Medical Floor Research Articles

The Response of an Orthopedic Department and Specialty Hospital at the Epicenter of a Pandemic: The NYU Langone Health Experience

As the world grapples with the COVID-19 pandemic, we as health care professionals thrive to continue to help our patients, and as orthopedic surgeons, this goal is ever more challenging. As part of a major academic tertiary medical center in New York City, the orthopedic department at New York University (NYU) Langone Health has evolved and adapted to meet the challenges of the COVID pandemic. In our report, we will detail the different aspects and actions taken by NYU Langone Health as well as NYU Langone Orthopedic Hospital and the orthopedic department in particular. Among the steps taken, the department has reconfigured its staff’s assignments to help both with the institution’s efforts and our patients’ needs from reassigning operating room nurses to medical COVID floors to having attending surgeons cover urgent care locations. We have reorganized our residency and fellowship rotations and assignments as well as adapting our educational programs to online learning. While constantly evolving to meet the institution’s and our patient demands, our leadership starts planning for the return to a new “normal”.

High Prevalence of Concurrent Gastrointestinal Manifestations in Patients With Severe Acute Respiratory Syndrome Coronavirus 2: Early Experience From California

High Prevalence of Concurrent Gastrointestinal Manifestations in Patients With Severe Acute Respiratory Syndrome Coronavirus 2: Early Experience From California

MP66-01 HEMATURIA COMMUNICATION

INTRODUCTION AND OBJECTIVE: Gross hematuria can be a challenge to describe for non-urologic health care providers. Tools to aid in accuracy of communication are lacking and not commonly incorporated in healthcare systems. Our aim is to determine the current status of hematuria communication and assess the ability to improve consistency in communication by using a color picture guide and specific assessment prompting. METHODS: We prospectively performed a single-institution, hospital wide-assessment including all inpatient floor nurses. A 15-item questionnaire was distributed electronically during a 3 week completion period. To evaluate hematuria communication, participants were shown an image of indwelling catheter tubing with gross blood in the urine. In 2 sequential pages, participants were asked to describe the same hematuria image using 1) currently established electronic medical record selection choices, then 2) using a newly devised color reference guide with specific prompting to evaluate clarity and presence of blood clots. Comparisons were made between assessments to evaluate the number of unique responses and rate of documenting clarity and clots. RESULTS: A total of 311 nurses participated in the survey (response rate of 21%) from varied health care settings including the intensive care unit (32%), medical floor (22%), surgical floor (18%), Urology floor (5%), or other (23%). Although the majority of nurses previously managed a patient with active hematuria (87%), 35% believed the urine in the catheter bag was most informative when describing patients with hematuria. The number of unique responses significantly decreased when using a color reference guide compared to current hospital practice (n=9 vs n=37, respectively). All nurses commented on clots (100% vs 1%) and clarity (100% vs 87%) after specific prompting compared to lower rates for current practices. Majority of nurses described the color reference guide as useful (n=287, 97%) and would utilize the tool in current practice if readily available (n=291, 98%). CONCLUSIONS: A newly devised hematuria color guide and prompting assessment significantly reduced variations in hematuria descriptions from health care providers. Nearly all surveyed nursing personnel would prefer to utilize such methodology when describing patients with hematuria. Prospective implementation to assess impact is warranted to further evaluate the potential benefit with hematuria communication. Source of Funding: N/A

Management of Hemodialysis Patients with Suspected or Confirmed COVID-19 Infection: Perspective of Two Nephrologists in the United States.

The coronavirus disease 2019 (COVID-19) pandemic is unprecedented and information about the severe acute respiratory syndrome coronavirus 2 is evolving rapidly. New York is one of the epicenters of the COVID-19 outbreak in the United States, reporting >1000 confirmed cases as of March 17, 2020, and cases are escalating exponentially. The majority of cases are in Westchester County ( n =220) and New York City (NYC; n =463), which includes Bronx (1). The local index patient case was a Westchester man who became ill on February 22, was not associated with a recent travel exposure to a country on the watch list (China, Iran, South Korea, and Italy), or known to have had direct contact with a COVID-19–confirmed patient. At the present time it is estimated that community-wide transmission accounts for 87% of confirmed cases. Nephrologists in the Bronx have been handicapped in managing patients with ESKD during the early weeks of the COVID-19 pandemic due to the limitations of available rapid testing for severe acute respiratory syndrome coronavirus 2. Montefiore Medical Center, located in the north Bronx in close proximity to Westchester, has been one of the main tertiary care hospitals in NYC caring for persons under investigation (PUIs) and for COVID-19–confirmed patients. Our nephrology division’s clinical faculty care for approximately 850 patients with ESKD (approximately 800 on hemodialysis and approximately 50 on peritoneal dialysis) in 12 outpatient hemodialysis facilities (two Fresenius and 10 DaVita facilities) in the Bronx. We report our experience with caring for the ESKD population and patients who are hospitalized with AKI in the Bronx during the first 3 weeks of the local NYC COVID-19 pandemic. Strategies proposed for the prevention and management of COVID-19 transmission for patients with ESKD in the outpatient dialysis facilities have been dynamic. The American Society of Nephrology’s (ASN’s) Nephrologists Transforming …

Coronavirus Disease 2019 (COVID-19) Complicated by Acute Respiratory Distress Syndrome: An Internist’s Perspective

A pandemic outbreak of a novel coronavirus disease (COVID-19) that began in Wuhan, China, in December 2019 has spread rapidly to multiple countries. In the United States, the first confirmed case was reported on January 20, 2020, and since then, the number of cases is rising exponentially on a daily basis. We report a case of COVID-19 infection that presented with symptoms suggestive of pneumonia. Due to the major backlog with an immense number of pending tests, it took 48 hours for the result to come back positive, while the patient went into acute respiratory distress syndrome. We provide an internist’s perspective of the difficulties encountered in terms of the available management options, as the patient progressively deteriorated on the regular medical floor prompting transfer to the intensive care unit.

