using Pubmed keywords, COVID-19, iliac, aortoiliac, aorta, thrombosis. The articles were then narrowed to the ones only pertaining to aortic (AT) or iliac thrombosis (IT) with COVID-19 infection. Result(s): Our literature review found 12 articles detailing a total of 14 cases of AT or IT in the setting of COVID-19 infection. Ages ranged from neonate to 85 years old. Incidence of smoking was 30% and diabetes was 25%. Mortality rate was noted to be 14% (2 out of 14 patients). Approximately, 50% (7 out of 14) of the patients were treated with surgery and 21% (3 out of 14) received anticoagulation. 64%, (9 out of 14) of the patients presented with symptoms of acute limb ischemia. Amputation rate was noted to be 7% (1 out of 14). Conclusion(s): Large vessel thrombosis caused by COVID- 19 infections seems to carry high mortality and amputation rates. To prevent devastating sequel of COVID infection with concurrent large arterial thrombosis we emphasize that physicians employ a high index of suspicion and urgent involvement of the vascular interventionists. The case that we presented emphasized the importance of understanding the effect of COVID-19.

5.
Circulation Conference: American Heart Association's ; 146(Supplement 1), 2022.
Artigo em Inglês | EMBASE | ID: covidwho-2194388

RESUMO

Introduction: Transesophageal echo (TEE) is routinely used to exclude left atrial appendage (LAA) thrombus prior to direct current cardioversion (DCCV) for atrial fibrillation (AF). However, the COVID-19 pandemic accelerated the use of non-invasive modalities such as cardiac computed tomography (CCT) to avoid aerosolizing viral particles during intubation, such as with introduction of a TEE probe. CCT is not routinely used as a clinical strategy to exclude LAA thrombus prior to DCCV. Therefore, we sought to determine the feasibility of CCT-guided DCCV.Hypothesis: CCTguided elective cardioversion for atrial arrhythmias is a feasible modality to rule out left atrial appendage thrombus. Method(s): We identified patients at Abbott Northwestern Hospital who underwent CCT in lieu of or in addition to TEE within 24 hours of elective DCCV for AF or atrial flutter from March 2020 to February 2022. Thirty-day outcomes were collected including cerebrovascular accident (CVA), myocardial infarction, cardiovascular death, re-hospitalization, arrhythmia recurrence, and overall mortality. Delayed imaging, 90 seconds after arterial phase, was obtained to exclude LAA thrombus. Result(s): Thirty-two patients were included in our analysis, 10 (31%) were female. Ten (31%) presented with new-onset of AF. CCT did not identify LAA thrombus in any patient. Post-DCCV, the mean time to arrhythmia recurrence was 16.5 days (SD: 9.3). At 30 days, 11 (34%) had been rehospitalized but mostly for elective procedures. There was no CVA or mortality reported at the 30-day follow-up. Conclusion(s): CCT-guided elective cardioversion for atrial arrhythmias was evaluated for feasibility in a small pilot. In patients who had no LAA thrombus on CCT and subsequently underwent cardioversion, there were no CCT-related complications, CVA, or deaths at 30 days. Many patients benefit from early DCCV rather than waiting with uninterrupted anticoagulation. CCT guidance is a feasible alternative to TEE but needs further prospective comparison to TEE and uninterrupted anticoagulation in this clinical setting.

6.
Circulation Conference: American Heart Association's ; 146(Supplement 1), 2022.
Artigo em Inglês | EMBASE | ID: covidwho-2194362

RESUMO

Case Description: 54-year-old man presented to the Emergency Department (ED) three weeks after Covid-19 infection for progressively worsening dyspnea and hypoxemia. Dexamethasone and prophylactic apixaban (2.5mg twice a day) were initiated and he was discharged 48 hours later. A week after discharge he re-presented to the ED requiring 6L of oxygen (O ) despite uninterrupted dexamethasone and apixaban therapy. His past medical history was significant for quiescent IgG4 disease on Rituximab and Type 1 Diabetes. He was afebrile, tachycardic and tachypneic with decreased right lower lobe breath sounds. He had an elevated erythrocyte sedimentation rate and C-reactive protein, no leukocytosis and no pulmonary embolism of CT. He was admitted and vancomycin and cefepime antibiotic therapy for a superimposed bacterial pneumonia was begun. On day 12 of the hospital stay, he experienced new onset chest pain. Evaluation showed an elevated troponin and submillimeter ST segment elevation concerning for an evolving STEMI. Coronary angiography demonstrated an 90% diffuse mid LAD stenosis and two large coronary aneurysms of the left circumflex artery (LCx). The mid-LAD was stented using a 3.0 x 38 mm and 2.75 x 26 mm Onyx drug eluting stents with resolution of his chest pain. IgG4 serum level was normal and imaging did not demonstrate active IgG4 disease. He was discharged on aspirin and clopidogrel. Due to concern for a hypercoagulable state in the setting of Covid 19 infection, IgG4 disease and the large coronary aneurysms for thrombus formation, warfarin anticoagulation was also initiated. On review of his coronary imaging, the largest LCx aneurysm was 9mm on admission and 12mm three weeks later with evidence of diffuse coronary inflammation. CT Fractional Flow Reserve (abnormal <= 0.80) demonstrated decreased flow at the distal aneurysm with no focal stenosis to account for flow reduction. Conclusion(s): 54-year-old man with IgG4 disease presenting with prolonged Covid-19 infection and acute NSTEMI. He was found to have large, flow limiting coronary aneurysms and inflamed coronary arteries all consistent with his IgG4 disease. Management of these aneurysms will be discussed.

