ICU-level Care Research Articles

310. Cryptococcal Infection Following COVID-19 infection in Solid Organ Transplant Recipients: A Case Series

BackgroundFungal infections have been identified with or following SARS-CoV-2 infection, most commonly COVID associated pulmonary aspergillosis. Cryptococcus species are ubiquitous in the environment and the third most common invasive fungal infection following Solid Organ Transplant (SOT). We describe four cases of concurrent or subsequent cryptococcal infection within 90 days following COVID-19 infection.MethodsWe conducted a retrospective study of patients presenting with proven cryptococcosis either concurrently or within 90 days following COVID-19 diagnosis. Cases were identified March 2020 through May 2021. All were seen at the University of Alabama in Birmingham, a regional referral and comprehensive transplant center. Exemption for this review was approved by our IRB.ResultsFour cases were identified, all were SOT recipients. Case details are provided in Table 1. No patients required ICU level care at any point. COVID-19 treatment included 10 days of increased steroids for 3 patients, remdesivir for 2, and 1 received no treatment for COVID-19. In contrast to the typical time-course for cryptococcal infection post-SOT (median time approx. 500 days post-transplant), three patients were greater than 2 years post-transplant and were without rejection or recent changes in immunosuppression. Patient 1 was less than 6 months post liver-kidney transplant and was diagnosed at time of admission with concurrent COVID-19 and cryptococcal pneumonia. Infection was disseminated in the other 3 cases including positive blood cultures in 2 patients and cryptococcal meningitis (CM) in 2 patients. CM cases presented later following COVID-19 and had the longest delay between symptom onset (headache, neurologic symptoms) and CM diagnosis. One patient had CM 8 years prior, but had done extremely well off fluconazole for over 6 years prior to this recurrence. All patients are doing well at most recent follow-up evaluations.Table 1. Summary of Cases ConclusionWe describe the first case series with a temporal association between SARS-CoV-2 infection and cryptococcosis. All cases were immunocompromised due to SOT. Some symptoms were attributed to post-COVID syndrome leading to significant delays in diagnosis for those patietns, highlighting the importance of considering this association for at-risk patients.Disclosures Todd P. McCarty, MD, Cidara (Grant/Research Support)GenMark (Grant/Research Support, Other Financial or Material Support, Honoraria for Research Presentation)T2 Biosystems (Consultant)

1215. A Mixed Methods Study on Severe Bacterial Infections in People Who Inject Drugs

BackgroundSevere bacterial infections (SBI) associated with intravenous drug use have been increasing in frequency in the U.S. over the last decade. This mixed methods study aims to identify the risk factors associated with SBI in hospitalized individuals with recent injection drug use.MethodsWe conducted 34 quantitative and 15 qualitative interviews between August 2020 and June 2021 at Bellevue Hospital in New York City. Eligible participants were (1) >/= 18 year of age, (2) admitted with a SBI, and (3) reported injection drug use within the 90 days prior to admission. Quantitative and qualitative data was obtained using a quantitative survey and in-depth, semi structured interviews of participants respectively. Analysis was performed to examine trends and explore common themes potentially contributing factors to SBI.ResultsOf the 34 participants included, the median age was 37.5, 85% were male, 53% white, and 65% reported being homeless within the past 3 months. Endocarditis was the most common primary diagnosis (65%). Median length of hospital stay was 24 days and 35% required ICU level care during admission. A causative microorganism was identified in 85% of participants and 50% had Staphylococcus aureus as the sole organism. Discharges against medical advice occurred in 35%. Daily injection drug use in prior 30 days was 95% with a median of 10 injections per day. In the 30 days prior to admission, 50% reported an increase in injection frequency, 80% reported reusing needles and/or syringes, 75% reused cookers, 65% reused cottons. Analysis of qualitative interview data revealed high risk injection behaviors. Participants were not practicing and unaware of strategies to reduce their risk of drug injection-related SBI. Prior hospitalizations for SBI did not impact on this knowledge deficit on what constitutes bacterial infection risk and how to prevent it. ConclusionStudy findings highlight the complexity of the injection drug use process and the potential social and physiological pathways leading to SBI. Multiple domains at the structural, network, and individual level that impact drug injection practices and provide context by which these factors predispose and lead to physiological tissue damage and the development of SBI among PWID. Disclosures Benjamin Eckhardt, MD, MS, Gilead Sciences (Grant/Research Support)