WHAT'S YOUR STATUS? RESUSCITATING A DYING DISCUSSION IN PSYCHIATRY

Although the Patient Self-Determination Act of 1991 required that all Medicare/Medicaid-certified institutions inform patients about their right to refuse life sustaining treatments like CPR, the medical literature consistently documents a deficit in code status assessment and documentation for patients admitted to the hospital (1). A 2011 study showed that only 9.3% of over 11000 patients had a code status documented within 24 hours of admission to a medical floor (2). While the literature is limited, this deficit appears to be even greater in psychiatric units: a study of about 600 psychiatric and medical inpatients found the rates of code status documentation among psychiatric patients was significantly lower compared to patients admitted to the medical floor (65 vs 96%, p<0.001) (3). As the population continues to age, the appropriate assessment and documentation of code status becomes particularly relevant for older psychiatric patients. Specific challenges relevant to older adults on inpatient psychiatric units include higher cardiac risks due to self-injurious behaviors, neurocognitive deficits and communication barriers. Common psychiatric conditions that may affect capacity in hospitalized psychiatric patients including psychosis, catatonia, delirium, suicidality. Clinicians should be aware that even in the presence of severe psychiatric burden, capacity may be preserved and should not be presumed absent. A resident-driven quality improvement project at Stanford Hospital aimed to improve code status documentation practices will be described. As many trainees lack formal training in these discussions and report underutilization of capacity determination, it is particularly important that the ethical and legal implications of code status assessment and documentation practices are considered. This session will illustrate the clinical relevance of assessing code status in older adults with psychiatric illnesses and provide an overview of the literature on this topic. Strategies for improved code status assessment and documentation practices will be discussed. 1. Yuen JK, Reid MC, Fetters MD. Hospital do-not-resuscitate orders: why they have failed and how to fix them. J Gen Intern Med. 2011;26:791–7. 2. Anderson WG, Pantilat SZ, Meltzer D, Schnipper J, Kaboli P, Wetterneck TB, et al. Code status discussions at hospital admission are not associated with patient and surrogate satisfaction with hospital care: results from the multicenter hospitalist study. Am J Hosp Palliat Med. 2011;28:102–8. 3. Warren MB, Lapid MI, McKean AJ, Cha SS, Stevens MA, Brekke FM, et al. Code status discussions in psychiatric and medical inpatients. J Clin Psychiatry. 2015;76:49–53.

Unanticipated Respiratory Compromise and Unplanned Intubations on General Medical and Surgical Floors.

Unanticipated respiratory compromise that lead to unplanned intubations is a known phenomenon in hospitalized patients. Most events occur in patients at high risk in well-monitored units; less is known about the incidence, risk factors, and trajectory of patients thought at low risk on lightly monitored general care wards. The aims of our study were to quantify demographic and clinical characteristics associated with unplanned intubations on general care floors and to analyze the medications administered, monitoring strategies, and vital-sign trajectories before the event. We performed a multicenter retrospective cohort study of hospitalized subjects on the general floor who had unanticipated, unplanned intubations on general care floors from August 2014 to February 2018. We identified 448 unplanned intubations. The incidence rate was 0.420 per 1,000 bed-days (95% CI 0.374-0.470) in the academic hospital and was 0.430 (95% CI 0.352-0.520) and 0.394 per 1,000 bed-days (95% CI 0.301-0.506) at our community hospitals. Extrapolating these rates to total hospital admissions in the United States, we estimate 64,000 events annually. The mortality rate was 49.1%. Within 12 h preceding the event, 35.3% of the subjects received opiates. All received vital-sign assessments. Most were monitored with pulse oximetry. In contrast, 2.5% were on cardiac telemetry, and only 4 subjects used capnography; 53.7% showed significant vital-sign changes in the 24 h before the event. However, 46.3% had no significant change in any vital signs. Our study showed unanticipated respiratory compromise that required an unplanned intubation of subjects on the general care floor, although not common, carried a high mortality. Besides pulse oximetry and routine vital-sign assessments, very little monitoring was in use. A significant portion of the subjects had no vital-sign abnormalities leading up to the event. Further research is needed to determine the phenotype of the different etiologies of unexpected acute respiratory failure to identify better risk stratification and monitoring strategies.

Evaluation of Medication Administration Timing—Are We Meeting Our Goals?

Background: Per the Centers for Medicare and Medicaid Services (CMS) Code of Federal Regulations (CFR) 482.23(c) regarding medication administration, hospital policies and procedures must identify time-critical scheduled medications which must be administered within 30 minutes either before or after the scheduled dosing time, for a total administration window of 1 hour. Objective: The general objective of this analysis was to determine whether there was a difference in meeting medication administration goals when comparing time-critical to non-time-critical scheduled medication administration in both intensive care units (ICUs) and general medical floors at a large, academic medical center. Methods: Data were collected in 6 inpatient nursing units (3 general medical units and 3 ICUs) during the month of June 2017. Electronic medical record charge data for medications were used to evaluate timeliness of medication administration. Results: In total, 69,794 medication administrations were evaluated. Of 389 administrations of time-critical scheduled medications, 268 (69%) were administered on time. Of 69,405 administrations of non-time-critical scheduled medications, 58,099 (84%) were administered on time (P < 0.001). ICUs had a higher percentage of on-time administrations than general medical units (89% vs 77%, P < 0.001), and nurses had a higher percentage of on-time administrations than respiratory therapists (84% vs 63%, P < 0.001). Conclusions: Non-time-critical scheduled medications were more commonly administered on time compared with time-critical scheduled medications. Staff education and optimizations to the electronic health record (EHR) are interventions that may improve administration of time-critical scheduled medications.