7.
BMJ Open ; 13(1):e066623, 2023.
Artigo em Inglês | PubMed | ID: covidwho-2193796

RESUMO

INTRODUCTION: In COVID-19-related acute respiratory distress syndrome (ARDS), the clot play a role in gas exchange abnormalities. Fibrinolytic therapy can improve alveolar ventilation by restoring blood flow. In this systematic review and meta-analysis protocol, we aim to assess the safety and efficacy of fibrinolytic therapy in such a population. METHODS: We will perform a systematic search in MEDLINE, EMBASE, Cochrane CENTRAL and LILACS databases without language restrictions for relevant randomised controlled trials (RCTs) and quasi-RCTs. Two review authors will independently perform data extraction and quality assessments of data from included studies. In case of divergence, a third author will be contacted. The Cochrane handbook will be used for guidance. If the results are not appropriate for a meta-analysis, a descriptive analysis will be performed. DISCUSSION: This systematic review and meta-analysis protocol will provide current evidence about the safety and efficacy of fibrinolytic therapy in patients with COVID-19 and ARDS. These findings will provide if fibrinolytic therapy might be an option for a desperate clinical setting, where all medical efforts have been used. PROSPERO REGISTRATION NUMBER: PROSPERO CRD42020187482. ETHICS AND DISSEMINATION: Ethics committee approval is not necessary. We intend to update the public registry, report any protocol amendments and publish the results in a widely accessible journal.

8.
Critical Care Medicine ; 51(1 Supplement):555, 2023.
Artigo em Inglês | EMBASE | ID: covidwho-2190672

RESUMO

INTRODUCTION: Patients supported on extracorporeal membrane oxygenation (ECMO) due to COVID-19 are at an increased risk of both thromboembolic complications and thrombocytopenia. Bivalirudin, a direct thrombin inhibitor, is increasingly being utilized for anticoagulation in the ECMO patient though there is largely a lack of literature within the COVID-19 population. The objective of our study was to evaluate the safety and efficacy of alternative anticoagulation with bivalirudin in patients on ECMO with COVID-19 respiratory failure. METHOD(S): This was a non-interventional retrospective chart review conducted at a single center large community hospital between January 2020 - November 2021. We included both venovenous (VV) and venoarterial (VA) adult ECMO patients anticoagulated with bivalirudin that tested positive for COVID-19. Patients were excluded if their duration of ECMO cannulation was less than 48 hours. Descriptive statistical analyses were performed utilizing median with interquartile range and frequency with percent as appropriate. RESULT(S): Overall, 180 ECMO patients were included in the study. The duration of ECMO cannulation was 29 (9-54) days and our cohort experienced a 42% mortality rate. The rate of thrombotic events including in-circuit thrombosis, arterial and venous thrombotic events was 22%. The median initial platelet count on ECMO was 206 (157-274) and the median nadir was 85 (48-121). ELSO defined major bleeding occurred at a rate of 53% within this cohort. CONCLUSION(S): To our knowledge, this study describes the largest number of patients anticoagulated with bivalirudin for ECMO secondary to COVID-19. Our results suggest similar rates of thrombotic events compared to ELSO registry data. While the half-life of bivalirudin is short, clinicians should still be cautious of bleeding due to lack of a specific reversal agent. Retrospective studies with a comparator cohort, as well as randomized trials are warranted to further evaluate the selection of intravenous anticoagulants in the ECMO population with and without COVID-19.