989. Isavuconazonium Sulfate Treatment of Blastomycosis: A Case Series

Abstract Background Blastomyces fungi, endemic to the Ohio and Mississippi River Valleys, cause pneumonia and disseminated disease in both immunocompetent and immunocompromised patients. Prolonged antifungal therapy is commonly complicated by hepatic toxicity, QT prolongation, and drug interactions. Isavuconazonium sulfate is dosed once daily, does not prolong the QT interval, and has fewer drug interactions, but there is a paucity of data for its use in blastomycosis. Methods This case series of blastomycosis treated with isavuconazonium sulfate at the University of Wisconsin Hospital and Clinics from 2015 to December 2019 focuses on long term outcomes. Inclusion criteria were adults, that received at least one day of isavuconazole. Exclusion criteria was no blastomycosis diagnosis. Results Of 14 cases, median age was 53 years, 6/14 were female, 11/14 White, 2/14 Black, 1/14 Hmong, 6/14 had a solid organ transplant (4 renal, 1 heart, 1 bilateral lung), 1/14 on a TNF-alpha inhibitor (infliximab). Most cases, 9/14 had moderate severity illness requiring inpatient care, 2/14 required ICU level care, and 3/14 were outpatient. Most cases, 11/14, were initially treated with Liposomal Amphotericin B (LAMB) for a median duration of 14 days, 9/14 cases received itraconazole, 8/14 voriconazole, 1/14 posaconazole. Isavuconazonium sulfate was started after adverse drug effects with other azoles in 10/14 cases, prolonged QT interval in 3/14, drug interactions in 2/14, subtherapeutic azole levels in 2/14. Isavuconazonium sulfate was well tolerated and used for median duration of 255 (average 68% total treatment course). 3/14 cases had adverse reactions to isavuconazonium sulfate: nausea, rash, elevated liver enzymes. There was only one death during therapy from a fatal hemorrhagic stroke, and 2/14 cases were still on therapy at end of data collection. 11/14 were cured after treatment course. Conclusion This is the largest case series treating Blastomycosis with isavuconazonium sulfate, and it adds to the evidence that isavuconazonium sulfate can be safely used to treat pulmonary and disseminated blastomycosis. Prospective data is needed to compare isavuconazonium sulfate to other antifungals for the treatment of Blastomycosis. Disclosures All Authors: No reported disclosures

839. Examining the Effects of HIV Infection on Severity of Outcomes in Those with COVID-19

BackgroundThroughout the SARS-CoV-2 pandemic, there have been many questions about how COVID-19 affects patients living with HIV (PLWH). We examined the clinical courses of 45 PLWH who required hospitalization with SARS-CoV-2 infection.MethodsThis is a retrospective cohort study in which ICD-10 codes were used to identify PLWH who were admitted to three large hospital systems in Memphis, TN with COVID-19. We included all patients ≥ 18 years of age with HIV and a documented positive SARS-CoV-2 PCR test. After manual abstraction from the electronic health records, chi-squared and T-tests were performed to evaluate associations between patient-level factors and outcomes.ResultsA total of 45 patients with HIV who tested positive for SARS-CoV-2 were admitted to Memphis, TN area hospitals between March 2020 and October 2020. 18 (40%) were female, 43 (95.6%) were Black, and the average age was 50.3 years (SD 12.6). The average BMI was 30.2 (SD 8.6). 40 (88.9%) patients admitted had at least one comorbidity with the most common being hypertension (28 patients, 62.2%) and diabetes (14 patients, 31.1%). 24 (46.7%) patients had a Charlson Comorbidity Index > 3. 15/43 (48.4%) patients had a CD4 count < 200, and 35 (77.8%) were on ART. 30 (66.7%) patients met SIRS criteria within 24 hours of admission, and 27 (60%) required some form of oxygen supplementation during hospitalization, including 4 (8.9%) who required intubation. The average length of stay was 10.4 days (SD 12.5). 9 (20%) patients required an ICU stay, and 3 (6.7%) died. BMI > 30, CD4 count < 200, and viral load > 1000 were not associated with worse outcomes. Both a Charlson Comorbidity Index > 3 and the absence of ART were associated with need for ICU-level care.ConclusionViral load, CD4 count, and BMI were not correlated with differences in mortality or oxygen use in our study. Patients with higher Charlson Comorbidity Indices and patients who were not on ART at presentation were significantly more likely to require the ICU. Further study is needed to definitively determine factors affecting the outcomes of PLWH with SARS-CoV-2 infection.Disclosures All Authors: No reported disclosures

An emergency department-based intensive care unit is associated with decreased hospital length of stay for upper gastrointestinal bleeding.

Upper gastrointestinal bleeding (UGIB) is associated with substantial morbidity, mortality, and intensive care unit (ICU) utilization. Initial risk stratification and disposition from the Emergency Department (ED) can prove challenging due to limited data points during a short period of observation. An ED-based ICU (ED-ICU) may allow more rapid delivery of ICU-level care, though its impact on patients with UGIB is unknown. A retrospective observational study was conducted at a tertiary U.S. academic medical center. An ED-ICU (the Emergency Critical Care Center [EC3]) opened in February 2015. Patients presenting to the ED with UGIB undergoing esophagogastroduodenoscopy within 72 h were identified and analyzed. The Pre- and Post-EC3 cohorts included patients from 9/2/2012-2/15/2015 and 2/16/2015-6/30/2019. We identified 3788 ED visits; 1033 Pre-EC3 and 2755 Post-EC3. Of Pre-EC3 visits, 200 were critically ill and admitted to ICU [Cohort A]. Of Post-EC3 visits, 682 were critically ill and managed in EC3 [Cohort B], whereas 61 were critically ill and admitted directly to ICU without care in EC3 [Cohort C]. The mean interval from ED presentation to ICU level care was shorter in Cohort B than A or C (3.8 vs 6.3 vs 7.7 h, p < 0.05). More patients in Cohort B received ICU level care within six hours of ED arrival (85.3 vs 52.0 vs 57.4%, p < 0.05). Mean hospital length of stay (LOS) was shorter in Cohort B than A or C (6.2 vs 7.3 vs 10.0 days, p < 0.05). In the Post-EC3 cohort, fewer patients were admitted to an ICU (9.3 vs 19.4%, p < 0.001). The rate of floor admission with transfer to ICU within 24 h was similar. No differences in absolute or risk-adjusted mortality were observed. For critically ill ED patients with UGIB, implementation of an ED-ICU was associated with reductions in rate of ICU admission and hospital LOS, with no differences in safety outcomes.