IPRATROPIUM BROMIDE NEBULIZER-ASSOCIATED ANISOCORIA

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Anisocoria, is a rare clinical sign with a long list of differential diagnoses. It is often treated as a form of intracranial pathology until proven otherwise. However, if a patient lacks additional ocular abnormalities or neurological deficits, it is less likely that this clinical sign is due to intracranial pathology. Here, we present a patient with COPD exacerbation who developed anisocoria after inhaled ipratropium bromide treatment. CASE PRESENTATION: 71-year-old female was admitted to the intensive care unit for acute hypoxic respiratory failure due to a COPD exacerbation and pneumonia. The patient was intubated and started on broad spectrum antibiotics. She was later extubated to BiPAP and subsequently transferred to the general medical floor. While on BiPAP, she was receiving nebulized Ipratropium bromide/albuterol sulfate every 4 hours. Shortly after starting one of her nebulizer treatments, the rapid response team was called to evaluate to the patient for a new onset fixed and dilated left pupil. She did not have any other neurological deficits and a CT head was negative for acute intracranial pathology. After further evaluation, the BiPAP face mask was found to have a faulty seal. Patient was given a new face mask with minimal leaks, and the mydriasis resolved within 12 hours. DISCUSSION: Anisocoria is a clinical sign that can warrant concern. Rare but life-threatening diagnoses include uncal herniation, intracranial hemorrhage/mass or posterior-communicating artery aneurysm, that each impair adjacent parasympathetic innervation leading to unopposed sympathetic innervation of the iris. Consequently, this clinical sign is often treated as intracranial pathology until proven otherwise. However, in the absence of other ocular abnormalities or neurological deficits, it is unlikely that this clinical sign is due to intracranial pathology. Pharmacological causes should initially be considered. Ocular anticholinergics that cause temporary mydriasis include atropine, scopolamine, hyoscyamine, and often mis-directed aerosolized ipratropium bromide. In our patient, the mydriasis was a result of nebulized ipratropium with unintentional contact the eye by an improperly fitted nebulizer mask. The use of the pilocarpine eye drop test can help confirm a pharmacological muscarinic blockade if pilocarpine has no miotic effect. Additionally, the subsequent resolution of anisocoria 2-48 hours after discontinuation of nebulized anticholinergic is further support. An alternative diagnosis should be pursued if the pilocarpine test causes miosis, if the mydriasis becomes fixed and persistent, or if there are additional ocular or neurological abnormalities. CONCLUSIONS: With the widespread use of nebulized treatments, it is essential to be aware of this sign as it is important to consider these reversible causes as a potential diagnosis that guides subsequent management. Reference #1: Chaudhry P, Friedman DI, Yu W. Unilateral pupillary mydriasis from nebulized ipratropium bromide: A false sign of brain herniation in the intensive care unit. Indian J Crit Care Med. 2014;18(3):176-7. Reference #2: Yalcin S, Pampal K, Erden A, Oba S, Bilgin S. Do we really need to panic in all anisocoria cases in critical care?. Indian J Anaesth. 2010;54(4):365-6. Reference #3: Yalcin S, Pampal K, Erden A, Oba S, Bilgin S. Do we really need to panic in all anisocoria cases in critical care?. Indian J Anaesth. 2010;54(4):365-6. DISCLOSURES: No relevant relationships by Mirza Ali, source=Web Response No relevant relationships by M Bakir, source=Web Response No relevant relationships by SarahGrace Carbrey, source=Web Response No relevant relationships by Abdisamad Ibrahim, source=Web Response No relevant relationships by Thamer Sartawi, source=Web Response