9.
Critical Care Medicine ; 51(1 Supplement):535, 2023.
Artigo em Inglês | EMBASE | ID: covidwho-2190658

RESUMO

INTRODUCTION: Thrombosis associated with SARSCoV-2 infection has been well established. Even patients with mild disease, who are able to treat their symptoms at home without supplemental oxygen, are prone to significant sequelae of the disease process. IVC filters, while once considered a standard treatment for deep vein thrombosis (DVT), have fallen out of favor except when there are absolute contraindications for therapeutic anticoagulation due to increased risk of significant adverse events directly correlating with time in-situ including migration, thrombosis, and tears/dissection of the aorta or associated vessels. DESCRIPTION: A 45 y/o F with h/o insulin dependent DM2 and HTN presented for evaluation of bilateral leg cramps with subjective numbness and abdominal pain in the setting of recent COVID-19 infection treated at home. Her exam was notable for significant quadriceps tenderness and induration bilaterally with diminished distal pulses. Initial lab work was significant for lactic acidosis of 6.1, CK 110, and creatinine 2.2. She was admitted to ICU for oliguric AKI and vasopressor support. Broad autoimmune workup was negative. Her renal function continued to deteriorate eventually prompting kidney replacement therapy. Doppler US revealed bilateral DVT in the femoral and popliteal veins. Her CK was monitored daily given continued concern for rhabdomyolysis. CK was >20,000 by day five. Concern for congestive nephropathy prompted CT with contrast of abdomen, pelvis which showed extensive DVT throughout the visualized femoral and iliac veins, extending superiorly past an IVC filter to the inferior margin of the liver. At this time, the patient confirmed she had an IVC filter placed roughly eight years prior after an MVC. The patient underwent successful catheter-directed thrombolysis. Her symptoms slowly improved during her hospitalization which totaled 33 days. The patient was able to discontinue outpatient hemodialysis after 1.5 months. DISCUSSION: It is imperative to obtain complete history in patients with recent COVID as underlying predisposition for thrombosis can greatly increase their morbidity and mortality even with seemingly mild infection. The combination of two highly pro-thrombotic foci in this patient resulted in multisystem sequelae of large IVC and femoral vein thrombosis.

10.
Critical Care Medicine ; 51(1 Supplement):388, 2023.
Artigo em Inglês | EMBASE | ID: covidwho-2190603

RESUMO

INTRODUCTION: Coronavirus disease 2019 (COVID-19) has led to significant morbidity and mortality worldwide. Corticosteroids have been shown to reduce mortality in hospitalized COVID-19 patients requiring supplemental oxygen. Current guidelines recommend dexamethasone (DEX);however, some studies suggest methylprednisolone (MP) may reduce hospital length of stay (HLOS) compared to DEX. The purpose of this study was to compare the efficacy and safety of MP and DEX in hospitalized COVID-19 patients. METHOD(S): A retrospective, single-center study evaluated adult patients with confirmed SARS-CoV-2 infection that received at least one dose of MP or DEX during their hospital admission from 3/1/2020 to 9/28/2021. The primary outcome was HLOS. Secondary outcomes included duration of mechanical ventilation (MV), intensive care unit length of stay (ICU LOS), inpatient mortality, incidence of hyperglycemia, nosocomial infection, and gastrointestinal bleeding. A sample size calculation indicated 49 patients per group would detect a 3-day reduction in HLOS in those given MP (alpha=0.05, power=0.8). Data are reported as percentage, median (IQR), or OR (95% CI). RESULT(S): 230 patients were included (100 patients in MP, 130 patients in DEX). Differences in demographics included ICU admission (80% vs. 56.9%;p=0.0002), invasive ventilation (52% vs. 30.8%;p=0.002), vasopressor use (53% vs. 30%;p=0.001), renal replacement therapy (27% vs. 10%;p=0.001), ARDS diagnosis (78% vs. 52.3%;p=0.001), and intermediate intensity anticoagulation (8% vs. 17.7%;p=0.034) for MP and DEX groups, respectively. Patients given MP had longer HLOS (17.8 days [9.3, 26.6] vs. 8.9 days [4.4, 16.2];p< 0.001), ICU LOS (13 days [5.6, 22.5] vs. 8.2 days [3.9, 14.1];p=0.017), and higher mortality (42% vs. 24.6%;p=0.007). Nosocomial infection (41% vs. 26.9%;p=0.034) and gastrointestinal bleeding (10% vs. 2.3%;p=0.019) occurred more frequently in the MP group. There were no differences in duration of MV or hyperglycemia. MP was associated with longer HLOS after multivariate analysis that adjusted for ICU admission, adverse effects, ARDS diagnosis, and anticoagulation (OR 2.76 [95% CI 1.18-6.4];p=0.019). CONCLUSION(S): MP was associated with increased HLOS, increased ICU LOS, higher mortality, and higher incidence of adverse effects compared to DEX.