Abstract 13068: Use of Cardiac Implantable Electronic Devices in Carcinoid Heart Disease

Introduction: Carcinoid heart disease (CHD) is a rare sequelae of hormonally active neuroendocrine tumors that often requires cardiac surgical intervention. Little is reported on cardiac implantable electronic device (CIED) implantation in the CHD patient population. Hypothesis: We sought to establish the safety and efficacy of CIED implantation in patients with CHD. Methods: We retrospectively reviewed patients with a diagnosis of CHD who underwent CIED implantation at our institution (Mayo Clinic) and evaluated indications for implant, perioperative complications, and mortality. Results: A total of 27 patients with a cumulative follow up of 75 patient-years were identified during the study period. The most common indication for device implant was high grade atrioventricular block (n=18, 66.7%). 14 (51.8%) had baseline conduction disease and 26 (96.2%) underwent cardiac surgery prior to CIED implant. The majority of devices implanted were dual chamber permanent pacemakers (PPM) (n=17, 63.0%), while other devices included single chamber PPM, epicardial PPM, chronic resynchronization devices, and intracardiac defibrillators. Peri-operative complication occurred in 6 patients (22.2%), with 2 patients requiring ICU level care. No patient suffered carcinoid crisis during implantation and there was no peri-implant mortality. Long term, 3 patients required device extraction: 1 for infection, 1 for lead related pain, and 1 for generator migration. The median time to death from implant was 2.5 years, with one-year mortality at 15%. Conclusions: In this unique cohort of patients with CHD, CIED can be performed safely. CIED most often occurred in the post cardiac surgical period and carcinoid crisis was uncommon.

Is Intensive Care Unit Monitoring Necessary After Maxillomandibular Advancement for Management of Obstructive Sleep Apnea?

Maxillomandibular advancement (MMA) is an accepted treatment modality for obstructive sleep apnea. The purpose of this study was to evaluate the incidence of complications requiring an intensive care unit (ICU) level of care and the necessity of routine overnight ICU airway monitoring after MMA. This was a retrospective cohort study of patients undergoing MMA at Massachusetts General Hospital from 2003 to 2020. The primary predictor variable was postoperative admission to the ICU versus post anesthesia care unit (PACU) or ward. The primary outcome variable was grade IV or V complications as scored using the Clavien-Dindo classification system. The secondary outcome variables included postoperative SpO2 nadir and length of hospital stay. Descriptive and bivariate statistics were computed to measure the association between complications and predictor variables. The study sample consisted of 104 patients (74.0% male, mean age 37.6±12.1years), 61 of whom were admitted to the ICU (58.7%). During the initial 24hours of airway monitoring, the mean SpO2 nadir was 93.7±2.59% for patients admitted to the ICU compared with 94.0±6.56% for patients admitted to the PACU or ward (P=.862). Patients experienced 2 grade IV complications (1.92%) and no grade V complications, with no statistical association between complications and postoperative admission location (P=1.000). Age (P=.002) and operative time (P=.046) were the only variables statistically associated with grade IV or V complications. There was no difference in length of hospital stay between patients admitted to the ICU (2.64±1.37days) versus PACU or ward (2.58±1.62days). The incidence of complications requiring ICU-level care after MMA for obstructive sleep apnea is low. Additional studies are warranted to guide development of feasible, cost-effective perioperative protocols for patients undergoing MMA.

COVID-19 in Patients With Hematologic Malignancies: A Single Center Retrospective Study.

Initial studies that described the novel coronavirus (COVID-19) reported increased morbidity and mortality in patients with cancer. Of this group, patients with hematologic malignancies (HM) had the highest disease severity and death rates. Subsequent studies have attempted to better describe how COVID-19 affects patients with HM. However, these studies have yielded variable and often contradictory results. We present our single-institution experience with patients with HM who were diagnosed with COVID-19 from March 2020 to March 2021. We report 62 total cases with 10 patients who died during this time. The overall mortality was 16.1%. Mortality during the first two waves of COVID was 27.8% and 25%. Mortality during the third wave of COVID was 10%. The median age of patients was 67 years (range 20-89 years). 55% of patients had lymphoid malignancies and the majority had active disease at the time of diagnosis with COVID-19. 87% of patients had more than one co-morbidity. Important co-morbidities included cardiovascular disease and smoking history. 38.7% of patients had asymptomatic or mild disease, 54.8% required hospitalization, and 17.5% required ICU level care. In patients who required ICU level care, the mortality was 60%.