A CASE OF DUODENAL DIEULAFOY’S LESION

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Dieulafoy’s lesion is a rare cause of gastrointestinal (GI) hemorrhage, predominantly occurring in the upper part of the stomach, along the gastric lesser curve; extra-gastric lesions are uncommon. We present a case of a massive GI bleed due to Dieulafoy’s lesion in the duodenum. CASE PRESENTATION: 51 y/o female that presented to ED from home with a 2-day history of right-sided abdominal pain and bloody diarrhea. Pain was associated with multiple episodes of dark red/black diarrhea, nausea and one episode of coffee ground emesis subjective fevers and chills. Of note, she had just finished a 10 day course of PO Augmentin that was prescribed for a dog bite. She has a PMH of neuroendocrine tumors, lymphoma s/p chemotherapy and uterine tumor s/p hysterectomy. Physical exam was positive for abdominal tenderness in the right upper and lower quadrants. On admission, Hgb was 12.5 g/dL, WBC 20.2, lactate 3.5 with normal LFTs and lipase. Patient was admitted to the general medical floor for evaluation of bloody diarrhea and to rule out C. difficile colitis. A CT scan of the abdomen without contrast was done which showed the third part of the duodenum to be compressed by the super mesenteric artery (SMA) suggestive of SMA syndrome; surgery was consulted with no intervention warranted. Within 24 hours of admission, patient continued to complain of severe abdominal pain, bloody diarrhea and sudden dizziness; she was noted to be hypotensive with BP 90/60, tachycardic and Hgb had dropped to 7.9 g/dL. Crystalloids were administered without improvement in BP. She was transfused 1 unit of pRBCs, started on a Protonix drip and transferred to MICU. She received a total of 3U of pRBCs prior to stabilization of vital signs and hemoglobin. An EGD was done, which revealed active bleeding from a spurting vessel in the duodenal bulb; epinephrine was injected and 2 clips were placed with successful hemostasis. Patient’s Hgb remained stable after the procedure and she was discharged home 3 days later without sequelae. DISCUSSION: Dieulafoy’s lesion is a dilated, aberrant submucosal artery which doesn’t undergo normal branching within the wall of the stomach and erodes the mucosa in the absence of a primary ulcer. They are primarily found in the upper part of the stomach, within 6 cm of GE junction, particularly in the lesser curvature; extragastric incidence in esophagus, duodenum and colon is rare. It is the cause of less than 5% of all GI bleeds in adults, and occurs twice as often in men than women. Condition is usually diagnosed via EGD, however diagnosis can oft be difficult due to size and obscure location. Etiology is unknown. CONCLUSIONS: Although it is a rare condition, clinicians should maintain a high index of suspicion for this disease in the etiological evaluation of patients presenting with gastrointestinal hemorrhage, principally as it can cause massive and life threatening bleeding. Reference #1: Nojkov B, Cappell MS. Gastrointestinal bleeding from Dieulafoy's lesion: Clinical presentation, endoscopic findings, and endoscopic therapy. World J Gastrointest Endosc. 2015;7(4):295-307 Reference #2: Lee, Y., Walmsley, R. S., Leong, R. W., & Sung, J. J. (2003). Dieulafoy's Lesion. Gastrointestinal Endoscopy, 236-24 Reference #3: Isik A, Alimoglu O, Okan I, Bas G, Turgut H, Sahin M. Dieulafoy lesion in the stomach. Case Rep Gastroenterol. 2008;2(3):469-73 DISCLOSURES: No relevant relationships by Nayma Casamayor, source=Web Response No relevant relationships by Yelenis Fuertes Yanes, source=Web Response No relevant relationships by Michelle Hernandez Guzman, source=Web Response

1848 Chronic Diarrhea Complicated by Hyponatremia as a First Clue to Establish the Diagnosis of Pellagra

INTRODUCTION: We report a case of middle age man with a history of chronic alcohol abuse, who presented with chronic diarrhea for a month resulted in moderate to severe hyponatremia and was diagnosed with a rare in Western World disease of Pellagra. CASE DESCRIPTION/METHODS: This is a relatively young man 49yo with long history of alcohol abuse, who presented with mainly GI symptoms of nausea, non bloody vomiting, watery diarrhea for a month, abdominal pain, and leg rash. Blood work was significant for hyponatremia (121), thrombocytopenia (133), and alcohol level of 87.5. The physical exam was significant for erythematous, dry rash with areas of desquamation on both legs, associated with pruritus and LLQ tenderness. He was evaluated by MICU team, treated for moderate to severe hyponatremia in ER with IV fluids and admitted to medical floor for chronic diarrhea and LE rash workup. Patient has been evaluated by dermatology and Pellagra with other nutritional deficiencies vs Tinea was suspected. He underwent a punch biopsy and started on niacin as well as urea 40% cream. Pathology was consistent with nutritional deficiencies (i.e. zinc, niacin). After careful compilation of all parts of history, physical exam, and pathology, patient was diagnosed with Pellagra and continued on niacin supplementation with resolution of diarrhea and improvement of skin appearance. DISCUSSION: Pellagra is a nutritional disorder that results from inadequate intake of niacin or its precursor, the essential amino acid tryptophan. Pellagra is a disease very nearly eradicated in US and Europe except sporadic cases in at-risk groups (chronic alcoholism, malnutrition, malabsorption. It is classically described by the 3 D’s “diarrhea, dermatitis, and dementia”. While the life threatening presentation of Pellagra is very uncommon nowadays, the most severe cases are usually presented as encephalopathy. In our case patient presented with chronic diarrhea, which caused almost life threatening hyponatremia. Diarrhea as the first presenting symptom along with characteristic rash and history of chronic alcohol leaded to diagnosis of Pellagra, the disease easily treated with prompt administration on niacin. Pellagra is mostly a clinical diagnosis and careful collection of all parts of history and physical exam required to early recognize the disease and initiate a niacin intake. Physicians should have a high index of suspicion in certain groups of patients to early diagnose and cure this potentially fatal but treatable disease.