11.
Critical Care Medicine ; 51(1 Supplement):381, 2023.
Artigo em Inglês | EMBASE | ID: covidwho-2190601

RESUMO

INTRODUCTION: Anticoagulation is critical in preventing thrombosis in extracorporeal membrane oxygenation (ECMO). Unfractionated heparin (UFH) has historically been the anticoagulant of choice;however, is limited by a co-factor to assert its action that leads to fluctuations in dose responsiveness and complications like heparin-induced thrombocytopenia and heparin resistance. For these reasons, use of direct thrombin inhibitors is increasing in ECMO. The purpose of this study is to compare the efficacy and safety of UFH vs. bivalirudin for anticoagulation in ECMO with a subset of COVID-19 patients. METHOD(S): This was a retrospective, single-centered, cohort study of patients receiving UFH (n=106) vs. bivalirudin (n=27) for ECMO. The primary outcome was the percentage of thrombotic events (in-circuit, non-circuit related thrombosis) during ECMO between patients receiving UFH and bivalirudin. RESULT(S): There were significant differences between bivalirudin and UFH patients with the following baseline characteristics: BMI (29.9 vs. 26.5;p=0.02), Caucasian race (29.6% vs. 65.1%;p< 0.01), positive COVID-19 status (66.7% vs. 0.9%;p< 0.01), and indication for ECMO (respiratory failure 100% vs. 67.9%;p< 0.01). The time to goal anticoagulation was longer in bivalirudin patients (7.1 vs. 25.0 hr;p< 0.01). COVID-19 patients had greater thrombotic events (47.4% vs. 25.4%;p=0.05), number of bleeding events per patient (2 vs.1;p< 0.01), as well as longer ECMO duration (42.2 vs. 6.6 days;p< 0.01), length of ICU (46.4 vs. 6.6 days;p< 0.01) and hospital stay (52.1 vs. 33.2 days;p=0.03) compared to non-COVID-19 patients. A sub-group analysis of venovenous (VV) ECMO, non-COVID-19 patients was propensity score matched by age, sex, Caucasian race, BMI, and ECMO duration. This analysis demonstrated no significant differences between UFH and bivalirudin in thrombotic or bleeding events, however, there was greater mortality in the UFH arm (100% vs. 28.6%;p=0.02). CONCLUSION(S): Patients with COVID-19 experienced greater thrombotic and bleeding events, with longer ECMO duration and lengths of stay. In the propensity matched analysis comparing UFH vs. bivalirudin in VV-ECMO, non- COVID-19 patients, there were no significant differences between thrombotic or bleeding events, but significantly greater mortality in the UFH arm.

12.
Critical Care Medicine ; 51(1 Supplement):341, 2023.
Artigo em Inglês | EMBASE | ID: covidwho-2190588

RESUMO

INTRODUCTION: Granulomatosis with polyangiitis (GPA) is a rare rheumatologic disease in pediatric patients but with a similar presentation and organ involvement as an adult patient. We present a case of a patient with pulmonary hemorrhage due to GPA who was managed without extracorporeal life support. DESCRIPTION: A 14 year-old female with no medical history presented with migratory polyarthritis, sore throat, chest tightness, fatigue, and positive rheumatoid factor. Found to be hypoxic on presentation. Her respiratory failure progressed, requiring intubation and inhaled nitric oxide, with minimal improvement. A chest CT showed nonspecific bilateral multifocal, patchy airspace opacification. Her C-ANCA and proteinase 3 antibody were positive, making GPA the most likely diagnosis for which she was started on methylprednisolone and rituximab. Her hypoxemia continued to worsen despite maximal mechanical ventilator support and neuromuscular blockade infusion. She had bloody secretions from her endotracheal tube, concerning for pulmonary hemorrhage, despite high positive end-expiratory pressure. A chest radiograph at that time was consistent with worsening bilateral infiltrates. Echocardiogram showed normal biventricular function, pulmonary hypertension, and a 1.8 cm by 1.5 cm thrombus at the cavoatrial junction. A multidisciplinary team determined that the location of the clot precluded placement of ECMO cannulas without risking clot mobilization. Plasmapheresis was emergently initiated followed by further rituximab and cyclophosphamide. Her respiratory status stabilized after being placed in the prone position. She was ultimately discharged home after a prolonged period of intubation and hospitalization, on a steroid taper, oral anticoagulation for her cavoatrial thrombus, and maintenance rituximab therapy. DISCUSSION: This case highlights a rare case of GPA with multiorgan involvement in a pediatric patient resulting in refractory hypoxemia treated with aggressive rheumatologic therapy and proning. There is limited evidence for the efficacy of plasmapheresis in patients with GPA, although this patient may have benefited from it since she was not safe for extracorporeal life support. Furthermore, as highlighted through the COVID-19 pandemic, proning proved crucial in managing her severe hypoxemia.