Clinical Characteristics and Short-Term Outcomes of Children With Asparaginase-Associated Pancreatitis.

Acute pancreatitis is a significant toxicity of l-asparaginase, a chemotherapeutic agent used to treat acute lymphoblastic leukemia. This case series describes the short-term clinical course and disposition of patients who developed asparaginase-associated pancreatitis (AAP) at one quaternary pediatric center. Clinical data, including laboratory data, inpatient and intensive care unit (ICU) days, imaging findings, presence of complications such as need for ventilation, dialysis, and the development of pleural effusions, and mode of nutrition were abstracted from the medical record of patients with AAP. Pediatric criteria were used to classify episode severity based on the development of organ failure and local complications, such as pancreatic necrosis. Between 2005 and 2015, 34 patients had AAP with 43 distinct episodes of pancreatitis. The median inpatient length of stay was 10 days (range 2-65). Seven episodes (16.3%) required intensive care unit (ICU)-level care. Seventeen episodes (39.5%) were severe based on the development of organ failure or presence of pancreatic necrosis. Total parenteral nutrition (TPN) was used in 17 episodes (39.5%); for 34 episodes (79.1%), patients were discharged on entirely oral feeds. Antibiotics were administered in 20 episodes (46.5%). Pancreatic necrosis was identified within the first week in 12 episodes (27.9%). There were no deaths due to AAP. The clinical course varies widely among patients with AAP. Over one-third of the patients in this series developed severe pancreatitis. Although the prognosis of AAP is generally good, many patients develop systemic complications of AAP, requiring TPN or ICU-level care.

Efficacy and Safety of Therapeutic-Dose Heparin vs Standard Prophylactic or Intermediate-Dose Heparins for Thromboprophylaxis in High-risk Hospitalized Patients With COVID-19

Hospitalized patients with COVID-19 are at risk for venous and arterial thromboembolism and death. Optimal thromboprophylaxis dosing in high-risk patients is unknown. To evaluate the effects of therapeutic-dose low-molecular-weight heparin (LMWH) vs institutional standard prophylactic or intermediate-dose heparins for thromboprophylaxis in high-risk hospitalized patients with COVID-19. The HEP-COVID multicenter randomized clinical trial recruited hospitalized adult patients with COVID-19 with D-dimer levels more than 4 times the upper limit of normal or sepsis-induced coagulopathy score of 4 or greater from May 8, 2020, through May 14, 2021, at 12 academic centers in the US. Patients were randomized to institutional standard prophylactic or intermediate-dose LMWH or unfractionated heparin vs therapeutic-dose enoxaparin, 1 mg/kg subcutaneous, twice daily if creatinine clearance was 30 mL/min/1.73 m2 or greater (0.5 mg/kg twice daily if creatinine clearance was 15-29 mL/min/1.73 m2) throughout hospitalization. Patients were stratified at the time of randomization based on intensive care unit (ICU) or non-ICU status. The primary efficacy outcome was venous thromboembolism (VTE), arterial thromboembolism (ATE), or death from any cause, and the principal safety outcome was major bleeding at 30 ± 2 days. Data were collected and adjudicated locally by blinded investigators via imaging, laboratory, and health record data. Of 257 patients randomized, 253 were included in the analysis (mean [SD] age, 66.7 [14.0] years; men, 136 [53.8%]; women, 117 [46.2%]); 249 patients (98.4%) met inclusion criteria based on D-dimer elevation and 83 patients (32.8%) were stratified as ICU-level care. There were 124 patients (49%) in the standard-dose vs 129 patients (51%) in the therapeutic-dose group. The primary efficacy outcome was met in 52 of 124 patients (41.9%) (28.2% VTE, 3.2% ATE, 25.0% death) with standard-dose heparins vs 37 of 129 patients (28.7%) (11.7% VTE, 3.2% ATE, 19.4% death) with therapeutic-dose LMWH (relative risk [RR], 0.68; 95% CI, 0.49-0.96; P = .03), including a reduction in thromboembolism (29.0% vs 10.9%; RR, 0.37; 95% CI, 0.21-0.66; P < .001). The incidence of major bleeding was 1.6% with standard-dose vs 4.7% with therapeutic-dose heparins (RR, 2.88; 95% CI, 0.59-14.02; P = .17). The primary efficacy outcome was reduced in non-ICU patients (36.1% vs 16.7%; RR, 0.46; 95% CI, 0.27-0.81; P = .004) but not ICU patients (55.3% vs 51.1%; RR, 0.92; 95% CI, 0.62-1.39; P = .71). In this randomized clinical trial, therapeutic-dose LMWH reduced major thromboembolism and death compared with institutional standard heparin thromboprophylaxis among inpatients with COVID-19 with very elevated D-dimer levels. The treatment effect was not seen in ICU patients. ClinicalTrials.gov Identifier: NCT04401293.