RARE AND RAPID: A CASE OF EXPLOSIVE PLEURITIS

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Parapneumonic effusions (PPE) are pleural effusions associated a bacterial pneumonia or lung abscess. Between 20 to 57% of the 1 million patients hospitalized yearly with pneumonia develop a PPE. We present a rare case of rapidly developing PPE, known as “explosive pleuritis.” CASE PRESENTATION: 56 year old male smoker with mild persistent asthma presented with worsening pleuritic chest pain. Pain was around the right scapula and had been progressively worsening over 5 days. It had no alleviating factor, and worsened with coughing and deep inhalation. He also had intermittent nonproductive coughs as well as a single episode of subjective fever 1 day prior, but no other symptoms. He denied sick contacts and recent travel outside of New York. CT pulmonary embolism protocol was obtained initially, which revealed a mass like structure in the right lower lobe, suspicious for a pneumonia versus an early abscess. He was admitted to the general medical floor and remained hemodynamically stable, required no oxygen supplementation, had no leukocytosis, and was initiated on Ampicillin/Sulbactam therapy. The following day, the patient became more tachypneic needing supplemental oxygen, and developed a leukocytosis of 13.9K/uL. Chest X-ray showed a new right side infiltrate and pleural effusion. Due to his rapidly deteriorating status, he was transferred to the medical ICU. Antibiotics were broadened and a repeat CT scan was obtained. The repeat scan revealed a large loculated right sided pleural effusion. A tube thoracostomy was attempted, however bedside ultrasound exam showed extensive stranding and haziness of the pleural effusion without a safe insertion site. Cardiothoracic surgery was consulted and patient had a video assisted thoracoscopic surgery. Large amount of empyema was evacuated, and the patient had 3 chest tubes inserted. Over the next 4 days, the patient’s respiratory status and leukocytosis had improved, and he had his chest tubes removed without any complications. Patient was discharged on day 8 of admission, and is now completing a 6 week course of antibiotics. Cultures obtained throughout the admission including the pleural peel and rind have unfortunately been negative. DISCUSSION: Explosive pleuritis is a rare entity that develops within 24 hours, involves 90% of the affected hemithorax, and has the tendency to loculate early. Streptococcal infections have been associated with it, owing to the blockage of lymphatics with cellular debris. However, the causative organism often is not isolated. Once identified, prompt initiation of antibiotics and drainage of the effusion is needed. This can be achieved by either tube thoracostomy or by surgical decortication. CONCLUSIONS: Explosive pleuritis should be considered for a rapidly deteriorating patient with pneumonia. It is an emergency that requires prompt investigation and treatment consisting of both medical and surgical treatment. Reference #1: Sharma JK, Marrie TJ. Explosive pleuritis. Can J Infect Dis. 2001;12(2):104-7. Reference #2: Bryant RE, Salmon CJ. Pleural empyema.Clin Infect Dis 1996:22;747-62. Reference #3: Braman SS, Donat WE. Explosive pleuritis.Am J Med 1986;81:723-6. DISCLOSURES: No relevant relationships by Erica Altschul, source=Web Response No relevant relationships by Nader Ishak Gabra, source=Web Response No relevant relationships by Oki Ishikawa, source=Web Response No relevant relationships by Omar Mahmoud, source=Web Response No relevant relationships by Bushra Mina, source=Web Response No relevant relationships by Maly Oron, source=Web Response No relevant relationships by Varun Shah, source=Web Response

A HAIR OF THE DOG THAT BIT YOU: A CASE OF PASTEURELLA BACTEREMIA

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Pasteurella is a Gram-negative coccobacillus that is commonly transmitted from cat and dog bites, and causes a wide spectrum of diseases in humans. With more people keeping pets, there is an increased risk of possible infection with zoonotic organisms. Here, we present a case of septic shock caused by Pasteurella bacteremia. CASE PRESENTATION: A 59 year-old female with no known medical history and no medical follow-up presented with her dog following a motor vehicle accident. Vitals revealed hypotension, atrial fibrillation with rapid ventricular response, fever, and respiratory distress. Physical exam revealed multiple open wounds on her lower extremities with clinical signs of cellulitis. She was intubated for hypoxic respiratory failure and found to have combined distributive and cardiogenic shock, aortic stenosis and insufficiency, and pulmonary edema. The patient was admitted to the Intensive Care Unit where she received intravenous vasopressors, Vancomycin and Piperacillin/Tazobactam. Blood cultures were positive for gram-negative rods, and speciation revealed Pasteurella multocida. She was transitioned to Ceftriaxone and steadily improved. She was eventually weaned off vasopressor support, extubated, and transferred to the general medical floors. DISCUSSION: The most common infections caused by Pasteurella multocida are local wound infections following animal bites or scratches. Cats are the source of infection in 60-80% of cases and dogs in the majority of the remainder. While local skin infections are the most common result of Pasteurella multocida, bacteremia has been shown to occur in 25-50% of patients with pneumonia, meningitis, and septic arthritis. Severe Pasteurella infections are uncommon and appear more frequently in elderly patients and those with underlying chronic diseases such as cardiovascular disease, diabetes mellitus, AIDS, malignancy, cirrhosis and chronic kidney disease. Studies have shown 70% of systemic infections in those greater than 50 years of age and 21% in ages 20-50 years. In our patient’s case, it is suspected that the route of infection was via the skin, as the patient’s dog was witnessed to be licking her lower extremity wounds. Mortality in severe disease (i.e. septicemia) is estimated to be roughly 28%. This case is unique in that our patient had no signs of immunocompromise, but given undiagnosed coronary artery disease, she may have had increased susceptibility to developing severe infection. CONCLUSIONS: Adequate hygiene is essential in preventing transmission from pets. Due to the high mortality of severe Pasteurella infection, and the increasing number of pets, it is important to have a high suspicion for pet-related infections. Reference #1: Fajfar-Whetstone, C. J., et al. "Pasteurella multocida septicemia and subsequent Pasteurella dagmatis septicemia in a diabetic patient.” Journal of clinical microbiology 33.1 (1995): 202-204 DISCLOSURES: No relevant relationships by George Elkomos-Botros, source=Web Response No relevant relationships by Ayelet Hilewitz, source=Web Response No relevant relationships by Sameer Khanijo, source=Web Response

1547 Pseudomonas Aeruginosa: A Rare Cause of Community-Acquired Antibiotic-Associated Diarrhea in an Immunocompetent Adult