13.
Critical Care Medicine ; 51(1 Supplement):176, 2023.
Artigo em Inglês | EMBASE | ID: covidwho-2190521

RESUMO

INTRODUCTION: While myopericarditis due to Coxsackie virus-B has been widely reported, multi-organ involvement is rare. We report a unique case of Coxsackie B myopericarditis, which presented with rash, atypical pneumonia, hepatitis, and sepsis. DESCRIPTION: A previously healthy 32-year-old man presented to the emergency department in January 2022 endorsing shortness of breath, high-grade fever (39.2degreeC), non-pruritic rash on extremities, vomiting, and diarrhea. He had tachypnea (24/min), hypoxia (SpO2 93% on air), and mild lymphadenopathy in the neck. Initial evaluation was pertinent for leukocytosis (17.8 thousand/muL) with neutrophil predominance (89.4%), elevated inflammatory markers (D-dimer [4390 ng/mL], procalcitonin [1.79 ng/ mL], CRP [180.7 mg/L], lactate [3.19 mmol/L]), and transamnitis (AST: 160 U/L, ALT: 116 U/L);SARS-CoV-2 and blood cultures were negative. Chest imaging showed bibasilar consolidation, perihilar ground-glass nodules, and pericardial effusion;ultrasound showed acute hepatitis. He was empirically started on ceftriaxone and azithromycin. However, absence of clinical improvement, persistence of high-grade fever, and leukocytosis with low absolute CD3, CD4, and CD8 counts (286 cells/UL, 199 cells/UL and 71 cells/UL, respectively) suggested atypical infection;vancomycin and doxycycline were added. Further infection and autoimmune workup was negative. He developed atrial fibrillation and an echocardiogram was remarkable for ejection fraction of 50-55%, moderate pericardial effusion circumferential to the heart, and minimal collapse of the right atrium. On subsequent testing, Coxsackie virus B type 3 IgM was positive (1:320, reference 1:10). All antibiotics were discontinued, and the patient was managed with diltiazem, colchicine, ibuprofen, and supportive care;anticoagulation was not initiated. After a remarkable improvement in symptoms and rash, he was discharged home. Follow-up imaging showed resolution of bibasilar consolidations and pericardial effusion. DISCUSSION: The likely mechanism of Coxsackie virus B-induced damage to myocytes (and possibly multiorgan involvement) is immune-mediated and direct viral cytotoxicity. Our patient's atypical pneumonia responded well to colchicine and ibuprofen. A high index of suspicion is warranted.

14.
Critical Care Medicine ; 51(1 Supplement):175, 2023.
Artigo em Inglês | EMBASE | ID: covidwho-2190520

RESUMO

INTRODUCTION: Lemierre's syndrome (LS) is characterized by fever, sore throat, neck swelling and tenderness, and septic thrombophlebitis of the jugular vein. It remains a fatal disease as serious complications commonly arise. DESCRIPTION: 20-year-old male patient with not known past medical history endorsed 1 week of sore throat, emesis, loose stools, weight loss as well as dyspnea associated with bilateral, non-pleuritic chest pain, night sweats, myalgias and subjective fever sensation. Patient was initially hypoxic, hypotensive, tachycardic, tachypneic and febrile, with scleral icterus, lymphadenopathy of neck and jaw bilaterally, enlarged tonsils, and diffuse abdominal tenderness. Laboratory results showed leukocytosis with neutrophile predominance, anemia, thrombocytopenia, elevated inflammatory markers. There was also pre-renal acute kidney injury, elevated alkaline phosphatase and hyperbilirubinemia. SARS-CoV-2 tests were negative. Initial computerized tomography (CT) of the chest showed extensive peripheral ground-glass nodules and rounded consolidations, with lower lobe predominance. Admission to medical ICU was warranted. Initial blood cultures showed no identification of speciation;Ceftriaxone was started with satisfactory response. However, patient developed worsening shortness of breath, orthopnea, rightsided neck pain and erythema. Repeat imaging showed new airspace opacities in both lungs with cavitation consistent with septic emboli, and thrombophlebitis of right jugular vein with no abscess. At that point, blood cultures grew Fusobacterium necrophorum and metronidazole was started. A four-week course was completed upon discharge with satisfactory response. DISCUSSION: Lemierre's syndrome remains as a rare but potentially fatal entity. Internal jugular vein (IJV) thrombophlebitis occurs through infection of the lateral pharyngeal space. Pulmonary metastases are common. Metronidazole comprises the foundation of the treatment given its tissue penetration and activity against all strains of Fusobacterium spp. Data regarding anticoagulation efficacy is limited. Clinicians should maintain high clinical suspicion, and a multidisciplinary approach with broad collaboration among specialties is imperative to aid early diagnosis and better clinical outcomes.