FENTANYL-INDUCED PERSISTENT ENCEPHALOPATHY

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Fentanyl is a synthetic opioid routinely used for sedation and analgesia in the intensive care unit (ICU). Though typically safe when used vigilantly for ICU-level care, it can sometimes cause serious adverse effects such as acute encephalopathy that usually improve with supportive care. We present a rare case of persistent encephalopathy caused by fentanyl. CASE PRESENTATION: An 85-year-old functionally independent woman with a history of chronic obstructive pulmonary disease (COPD) on 2 L oxygen, hypertension, and hypothyroidism presented with shortness of breath and dry cough for four days. She was intubated and mechanically ventilated for worsening respiratory distress and hypercapnia. She required deep sedation with maximum doses of fentanyl infusion 200 mcg/hr and propofol infusion 60 mcg/kg/min, and vasopressor support with norepinephrine for two days to maintain her blood pressure. Sputum cultures grew Haemophilus influenza. She was treated with 7 days of intravenous levofloxacin for tracheobronchitis and COPD exacerbation. She also received intravenous methylprednisolone and breathing treatments. Her respiratory status gradually improved and she was weaned down to minimal ventilator FiO2 and PEEP and sedation in five days, but she stayed unresponsive. Seven days off sedation, she had a partial return of consciousness but had altered mentation, quadriplegia, and absence of reflexes bilaterally. She showed minimal response to painful stimuli in all limbs. CT and MRI of the head and C-spine showed no acute pathology. Cerebrospinal fluid analysis and cultures ruled out infectious (including viral, bacterial, and fungal) etiologies. 12-hour EEG was consistent with metabolic encephalopathy. After multidisciplinary evaluation, her encephalopathy was attributed to fentanyl. Patient was eventually extubated after 16 days. One month later, she had mild improvement of neurological status with orientation only to person. She was able to slightly squeeze examiner's fingers in both hands, and foot plantar and dorsiflexion was 4/5 bilaterally with the rest of motor strength 0/5 in all extremities. She was discharged to a nursing home with unchanged neurological status. DISCUSSION: Fentanyl has a rapid onset and short duration of action making it sedation of choice in ICU. Acute encephalopathy is infrequently associated with other synthetic opioids like oxycodone and methadone [1,2]. Fentanyl uncommonly causes delayed hypoxic leukoencephalopathy which develops few days to weeks after exposure [3]. Acute persistent encephalopathy from fentanyl is rare and can lead to significant functional impairment. CONCLUSIONS: It is important for clinicians to be aware of persistent encephalopathy caused by fentanyl. Sedation should be used with caution especially in elderly patients. Intermittent pushes or shorter duration of use may prevent this rare complication. REFERENCE #1: Morales Odia Y, Jinka M, Ziai WC. Severe leukoencephalopathy following acute oxycodone intoxication. Neurocrit Care. 2010;13(1):93-97. REFERENCE #2: Haghighi-Morad M, Naseri Z, Jamshidi N, Hassanian-Moghaddam H, Zamani N, Ahmad-Molaei L. Methadone-induced encephalopathy: a case series and literature review. BMC Med Imaging. 2020;20(1):6. REFERENCE #3: Kim J, Hyung SW, Seo J, Lee H, Yu HJ, Sunwoo MK. Delayed post-hypoxic leukoencephalopathy caused by fentanyl intoxication in a healthy woman. Dement Neurocognitive Disord. 2020;19(4):170-172. DISCLOSURES: No relevant relationships by Qasim Jehangir, source=Web Response No relevant relationships by Yi Lee, source=Web Response No relevant relationships by Ali Najar, source=Web Response No relevant relationships by Jonathan Toot, source=Web Response

Primary brain tumor patients admitted to a US intensive care unit: a descriptive analysis.

Purpose:To describe our population of primary brain tumor (PBT) patients, a subgroup of cancer patients whose intensive care unit (ICU) outcomes are understudied.Methods:Retrospective analysis of PBT patients admitted to an ICU between 2013 to 2018 for an unplanned need. Using descriptive analyses, we characterized our population and their outcomes.Results:Fifty-nine PBT patients were analyzed. ICU mortality was 19% (11/59). The most common indication for admission was seizures (n = 16, 27%).Conclusion:Our ICU mortality of PBT patients was comparable to other solid tumor patients and the general ICU population and better than patients with hematological malignancies. Further study of a larger population would inform guidelines for triaging PBT patients who would most benefit from ICU-level care.

Anasarca as the presenting symptom of juvenile dermatomyositis: a case series

BackgroundJuvenile Dermatomyositis (JDM) is an autoimmune disease that typically presents with classic skin rashes and proximal muscle weakness. Anasarca is a rare manifestation of this disease and is associated with a more severe and refractory course, requiring increased immunosuppression. Early recognition of this atypical presentation of JDM may lead to earlier treatment and better outcomes.Case presentationWe present two female patients, ages 11 years old and 4 years old, who presented to the ED with anasarca and were subsequently diagnosed with JDM. Both patients required ICU-level care and significant immunosuppression, including prolonged courses of IV methylprednisolone, IVIG, and Rituximab.ConclusionsAnasarca is a rare presentation of Juvenile Dermatomyositis, but it is important for clinicians to recognize this manifestation of the disease. Early recognition and treatment will lead to better outcomes in these children and hopefully decrease the need for prolonged hospitalization and ICU level care.