INTRODUCTION: Pseudomonas aeruginosa (P. aeruginosa) is an opportunistic gram negative pathogen known to cause enterocolitis in children and nosocomial infections, including hospital acquired pneumonia (HAP) and catheter associated urinary tract infections (UTIs). Rarely, P. aeruginosa causes antibiotic-associated diarrhea in immunocompromised hosts, but this has not been reported in immunocompetent ambulatory hosts. CASE DESCRIPTION/METHODS: An 81 year old previously healthy woman presented to the emergency department (ED) with diarrhea for 2 days. A week prior to symptom onset, she completed a 17 day course of ciprofloxacin for a UTI, with resolution of dysuria. She described frequent, watery, nonbloody bowel movements with nausea and emesis. She was treated with intravenous saline and ondansetron, and discharged. The next day, she developed bloody bowel movements associated with weakness and mild lower abdominal pain. With ongoing diarrhea, she returned to the ED. Physical exam showed very mild left lower quadrant abdominal tenderness, without rebound or guarding. Laboratory studies showed white blood cell count 11,800 cells/mcL, potassium 3.3 meq/dL, and lipase 67 units/L. Electrolytes and liver enzymes were otherwise normal. Clostridium difficile (C difficile) stool toxin PCR was negative. CT abdomen and pelvis without contrast showed diverticulosis and mild inflammation surrounding the sigmoid colon (Figures 1 and 2). She was started empirically on ciprofloxacin and metronidazole, and admitted to the medical floor. Over the next 3 days, she gradually improved. Stool culture grew P. aeruginosa, with absence of normal fecal flora. Sensitivities showed resistance to ciprofloxacin and levofloxacin. Given her clinical improvement, antibiotics were discontinued after 7 days. DISCUSSION: We report a case of P. aeruginosa as a cause of bacterial colitis. Our patient's prior antibiotic therapy may have increased her susceptibility to this infection via loss of normal fecal microbiota, leading to a loss of competitive exclusion and diminished colonic barrier protection. To our knowledge, this is the first reported case of post-antibiotic diarrhea caused by P. aeruginosa in an immunocompetent ambulatory host. This may be an important diagnostic consideration in patients presenting with persistent diarrhea following antibiotics, with negative C. difficile stool testing. The role for antibiotic therapy in Pseudomonas associated diarrhea warrants further research.

2294 The Unusual Wolf in Sheep's Clothing

INTRODUCTION: Dronedarone is frequently employed for rhythm control in patients with atrial fibrillation (AF). Chronic therapy with Dronedarone has been associated with mild liver enzymes elevations in up to 12% of patients. There are also several reports of dronedarone induced Acute Renal Failure (ARF) on Adverse Drug Reaction reporting databases worldwide. CASE DESCRIPTION/METHODS: An 86-year-old male with past history of AF, COPD, CKD and HTN presented with 1 day duration of dyspnea and palpitations. He was found to be in AF with rapid ventricular response with a heart rate of 127. Vitals were otherwise stable. He was also suspected to have acute on chronic diastolic CHF likely precipitated by atrial fibrillation. Initial labs were pertinent for creatinine of 2.02 (baseline-1.60). Patient was initially started on Diltiazem drip in the ED which was later discontinued due to an IV site reaction. Upon transfer to the medical floor, Cardiology was consulted who recommended Dronedarone for rhythm control. Patient received a total of 3 doses of Dronedarone but did not cardiovert, therefore electrical cardioversion was performed. He developed fatigue few hours after the cardioversion. Liver function tests (LFTs) one day after the last dose of dronedarone and post cardioversion showed elevated ALT (3155), AST (3930), Alkaline Phosphatase (144), total (2.4) and direct (1.0) bilirubin levels. INR was also high (6.1). Viral hepatitis testing was negative. The patient's course was further complicated by acute renal failure (ARF) with creatinine rising to 5.38. Dronedarone mediated hepatic and renal injury was suspected. Dronedarone was discontinued and supportive measures were initiated. Patient's LFTs and creatinine trended down with improvement of symptoms four days following discontinuation of Dronedarone. Patient was discharged home with complete resolution of hepatic and renal failure noted during outpatient follow up. DISCUSSION: Dronedarone mediated acute liver toxicity is rare. Almost none of the cases involved rapid onset of liver injury after drug initiation, which resolved quickly after cessation of the agent. The onset of injury in reported cases ranged from 2 to 11 months. Besides reports on pharmacovigilance databases, two cases of dronedarone-associated ARF have also been published, one of which required hemodialysis. Only one of these cases reported a combined hepatic and renal failure. Our case is unique due to its early onset and severe features with concurrent involvement of both organ systems.