15.
Critical Care Medicine ; 51(1 Supplement):110, 2023.
Artigo em Inglês | EMBASE | ID: covidwho-2190499

RESUMO

INTRODUCTION: There is published literature about COVID-19 disease associated coagulopathy in hospitalized patients. We aim to study association of early heparin use among adult patients with COVID-19 and sepsis and hospital outcomes. METHOD(S): Retrospective study utilizing the EMR (electronic medical record) data at a large tertiary care academic center with ICU patients admitted for COVID-19 and sepsis and received therapeutic heparin for anticoagulation. We reported nominal variables in (gender, exposure - yes/no, etc) as number and percentage. And reported continuous (age, length of stay, etc) as median (IQR). We used Chi Square test and t-test as appropriate for nominal and continuous data analysis. This study was IRB approved. RESULT(S): A total of 230 patients with age >=18 years were included in final analysis. Out of these, 183 (79.6%) patients received heparin within 48 hours of ICU admission and 47 (20.4%) after 48 hours. The median (IQR) age was 67.5 years (58-77) with majority being caucasian (73.9%) male (68%) patients. Overall, 59 (26%) patients had died, 86 (37%) had been discharged home without assistance, 12 (5%) discharged home, with home health from the hospitals. In univariable analysis, early (< 48 hours) administration of heparin was associated reduced utilization of invasive mechanical ventilation (IMV) (OR 0.23, p=< 0.01) and non-IMV (NIMV) (OR 0.49, p=0.03) and reduced ICU (MD -1.64, SE 0.58, p=< 0.01 and hospital length of stay (LOS) (MD-4.15, SE 0.93, p=< 0.01. This association remained significant when model was adjusted for age, gender, BMI, race, ethnicity, SOFA score on day 1, APACHE-III score on ICU admission: IMV utilization (aOR 0.12, p=< 0.01), NIMV utilization (aOR 0.47, p=0.35), ICU LOS (MD -1.65, SE 0.57, p=< 0.01) and hospital length of stay (MD -4.43, SE 0.95, p=< 0.01). The hospital mortality was observed to be not statistically significant (unadjusted OR 0.68, p=0.28 and adjusted OR 0.67, p=0.32) due to small sample size. CONCLUSION(S): Early administration of heparin in patients with moderate to severe COVID-19 sepsis was associated with reduced utilization of IMV and NIMV and reduced hospital LOS. Association with reduced hospital mortality did not reach the statistical significance.

16.
Critical Care Medicine ; 51(1 Supplement):86, 2023.
Artigo em Inglês | EMBASE | ID: covidwho-2190485

RESUMO

INTRODUCTION: Bivalirudin remains a viable strategy during extracorporeal membrane oxygenation (ECMO). The accuracy of activated partial thromboplastin time (aPTT) for bivalirudin intensity in ECMO may be imperfect resulting in suboptimal dosing, which may increase the risk of bleeding or thrombotic complications. The purpose of this study was to evaluate the correlation between PTT and thromboelastography (TEG) reaction (R) time in adult ECMO patients anticoagulated with bivalirudin. METHOD(S): This was a multicenter, retrospective study conducted over a 22-month period (January 2020 to October 2021. Adult ICU patients requiring ECMO and bivalirudin therapy with >=1 corresponding TEG and aPTT samples drawn <=4 hours of each other were included. The primary endpoint was to determine the correlation coefficient between the TEG R time and bivalirudin aPTT serum concentrations. Pearson's correlation coefficient was used to evaluate the correlation using a kappa measure of agreement between TEG results and bivalirudin aPTT serum concentrations. RESULT(S): A total of 104 patients consisting of 848 concurrent laboratory assessments of R time and aPTT were included. COVID-19 positive tests were confirmed in 48.1% (n=50) of included patients. A moderate correlation between TEG R time and aPTT was demonstrated in the study population (r=0.41;p< 0.001). A similar relationship between TEG R time and aPTT was observed in both COVID-19 positive (r=0.44;p< 0.0001) and negative (r=0.45;p< 0.0001). Overall, 59.2% of all concurrent TEG R time and aPTT values showed agreement on the study institution's therapeutic category (sub-, supra-, and therapeutic) of bivalirudin. 78.3% (n=277) of aPTT values were categorized as therapeutic among all discordant assessment (n=346) between TEG R time and aPTT. The discordant TEG R times with a therapeutic PTT were almost equally distributed between subtherapeutic and supratherapeutic categories. CONCLUSION(S): Moderate correlation was found between TEG R time and aPTT associated with bivalirudin during ECMO in critically ill adults. Further research is warranted to address the optimal test to guide clinical decision-making for anticoagulation dosing in ECMO patients with discordant results.