Management of Minor Traumatic Brain Injury in an ED Observation Unit.

IntroductionTraumatic intracranial hemorrhages (TIH) have traditionally been managed in the intensive care unit (ICU) setting with neurosurgery consultation and repeat head CT (HCT) for each patient. Recent publications indicate patients with small TIH and normal neurological examinations who are not on anticoagulation do not require ICU-level care, repeat HCT, or neurosurgical consultation. It has been suggested that these patients can be safely discharged home after a short period of observation in emergency department observation units (EDOU) provided their symptoms do not progress.MethodsThis study is a retrospective cross-sectional evaluation of an EDOU protocol for minor traumatic brain injury (mTBI). It was conducted at a Level I trauma center. The protocol was developed by emergency medicine, neurosurgery and trauma surgery and modeled after the Brain Injury Guidelines (BIG). All patients were managed by attendings in the ED with discretionary neurosurgery and trauma surgery consultations. Patients were eligible for the mTBI protocol if they met BIG 1 or BIG 2 criteria (no intoxication, no anticoagulation, normal neurological examination, no or non-displaced skull fracture, subdural or intraparenchymal hematoma up to 7 millimeters, trace to localized subarachnoid hemorrhage), and had no other injuries or medical co-morbidities requiring admission. Protocol in the EDOU included routine neurological checks, symptom management, and repeat HCT for progression of symptoms. The EDOU group was compared with historical controls admitted with primary diagnosis of TIH over the 12 months prior to the initiation of the mTBI protocols. Primary outcome was reduction in EDOU length of stay (LOS) as compared to inpatient LOS. Secondary outcomes included rates of neurosurgical consultation, repeat HCT, conversion to inpatient admission, and need for emergent neurosurgical intervention.ResultsThere were 169 patients placed on the mTBI protocol between September 1, 2016 and August 31, 2019. The control group consisted of 53 inpatients. Median LOS (interquartile range [IQR]) for EDOU patients was 24.8 (IQR: 18.8 – 29.9) hours compared with a median LOS for the comparison group of 60.2 (IQR: 45.1 – 85.0) hours (P < .001). In the EDOU group 47 (27.8%) patients got a repeat HCT compared with 40 (75.5%) inpatients, and 106 (62.7%) had a neurosurgical consultation compared with 53 (100%) inpatients. Subdural hematoma was the most common type of hemorrhage. It was found in 60 (35.5%) patients, and subarachnoid hemorrhage was found in 56 cases (33.1%). Eleven patients had multicompartment hemorrhage of various classifications. Twelve (7.1%) patients required hospital admission from the EDOU. None of the EDOU patients required emergent neurosurgical intervention.ConclusionPatients with minor TIH can be managed in an EDOU using an mTBI protocol and discretionary neurosurgical consults and repeat HCT. This is associated with a significant reduction in length of stay.

Recession Increases Need for Intensive Care in Pediatric Hematologic Malignancy Presentation

Introduction: The Great Recession of 2007-2009 led a new group of families to fall into poverty and took a greater toll on the Black population than other segments of the population. Higher unemployment rates led to increased poverty levels and increased utilization of public insurance.1Given increasing rates of public insurance, we hypothesized that the need for intensive care unit (ICU)-level care at the time of hematologic malignancy diagnosis increased during and following the Great Recession and that this effect is more pronounced among the Black population.Methods: A retrospective cohort of children with new-onset acute lymphoblastic leukemia (ALL), acute myeloid leukemia (AML), or mature B cell lymphoma initially treated at free-standing pediatric hospitals between 2004-2013 was assembled from the Pediatric Health Information System (PHIS) administrative database. We defined the primary exposure as the epoch of diagnosis divided into 3 time periods: 2004-2007, 2008-2010, and 2011-2013 based on the plateau in rising unemployment after 2010. The primary outcome was patient acuity at presentation, defined as utilization of ICU-level care in the first 72 hours of the index cancer admission. Proportion of patients with public insurance across epochs was compared using the chi-square test. Logistic regression analyses were used to estimate crude odds ratios (cOR) and corresponding 95% confidence intervals (CI) for acuity by epoch and were subsequently stratified by race to evaluate for effect measure modification.Results: 12,941 patients (10,202 with ALL, 1,599 with AML, and 1,140 with mature B cell lymphoma) were included. Utilization of public insurance across diseases increased from 39% in the Pre-recession period to 47% in the Post-recession period (p <0.0001). In the periods during and after the Great Recession (when compared to the Pre-recession period), ICU-level care increased for AML (During recession cOR 0.81 [95% CI: 0.52, 1.27] and Post-recession cOR 1.49 [95% CI: 0.99, 2.23]) and mature B cell lymphoma (During recession cOR 1.66 [95% CI: 0.90, 3.06] and Post-recession cOR 2.16 [95% CI: 1.23, 3.80]), but not for ALL (During recession cOR 0.89 [95% CI: 0.70, 1.12] and Post-recession cOR 1.11 [95% CI: 0.89, 1.39]) as shown in Table 1. However, among Black patients with ALL, a similar temporal increasing trend in acuity of presentation was observed (During recession cOR 1.81 [95% CI: 0.88, 3.73] and Post-recession cOR 1.51 [95% CI: 0.73, 3.09]).Conclusions: These data suggest that the Great Recession was associated with increasing acuity of presentation over time for children with AML and mature B cell lymphoma. While the division of patients by time period reduces sample size and thereby limits the power of these analyses to detect statistically significant differences, the majority of measures were in the hypothesized direction and approached or reached statistical significance. The temporal trend of increasing rates of illness acuity among pediatric cancer patients at diagnosis highlights the potential negative healthcare consequences of a recession on economically vulnerable populations.1Anthony EK, King B, Austin MJ. Reducing child poverty by promoting child well-being: Identifying best practices in a time of great need. Children and Youth Services Review. 2011;33:1999-2009. [Display omitted] DisclosuresFisher:Merck: Research Funding; Pfizer: Research Funding.

Cancer, transplant, and immunocompromising conditions were not significantly associated with severe illness or death in hospitalized COVID-19 patients.

ObjectivePatients with cancer, transplant, and other immunocompromising conditions are at uncertain risk of severe COVID-19 illness. This study aimed to clarify whether patients with immunocompromising conditions were more likely to develop severe COVID-19 illness in a single urban academic medical center.MethodsA retrospective chart review and electronic data extraction of the first 401 patients at the University of Chicago Hospitals with SARS-CoV-2 infection was performed. Patients met criteria for severe COVID-19 illness if they required ICU level care, high flow oxygen, positive pressure support, helmet non-invasive ventilation, mechanical ventilation, or ECMO, developed ARDS, or died.ResultsThe mean age was 60 years, 52% were women, 90% were African American, and mortality at 30 days post discharge was 13%. Severe COVID-19 illness was found in 168 (40%) patients. Of the 56 patients with past or current cancer, 25 (45%) had severe illness (p=0.76). Of the 55 patients with other immunocompromised conditions, 24 (44%) had severe illness (p=0.89) After controlling for age, sex, and race, neither cancer (p=0.73) nor immunocompromised conditions (p=0.64) were associated with severe illness.ConclusionNo association was found between severe COVID-19 illness and cancer, transplant, and other immunocompromising conditions in a cohort of mostly African American patients.

Hospital Admissions from the Emergency Department and Subsequent Critical Care Interventions for Influenza during Pregnancy.

The objectives of this study were to determine (1) whether obstetrical patients were more likely to be admitted from the emergency department (ED) for influenza compared with nonpregnant women, and (2) require critical care interventions once admitted. Using data from the 2006 to 2011 Nationwide Emergency Department Sample, ED encounters for influenza for women aged 15 to 54 years without underlying chronic medical conditions were identified. Women were categorized as pregnant or nonpregnant using billing codes. Multivariable log linear models were fit to evaluate the relative risk of admission from the ED and the risk of intensive care unit (ICU)-level interventions including mechanical ventilation and central monitoring with pregnancy status as the exposure of interest. Measures of association were described with adjusted risk ratios (aRRs) with 95% confidence intervals (CIs). We identified 15.9 million ED encounters for influenza of which 4% occurred among pregnant women. Pregnant patients with influenza were nearly three times as likely to be admitted as nonpregnant patients (aRR = 2.99, 95% CI: 2.94, 3.05). Once admitted, obstetric patients were at 72% higher risk of ICU-level interventions (aRR = 1.72, 95% CI: 1.61, 1.84). Of pregnant women admitted from the ED, 9.3% required ICU-level interventions such as mechanical ventilation or central monitoring. Older patients and those with Medicare were also at high risk of admission and ICU-level interventions (p < 0.01). Pregnancy confers three times the risk of admission from the ED for influenza and pregnant women are significantly more likely to require ICU-level medical interventions compared with women of similar age. These findings confirm the significant disease burden from influenza in the obstetric population and the public health importance of reducing infection risk. · Pregnancy confers three times the risk of admission from the ED for influenza.. · Pregnant women admitted with influenza are significantly more likely to require ICU-level care.. · Influenza represents a significant disease burden in the obstetric population.

Blood usage at a large academic center in Maryland in relation to the COVID-19 pandemic in 2020.

BackgroundBlood usage and collections were impacted throughout 2020 both by the severity of the COVID‐19 pandemic as well as public health decisions affecting hospital operations. We sought to understand the longer‐term effects of the pandemic on blood usage via changes in case volume and clinical intensity as well as whether the blood needs of COVID‐19‐positive patients differed from other transfused patients.Study design and methodsA single‐center retrospective study of blood use in 2020 as compared to 2014–2019 was conducted at a tertiary care center. Statistical analysis was performed in an R‐based workflow. p values are reported using two‐sided t‐tests for total hospital blood usage and using Mann–Whitney U tests for comparisons of patient blood usage.ResultsMean monthly red cell usage in 2020 decreased by 11.2% (p = .003), plasma usage decreased by 23.8%, (p < .001) platelet usage decreased by 11.4% (p < .001), and monthly cryoprecipitate use increased by 18% (p = .03). A linear regression model predicted significant associations between total blood usage and the year, number of Medicare eligible discharges, and Case Mix Index. COVID‐19‐positive patients requiring at least one blood product did not use significantly different amounts of red cells, plasma, or platelets from all other transfused patients.ConclusionsYear 2020 began with decreased blood usage that was normalized by late spring. Reassuringly, transfused COVID‐19‐positive patients in general and those requiring ICU level care do not use significantly increased amounts of blood as compared to similar transfused hospital patients.

564 Managing California’s Creek Fire Mass Casualty’s Incident

Abstract Introduction California’s Creek Fire is not only the largest single wildfire in a state known for huge and destructive blazes, it spawned two rare fire tornados with winds over 100mph, a day after the fire started in early September. Huntington Lake and Mammoth Pool were the sites of these rare events leading to hundreds of trapped campers. An air rescue operation airlifted hundreds of trapped people to safety. Twenty days after the start of the fire, it had burned &amp;gt;300,000 acres with only 36% containment by fire crews. This review is an evaluation of our hospitals response team and the events surrounding that night. Methods Our on-call surgeon had called in the back-up surgeon to run a second trauma operating room. It was at this time, the news had reported trapped campers near Mammoth Pool. The burn surgeon was notified and reported to the emergency department (ED) as word of 65 possible victims spread. Local disaster response planning was initiated with an ED physician triaging patients at the regional airport. Initial calls were made to the division chief and burn medical director. The nursing director was notified along with any available nursing staff with 8 ICU nurses volunteering to report. Immediately, lateral transfer orders were placed for all burn patients housed in the burn center which has 10 ICU bed capabilities. Results The first helicopter landed with 5 of the burn victims presenting to our hospital. 4 of the victims were male and 1 female with ages ranging from 17 to 27. Total body surface area burn was estimated on each with 2 minor burns &amp;lt; 10% and 3 moderate sized burns of roughly 25%. These patients were quickly triaged in the ED and traumatic injuries evaluated. 3 of the patients were placed in ICU level care with the 2 remaining patients housed in the ED as word trickled in about another rescue effort with an additional 95 people. By morning, an additional 2 patients were transferred to our burn center from the surrounding hospitals and another 2 patients evaluated for burns sustained in separate events. All patients were taken to the operating room over the next 24–48 hours for excision and autologous spray on skin cells (ASCS) in combination with widely meshed skin grafts or ASCS alone. Conclusions Communication, teamwork, and personnel that are dedicated to the care of burn patients made this tragic incident manageable. The Creek Fire hit home for many of the burn staff not only because of the patients that were cared for, but because this area of California was a beloved respite for many. A debriefing with a chaplain, grief counselor, and psychotherapist, was held within 2 weeks of the incident to provide support to the staff during this devastating time.

Study of Pediatric Operative Recreational Trauma: A Retrospective Analysis of Pediatric Sports-Related Facial Fractures.

In the United States, most school-aged children participate in some form of organized sports. Despite the advantages to social and physical development that organized sports may have, these activities also place a significant number of America's youth at risk for facial injuries. Pediatric facial fractures resulting from sports trauma are well documented within pediatric literature. Despite knowledge of the importance of safety equipment, there is a continued need for increased awareness about fracture patterns resulting from sports injuries to develop better strategies for their prevention. A retrospective review of all pediatric patients (age <18) who presented to Children's Memorial Hermann Hospital as a level 1 trauma between January 2006 and December 2015 with radiologically confirmed facial fractures was performed. Data regarding patient demographic information, mechanism of injury, facial fracture location, associated injuries, hospital course, and need for surgical intervention was collected. Of the 1274 patients reviewed, 135 (10.59%) were found to have facial fractures resulting from sports trauma and were included in our cohort. The median age was 14 with 77.8% of the cohort being male. The most common fractures identified were orbital (n = 75), mandibular (n = 42), nasal (n = 27), maxilla (n = 26). Fractures were more frequently related to involvement in baseball/softball and bicycling n = 46 and n = 31 respectively. Eighty-two (60.74%) patients required admission, 6 requiring ICU level care, 70 (51.85%) were found to require surgery. There were 14 patients who were found to have a concomitant skull fracture and 6 with TBI. There were no fatalities in this cohort of patients. Pediatric facial fractures occur in the same anatomic locations as adult facial fractures. However, their frequency, severity, and treatment vary because of important anatomical and developmental differences in these populations. Despite available knowledge on this subject and increased use of protective equipment, pediatric facial fractures continue to occur with similar distribution as historically described. While sports participation confers numerous benefits, it is vital that we continue researching pediatric facial trauma and associated fractures to develop protective equipment and protocols to mitigate the risks of these activities.