KETAMINE IN THE ICU: TREATMENT OF POLYPHARMACY WITHDRAWAL SYNDROME

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: We present a case of severe polypharmacy withdrawal syndrome that was successfully treated with intravenous ketamine. CASE PRESENTATION: A 39-year-old male presented with aspiration pneumonia and hypoxic respiratory failure requiring mechanical ventilation for adult respiratory distress syndrome. He had a history of polysubstance abuse, bipolar disorder and severe anxiety, requiring psychiatric medications. High doses of propofol, midazolam, fentanyl, and dexmedetomidine were needed to control severe agitation while on the ventilator. There was substantial improvement in gas exchange and chest imaging to the extent that extubation was attempted following a successful spontaneous breathing trial. Soon after, the patient developed severe agitation with combative behavior and tachypnea that persisted despite sedative agents. The patient was reintubation followed by repeated attempts to adjust midazolam, propofol, fentanyl, and dexmedetomidine to levels that would control his agitation. A second extubation attempt was unsuccessful, and he required reintubation due to severe agitation, combative behavior as well as inability to control secretions. Intravenous ketamine was started - initial bolus 1 mg/kg followed by rapid titration to 2 mg/kg/hour to achieve coma. Fentanyl, propofol, midazolam, and dexmedetomidine were reduced and eventually discontinued completely. Ketamine was reduced until the patient was alert, calm, and cooperative followed by successful extubation. Ketamine was then tapered off, and the patient was transferred to the medical floors. DISCUSSION: We report the empiric use of ketamine to control severe agitation that was associated with successful extubation. Likely a history of polypharmacy recreational drug use combined with the need for very high dose of sedatives and opiates required for safe ventilatory support resulted in a severe withdrawal syndrome. Thus ketamine was chosen as a single agent to control delirium and combative behavior while discontinuing sedatives. Ketamine, an NMDA (N-Methyl-D-Aspartate) receptor antagonist in the central nervous system and spinal cord, is used as a sedative with dissociative and analgesic properties. This drug has several advantages: quick onset of action in thirty seconds of intravenous administration, short half-life, preservation of respiratory drive, and sympathomimetic effect that reduces risk of hypotension that is common with sedative agents. There are several reports its use in severe alcohol syndrome. Our case illustrates the potential benefit of ketamine to control polypharmacy withdrawal syndrome. CONCLUSIONS: This case shows that ketamine may have utility for control of severe agitation that is associated with withdrawal from high doses of sedatives and opiates required for the critically ill patient on mechanical ventilatory support with history of psychiatric illness and polysubstance drug use. Reference #1: Benken, S. T., & Goncharenko, A. (2016). The Future of Intensive Care Unit Sedation: A Report of Continuous Infusion Ketamine as an Alternative Sedative Agent. Journal of Pharmacy Practice, 30(5), 576-581. Reference #2: Malnoske, M. L, & Quill C (2017). Ketamine to facilitate weaning from mechanical ventilation: A case report. Journal of Anesthesia and Critical Care Case Reports, 3 (1), 11-13. Reference #3: Shah P, McDowell M, Ebisu R, Hanif T, Toerne T. Adjunctive Use of Ketamine for Benzodiazepine-Resistant Severe Alcohol Withdrawal: a Retrospective Evaluation. Journal of Medical Toxicology. 2018 Sep 1;14(3):229-36. DISCLOSURES: No relevant relationships by MORDECHAI GRABIE, source=Web Response No relevant relationships by Becky Lou, source=Web Response No relevant relationships by Paul Mayo, source=Web Response

1633 Extensive Colonic Ischemia Due to Sumatriptan: An Unusual Adverse Effect

INTRODUCTION: Ischemic colitis (IC) is attributed to variety of etiologies including hypo-perforation due to dehydration, sepsis; thrombosis and embolic/thrombotic arterial occlusion. Pharmacological agents like 5Hydroxytryptamine1 (5HT 1) receptor agonists including Sumatriptan, widely used for refractory headaches, have also been known to be a cause of IC in rare circumstances. There are approximately 12 cases of IC reported which are related to 5 HT1 use. We are reporting a case of IC, which is likely related to long-term use of Sumatriptan. CASE DESCRIPTION/METHODS: A 39-year-old female with no significant past medical history was admitted to medical floor due to diffuse crampy abdominal pain and bloody diarrhea. Laboratory workup shows WBC 11500 cell/ml and negative IBD serology. CT of the abdomen and pelvis revealed pan-colitis. Stool culture and C. Difficile DNA were negative. Colonoscopy performed during admission revealed severe colitis involving entire colon except the rectum and distal sigmoid colon, biopsy featured ischemic colitis. A mesenteric Doppler ultrasound was ordered which was not conclusive, subsequently CTA performed which showed no mesenteric vascular stenosis. She was not on oral contraceptive pills and through careful questioning she mentioned that she had been taking Sumatriptan for a while. Due to the presumed association between Sumatriptan and IC, Sumatriptan was discontinued. She was emperically started on mesalamine and steroid, which were discontinued. Her symptoms improved with conservative management. A repeat colonoscopy in a few months after her hospital discharge did not show any colitis or ileitis; random colonic biopsies were unremarkable while she was off sumatriptan. DISCUSSION: Although rare, Sumatriptan use can be associated with IC, therefore we should be vigilant in reviewing medication lists in situations where there is no obvious etiology. Incidence of drug-related ischemia might be more than reported. It is imperative to counsel about meidcation adverse effect and reporting adverse effects.

1768 Esophagitis Dissecans Superficialis Secondary to Ingestion of Hair Dye

INTRODUCTION: Esophagitis dissecans superficialis (EDS) is a rare and underdiagnosed esophageal lesion characterized by sloughing of the esophageal mucosa that has been associated with various autoimmune disorders and exposure to some chemical irritants. Our case highlights a 65-year-old woman diagnosed with EDS after incidental ingestion of hair dye containing resorcinol and paraphenylenediamine (PPD). CASE DESCRIPTION/METHODS: The patient is a 65 year-old female with a medical history of diabetes, hypertension, major depressive disorder, asthma, alcohol use disorder who presented to our emergency department complaining of nausea and vomiting after ingesting a colored hair dye. The patient stated she accidentally ingested 2 oz of hair dye believing it was cough syrup. Notable laboratory findings on admission included a complete blood count within normal limits; a venous blood gas showing a pH of 7.274; pCO2 of 39.2 mm Hg; HCO3 of 17.2 mEq/L and a lactic acid of 5.1. Notable imaging included a chest x-ray showing focal patchy opacities at both lung bases; and an X-ray of the neck showed no retropharyngeal soft tissue swelling. Physical exam was unremarkable. After initial evaluation esophagogastroduodenoscopy (EGD) was done and showed mild superficial mucosal desquamation in entire esophagus suggestive of esophagitis dissecans superficialis (Figure 1). After the procedure the patient was started on pantoprazole and admitted to the general medical floor for further monitoring. The following night the patients symptoms resolved and she was discharge with follow up appointments. DISCUSSION: PPD is an aromatic amine that is widely used in hair dye due to its favorable cosmetic outcomes. Adverse effects of PPD include cervicofacial edema, upper airway tract edema, oliguria, and shock. Resorcinol is a phenolic chemical that is also used in hair dye. Readily absorbed by the gastrointestinal tract, resorcinol is a corrosive acid that causes severe burns on direct contact. Its consumption may also result in pulmonary edema, hemolysis, and metabolic acidosis. Clinical manifestations of EDS are non-specific and include vomiting and dysphagia. Endoscopically it is characterized by sheets of sloughed squamous tissue which typically appear as multiple columns of strips, often described as "gift wrap paper" like distribution as was present in our case. Its prognosis is very favorable and long term complications are rare. To our knowledge this makes the first reported case of EDS occurring secondary to ingestion of hair dye.