17.
Critical Care Medicine ; 51(1 Supplement):81, 2023.
Artigo em Inglês | EMBASE | ID: covidwho-2190480

RESUMO

INTRODUCTION: Coagulopathy and thromboembolic events are poor prognostic indicators of COVID-19 disease. There is a discrepancy in the results of different studies regarding the effects of chronic anticoagulation on clinical outcomes. This systematic review aims to summarize the evidence on the impact of chronic anticoagulation on clinical outcomes in COVID-19. METHOD(S): A Literature search was performed on LitCovid PubMed, WHO, and Embase databases from inception (December 2019) till May 2022. Our eligibility criteria included original studies that reported the association between prior use of anticoagulants for unrelated indications at the time of COVID-19 diagnosis and the patient outcomes in adults suffering from COVID-19. The risk of thromboembolic events in COVID-19 infected patients on chronic anticoagulation is the primary outcome and severity of COVID-19 disease in terms of ICU admission or invasive mechanical ventilation/intubation requirements, and all-cause mortality were the secondary outcomes. Random effects models were used to compute crude ODDs ratios (OR) and adjusted odds ratios (aOR) with 95% confidence intervals (CIs). RESULT(S): A total of 44 observational studies met our inclusion criteria. In unadjusted analysis, prior anticoagulation was not associated with reduced risk of thromboembolic events in COVID-19 patients (N=43851, 9 studies, OR 0.67 [0.22, 2.07];p= 0.49;I2= 95%). However, pre-hospital use of anticoagulants significantly increase the risk of allcause mortality in COVID-19 patients (N= 580601;37 studies, OR 1.56 [1.22, 2.01];p=0.0005;I2= 97%). There was no statistically significant association between prehospital anticoagulants usage and COVID-19 disease severity (N=186239;20 studies, OR 0.96 [0.70, 1.33];p= 0.82;I2= 88%). Pooling adjusted estimates revealed no statistically significant association between pre-hospital use of anticoagulants and risk of Thromboembolic events in COVID-19 patients (aOR= 0.85 [0.34, 2.12];p= 0.72), COVID-19 related mortality (aOR= 0.93 [0.82, 1.07];p= 0.32), and the severity of COVID-19 infection (aOR= 0.96 [0.72, 1.30];p= 0.81). CONCLUSION(S): Prehospital use of anticoagulation was not significantly associated with reduced risk of thromboembolic events, improved survival, and lower severity of disease in COVID-19 patients.

18.
Critical Care Medicine ; 51(1 Supplement):79, 2023.
Artigo em Inglês | EMBASE | ID: covidwho-2190479

RESUMO

INTRODUCTION: Severe COVID increases the risk of thrombotic complications. Therapeutic anticoagulation with unfractionated heparin (UH) is commonly utilized to prevent venous thromboembolism (VTE). Thromboelastography (TEG) provides a dynamic and global assessment of hemostasis, which may be advantageous or complimentary with standard coagulation tests like anti-Xa activity or activated partial thromboplastin time (aPTT). The purpose of this study was to evaluate the correlation between anti-Xa activity and aPTT with the TEG parameters of reaction (R) time and coagulation index (CI) in patients with severe COVID receiving UH. METHOD(S): This was a single-center, retrospective study conducted over a 15-month period (2020-2021). Adult patients with severe COVID receiving UH with >=1 corresponding TEG and anti-Xa / aPTT samples assessed <=2 hours of each other were included. The primary endpoint was the correlation between anti-Xa activity and R time. Additional associations were determined for aPTT and R time and anti-Xa activity and aPTT with CI. Pearson's coefficient was used to evaluate the correlation using a kappa measure of agreement. RESULT(S): A total of 423 assessments across 237 patients were included. R time did not correlate with anti-Xa activity (r2=0.032;p< 0.0001) nor aPTT (r2=0.007;p=0.061). CI did not correlate with anti-Xa activity (r2=0.093;p< 0.0001) nor aPTT (r2=0.017;p=0.0073). Overall, 188 (45%) R times and anti-Xa values showed agreement in terms of both demonstrating therapeutic anticoagulation, sub-therapeutic anticoagulation, or supra-therapeutic anticoagulation. Twentyeight patients (11.8%) and 21 patients (8.9%) developed a clinically relevant bleed or VTE, respectively, but all coagulation and TEG parameters were similar between those with a bleed or VTE and those without. CONCLUSION(S): The TEG parameters of R time and CI did not correlate with anti-Xa activity or aPTT for monitoring of intensity of anticoagulation with UH in patients with severe COVID-19. Using TEG in these patients to monitor UH anticoagulation offers no benefit over anti-Xa activity or aPTT. Further research is necessary to address the laboratory tests needed to help with decision-making on anticoagulation dosing in patients with severe COVID.