ACUTE ON COPD

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Central Airway Obstruction (CAO) is pathologic obstruction of air flow in the trachea and main stem bronchi. The most common cause of CAO is non-small cell lung cancer, but other common causes are tracheobronchomalacia, tracheal strictures, and other malignancies. Less commonly, primary tumors of the trachea and metastatic cancers can also cause central airway obstruction. CASE PRESENTATION: A 68 year old female with a prior medical history of hypertension, hyperlipidemia, past alcohol dependence, and COPD due to a 45 pack year smoking history presented to the emergency department via EMS. She was intubated for acute hypoxic and hypercapnic respiratory failure and was admitted to the ICU where she underwent treatment for COPD exacerbation, community-acquired pneumonia, and urinary tract infection with azithromycin, methylprednisolone, and ceftriaxone. A review of the patient’s chart showed a screening CT had been completed two days prior to admission and showed a paratracheal mass with invasion into the trachea and right main bronchus. Given the patient’s lack of response to maximal medical therapy, bronchoscopic evaluation was pursued. During bronchoscopy, a mass was found protruding from the right main stem bronchus, occluding 80-90% of the trachea. The bronchoscope could not be passed around the mass, however biopsies were taken before the procedure was aborted. Interventional Pulmonology was consulted with plans for further evaluation and management. The patient underwent a second bronchoscopic evaluation, which showed near occlusion of the trachea due to tumor in the left main stem bronchus. Debulking provided rapid improvement in oxygen saturation. Further debulking of the trachea and right main stem bronchus were completed with rigid bronchoscopy and a stent was placed at the entrance of the right main stem to prevent further airway collapse. The following day, the patient was successfully extubated without further respiratory difficulties. She was transferred from the ICU to the general medical floor and ultimately to a rehabilitation facility with Oncology follow up. The patient has quit smoking, follows at UW medicine for her sarcoma, and is handling her symptoms well. DISCUSSION: Pathology on the specimens obtained showed poorly differentiated synovial sarcoma. Synovial sarcoma most commonly affects children and young adults. It routinely affects the knees and ankles but can involve other joints. It is normally found proximal to tendons and bursae without invasion of surrounding tissues, joint space, or synovial membranes. Case reports have described synovial sarcoma in almost all anatomical locations despite its predilection for synovial joints. CONCLUSIONS: Obstructive lung disease can have multiple causes, therefore it is important to consider that respiratory failure may be secondary to more than just a patient’s known underlying lung pathology. Reference #1: Herth, Felix JF. (2018). Clinical Presentation, diagnostic Evaluation, and management of central airway obstruction in adults. G. Finlay (Ed.), UpToDate. Retrieved March 10, 2019, from https://www.uptodate.com/contents/clinical-presentation-diagnostic-evaluation-and-management-of-central-airway-obstruction-in-adults Reference #2: Goldblum, John R. Rosai and Ackerman’s Surgical Pathology, 11th ed. Elsevier Inc. C2018. Chapter 41, Soft Tissues; p. 1810-1914. Reference #3: David Feller-Kopman, Atul C. Mehta and Momen M. Wahidi. Murray and Nadel's Textbook of Respiratory Medicine. 6th ed. Saunders. c2016. Chapter 23, Therapeutic Bronchoscopy; p. 383-392. DISCLOSURES: no disclosure on file for Jonathan Danaraj; No relevant relationships by Matthew Strohmeyer, source=Web Response

A234 Laparoscopic Reversal of a Gastric Bypass for Shortgut from a missed Internal hernia

The patient had a Roux en Y gastric bypass two years ago and had presented to an outside hospital for increasing abdominal pain. The patient was evaluated in the ER and was evaluated with a CT scan which was read as normal with no obstruction. General Surgery was consulted and felt patient would be appropriate for a medical floor bed. Patient was admitted to the medicine service with presumed diagnosis of marginal ulcer, placed on PPI and pain medications and GI medicine consult was obtained. Gastroenterology agreed with PPI's and schdeuled pt for outpatient endoscopy after discharge. Over the weekend patient's pain medications were escalated and on Monday morning patient begged his attending physician and stated " this amount of pain cannot be normal". The attending physician arranged for an inpatient endoscopy, Endoscopy revealed a necrotic roux limb. The patient was then transferred emergently to a nearby hospital that had a Bariatric Surgeon who emergently explored the patient and found necrotic bowel from an internal hernia with volvulus and resected bowel and refashioned the gj and recreated a jejunojejunostomy. Patient was left with 200 cm of total small bowel length with a 50 cm roux limb. Over the next several months patient had tremendous diarrhea and was treated with antidiarrheal agents, gatex and enteral supplementation. When pt was referred to us his albumin was 1.2 with anasarca. for 3 months he was given TPN and when his albumin was 2.8 we took him for a reversal.