19.
Critical Care Medicine ; 51(1 Supplement):63, 2023.
Artigo em Inglês | EMBASE | ID: covidwho-2190476

RESUMO

INTRODUCTION: Stroke is rare in the pediatric population but is often associated with significant morbidity and mortality prompting evaluation for a wide range of pathologic processes. Neurologic manifestations of COVID-19 infection include meningoencephalitis, acute demyelinating encephalomyelitis, Guillain barre and stroke. Throughout the literature, patients seen with neurologic disease had severe COVID-19 infection and/or the multi-system inflammatory syndrome (MIS-C). Only a small proportion of patients had neurologic manifestations as the presenting feature with confusion and seizures being most common. DESCRIPTION: We report the case of a 12-year-old male who presented with left sided weakness and confused speech. This occurred following a 3-day illness with reported fever, malaise, and headache with photophobia resolved. On admission he was afebrile with a left facial droop, grade 4 power in the left hemibody and ankle clonus. Labs revealed an elevated WBC (16.4 x 103 cell/mm3) and CRP (7.3mg/dl), a negative respiratory viral panel and COVID-19 PCR test but positive COVID-19 antibody 315 s/co ratio and increased fibrinogen (523mg/dl) and d-dimers (2.69 mcg/ml). CSF had no WBCs and a negative meningitisencephalitis panel. Computed tomography of the brain was normal but an MRI brain with angiography and venography showed multiple infarcts consistent with embolic strokes. An echocardiogram revealed a mobile mass at the left ventricular apex measuring 2.5 x 1.6 cm suggestive of a large clot in the presence of normal biventricular function, and no wall motion abnormalities. Due to the risk of re-embolization with devastating neuro-cardiac effects, he underwent left ventriculotomy and clot removal with cardiopulmonary bypass and was continued on therapeutic anticoagulation. Alternative etiologies such as thrombophilia, infective endocarditis or an intracardiac tumor were ruled out. DISCUSSION: Intracardiac thrombosis has been reported in adults and children with COVID-19 but often along with pneumonia, dilated cardiomyopathy and myocardial infarction or acute MIS-C and intracardiac devices. Delayed thrombosis in the absence of MIS-C or cardiac dysfunction is not as frequently seen and brings to light the prolonged prothrombotic state post COVID infection.

20.
Open Forum Infectious Diseases ; 9(Supplement 2):S167-S168, 2022.
Artigo em Inglês | EMBASE | ID: covidwho-2189556

RESUMO

Background. Patients hospitalized with severe COVID-19 infections are at risk for acute thromboembolism. There are few data on the impact of vaccines on COVID-associated acute thromboembolism (CA-ATE) in patients hospitalized with COVID-19 infection. Methods. Retrospective cohort of CA-ATE between March 2020 and March 2022 (Torrance Memorial Medical Center, pre-pandemic ATE incidence < 1%). Inclusion criteria were confirmed COVID infection, > 18 years, not admitted to ICU, and standard-dose thromboprophylaxis. Exclusion criteria were pregnancy, partial vaccination, and therapeutic dose anticoagulation. Primary outcome was CA-ATE incidence identified by routine clinical testing. We performed a multiple logistic regression for CA-ATE risk factors. Results. Of 3,218 hospitalized COVID-19 patients, 1,428 patients were included;185 were vaccinated (13%) and 1,243 unvaccinated (87%). Vaccinated status was associated with older age, diabetes, heart failure, and chronic kidney disease (p< 0.01). CA-ATE was noted in 7.0% (2.2% deep vein thrombosis (DVT), 0.5% pulmonary embolism (PE), 2.7% myocardial infarction (MI), 1.6% Ischemic stroke (IS)) in the vaccinated and 3.9% (2.7% DVT, 1.5% PE, 1.0% MI, 0.8% IS) in the unvaccinated. In our multivariate model, we found no significant difference in incident CA-ATE between vaccinated and unvaccinated (7.0% vs 3.9%, adj OR=1.35, [95% CI 0.67-2.58], p=0.38). CA-ATE was associated with older age (68 vs 61 years, OR=1.03, [95% CI 1.01-1.05], p=0.01) and heart failure (24% vs 7%, OR=2.84, [95% CI 1.35-6.00], p=0.006). No significant difference was seen in mortality (3.8% vs 4.8%, OR=0.79, [95% CI 0.35-1.69], p=0.56), CRP AUC24hr (5.7 vs 4.7, p=0.18), or D-dimer AUC24hr (596 vs 653, p=0.77) between vaccinated and unvaccinated patients. Conclusion. Adult, non-ICU, hospitalized, COVID-19 patients are at high risk for ATE. We found no association between vaccination status and ATE, but older age and congestive heart failure were predictive in this population. Decisions to anticoagulate non-ICU patients hospitalized with acute COVID-19 infections may not need to consider COVID vaccination status in as part of medical decision making, but may instead need to focus on underlying, high-risk, co-morbidities.

SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA