Need For Vasopressors Research Articles

Racial and Ethnic Disparities in Peripheral Vascular Disease Admissions Using a Nationally Representative Sample

Our study aimed to identify clinical outcomes and resource utilization associated with race and ethnicity in patients admitted with peripheral vascular disease (PVD) across the United States. We queried the National Inpatient Sample database from 2015 to 2019 and identified 622,820 patients admitted with PVD. Patients across 3 major race and ethnic categories were compared in terms of baseline characteristics, inpatient outcomes, and resource utilization. Black and Hispanic patients were more likely to be younger and of the lowest median income but incur higher total hospital costs. Black race predicted higher rates of acute kidney injury, need for blood transfusion, and need for vasopressor but lower rates of circulatory shock, and mortality. Black and Hispanic patients were less likely to undergo limb-salvaging procedures and more likely to undergo amputation than White patients. In conclusion, our findings indicate that Black and Hispanic patients experience health disparities in resource utilization and inpatient outcomes for PVD admissions.

Outcomes of viral myocarditis in patients with and without COVID-19: a nationwide analysis from the United States.

The authors conducted a retrospective cohort study using the National Inpatient Sample database to identify adult patients hospitalized for viral myocarditis in 2020 and to compare outcomes between those with and without COVID-19. The primary study outcome was in-hospital mortality. Secondary outcomes included in-hospital complications, length of stay, and total costs. The study population included 15390 patients with viral myocarditis, of whom 5540 (36%) had COVID-19. After adjustment for baseline characteristics, patients with COVID-19 had higher odds of in-hospital mortality [adjusted odds ratio (aOR) 3.46, 95% CI 2.57-4.67], cardiovascular complications (aOR 1.46, 95% CI 1.14-1.87) including cardiac arrest (aOR 2.07, 95% CI 1.36-3.14), myocardial infarction (aOR 2.97, 95% CI 2.10-4.20), venous thromboembolism (aOR 2.01, 95% CI 1.25-3.22), neurologic complications (aOR 1.82, 95% CI 1.10-2.84), renal complications (aOR 1.72, 95% CI 1.38-2.13), and hematologic complications (aOR 1.32, 95% CI 1.10-1.74), but lower odds of acute heart failure (aOR 0.60, 95% CI 0.44-0.80). The odds of pericarditis, pericardial effusion/tamponade, cardiogenic shock, and the need for vasopressors or mechanical circulatory support were similar. Patients with COVID-19 had longer length of stay (7 days vs. 4 days, P<0.01) and higher total costs ($21,308 vs. $14,089, P<0.01). Among patients with viral myocarditis, COVID-19 is associated with higher in-hospital mortality and cardiovascular, neurologic, renal, and hematologic complications compared to non-COVID-19 viruses.

PROGNOSTIC VALUE OF THE NEUTROPHIL-TO-LYMPHOCYTE RATIO IN ACUTE PESTICIDE POISONING

Background: Neutrophil to Lymphocyte ratio is a marker of oxidative stress and inflammation. It has gained increased attention in last few years for its prognostic value in several disease subsets. However, there is limited data about its potential role in setting of pesticide poisoning. This study aimed to explore the predictive value of NLR for severe clinical outcome in patients with acute pesticide poisoning. Methods: An observational study was done at medical ICU of Chitwan Medical College from October 2022 to March 2023 among 62 patients of acute pesticide poisoning. The primary endpoint was severe clinical outcome which was defined as a composite of requirement of mechanical ventilation, need for vasopressors, new renal replacement therapy, or in- hospital mortality. The study patients were divided based on patients with severe clinical outcome(n=13) and those without (n=49) for analysis. Results: The NLR ratio at hospital admission in patients with severe clinical outcome and those without were 2.8(1.9-5.9) and 3.3(2.6-11.6) respectively, higher in severe clinical outcome group but the difference was not statistically significant. The NLR had an area under receiver operating characteristics curve of 0.631 (95% confidence interval [CI], 0.472 to 0.790). NLR at hospital admission with a cut-off value ≥ 2.68 predicted severe clinical outcome with 76.9% sensitivity and 55% specificity. Conclusions: The NLR at hospital admission had sub-optimal prediction ability for severe clinical outcome in this study setting. Thus, this cannot be used solely for early identification of patients at risk of severe clinical outcome in acute pesticide poisoning.

Comparison of effectiveness between two different doses of intravenous dexmedetomidine as adjuvant to subarachnoid block for sub umbilical surgeries

Background. Spinal anesthesia was a commonly used technique in anesthetic practice for lower abdominal and lower limb surgeries. To prolong the duration of bupivacaine spinal anesthesia adjuvants like α2 agonists and opioids have been used intrathecally. Clonidine and dexmedetomidine have also been found to prolong the duration of spinal anesthesia when given intravenous. Dexmedetomidine was more suitable adjuvant to spinal anesthesia compared to clonidine as it has more sedative and analgesic effects due to more selective α2A receptor agonist activity. Dexmedetomidine has been shown to prolong the duration of analgesia of spinal anaesthesia in various studies. Here we compare the two doses of Dexmedetomidine in prolonging the duration of analgesia. Material and methods. 60 American Society of Anaesthesiologists(ASA) physical status I/II patients scheduled for elective lower abdominal and lower limb surgeries under spinal anesthesia were randomized into two groups of 30 each. Immediately after subarachnoid block with 3.5ml of 0.5% hyperbaric bupivacaine, Group A patients received a loading dose of 0.5µg/kg of dexmedetomidine intravenously in 100ml NS over 10 mins whereas Group B received 1.0µg/kg of dexmedetomidine intravenously in 100ml NS over 10 mins. Results. Time for rescue analgesic were higher in Group B compared to Group A which was statistically significant but clinically the extra duration was insignificant. Time for two segment regression and duration of motor blockade was significantly prolonged in Group B. Requirement of Mephentermine was comparable in both the groups. There was no excessive sedation in both the groups. Conclusion. Dexmedetomidine administered as isolated loading dose of 0.5 µg/kg IV immediately after spinal anaesthesia was clinically equi-efficacious in prolonging the duration of analgesia of spinal anaesthesia compared to a larger dose of 1.0 µg/kg. The side effect profile, hemodynamic stability, sedation levels, need for vasopressors and atropine were comparable in both groups.

Circulating cellular clusters are associated with thrombotic complications and clinical outcomes in COVID-19

We sought to study the role of circulating cellular clusters (CCC)-such as circulating leukocyte clusters (CLCs), platelet-leukocyte aggregates (PLA), and platelet-erythrocyte aggregates (PEA)- in the immunothrombotic state induced by COVID-19. Forty-six blood samples from 37 COVID-19 patients and 12 samples from healthy controls were analyzed with imaging flow cytometry. Patients with COVID-19 had significantly higher levels of PEAs (p value<0.001) and PLAs (p value= 0.015) compared to healthy controls. Among COVID-19 patients, CLCs were correlated with thrombotic complications (p value= 0.016), vasopressor need (p value= 0.033), acute kidney injury (p value= 0.027), and pneumonia (p value= 0.036), whereas PEAs were associated with positive bacterial cultures (p value= 0.033). In predictive in silico simulations, CLCs were more likely to result in microcirculatory obstruction at low flow velocities (≤1mm/s) and at higher branching angles. Further studies on the cellular component of hyperinflammatory prothrombotic states may lead to the identification of novel biomarkers and drug targets for inflammation-related thrombosis.

#6733 THE PREDICTORS OF CARDIO-RENAL SYNDROME AMONG PATIENTS WITH COVID-19 INFECTION

Abstract Background and Aims Several reports showed that some Covid-19 patients tend to have serious and fatal complications related to the kidney and heart. Rationale and mechanisms inducing this pathogenesis is unclear, but it's more common to happen in patients with hemodynamic instability and refractory severe hypotension related to cytokine storm. It represents an irreversible stage of a sepsis-like illness that induces simultaneous damage to various organs as the myocardium and renal tubules alike the cardio-renal syndrome. The predictors for this injurious effect of COVID-19 on both myocardium and renal tissues might be related to the co-morbidities, late presentation and other factors which need further evaluation.The aim of this article is to study the predictors of cardio-renal syndrome in COVID-19 patients Method Our study is a prospective observational study conducted upon confirmed 160 COVID-19 ICU patients admitted from 15th March till 20th May 2020. All patients were subjected to clinical assessment, full laboratory evaluation including PCR for COVID-19 from nasopharyngeal swab and full radiological evaluation Results As regards the predictors for cardio-renal syndrome [15-17]; Age showed high statistically significance (P &amp;lt;0.0004). Furthermore, serum creatinine and serum K were statistically significant in patients with cardio-renal affection (P= 0.015, 0.021) whereas GFR, D-dimer, need for mechanical ventilation and vasopressors were highly statistically significant with cardio-renal affected patients (P &amp;lt;0.001). Conclusion Cardio-renal syndrome was common in COVID-19 ICU patients. Hypokalemia, lower GFR on admission, mechanical ventilation, vasopressors, age and D-dimer were significant independent predictors for CRS. Moreover,CRS during hospitalization was associated with an increased risk of in-hospital death.

Prognosis of lung cancer patients followed in the intensive care unit: A cross-sectional study

Lung cancer is the most common solid organ malignancy requiring intensive care unit (ICU) admission. For many years, lung cancer patients were not considered in the priority patient category for admission to ICU because of their high mortality rate and poor response to therapy. Considering the developments in treatment modalities, we aimed to reevaluate the prognosis of patients with lung cancer in the ICU. Patients characteristics, date of diagnosis, the reason for ICU admission, the stage of cancer, histopathological type, history of chemotherapy, radiotherapy, or surgery for cancer, and APACHE-II and Charlson comorbidity index (CCI) were recorded retrospectively. A total of 100 patients had a mean age of 69.7 ± 9.0 years. Among these patients, 18% had small cell lung cancer, while 82% had non-small cell lung cancer. The in-hospital mortality rate was 69% for all patients, while among those discharged from the ICU, the first 6-month mortality rate was 58.1%. The median survival time was 8.2 months. Advanced age, the need for mechanical ventilation, the need for vasopressors, a high APACHE -II, and the CCI all reduced survival in multivariate analysis, whereas chemotherapy and surgical history improved survival. Patients admitted to the ICU with lung cancer continue to experience a high mortality rate. However, identifying the factors that are associated with survival can be crucial in establishing care plans and prioritizing ICU admission for further therapy.

Oral Midodrine as an Adjunct in Rapid Weaning of Intravenous Vasopressor Support in Spinal Cord Injury.

Background Majority of acute cervical spinal cord injury end up requiring long-term stay in intensive care unit (ICU). During the initial few days after spinal cord injury, most patients are hemodynamically unstable requiring intravenous vasopressors. However, many studies have noted that long-term intravenous vasopressors remain the main reason for prolongation of ICU stay. In this series, we report the effect of using oral midodrine in reducing the amount and duration of intravenous vasopressors in patients with acute cervical spinal cord injury. Materials and Methods Five adult patients with cervical spinal cord injury after initial evaluation and surgical stabilization are assessed for the need for intravenous vasopressors. If patients continue to need intravenous vasopressors for more than 24 hours, they were started on oral midodrine. Its effect on weaning of intravenous vasopressors was assessed. Results Patients with systemic and intracranial injury were excluded from the study. Midodrine helped in weaning of intravenous vasopressors in the first 24 to 48 hours and helped in complete weaning of intravenous vasopressors. The rate of reduction was between 0.5 and 2.0 µg/min. Conclusion Oral midodrine does have an effect in reduction of intravenous vasopressors for patients needing prolonged support after cervical spine injury. The real extent of this effect needs to be studied with collaboration of multiple centers dealing with spinal injuries. The approach seems to be a viable alternative to rapidly wean intravenous vasopressors and reduce duration of ICU stay.

What is the role of neutropenia in pediatric cancer patients with pneumatosis intestinalis?

We aimed to identify prognostic indicators in pneumatosis intestinalis (PI) in a pediatric oncology population. We hypothesized that neutropenia would be an independent risk factor for adverse outcomes, including the need for abdominal operation to treat PI and for the development of recurrent PI. We performed a retrospective review of all patients treated for PI between 2009 and 2019 with a diagnosis of cancer or history of bone marrow transplant (BMT). Sixty-eight children were treated for their first episode of PI; 15 (22%) were not neutropenic at presentation; eight underwent urgent abdominal operation (12%). Patients with neutropenia were more likely to receive TPN, had a longer course of NPO, and received a longer course of antibiotics. Neutropenia at presentation was associated with a decreased risk of PI recurrence (40% vs 13%, p = 0.03). Children who required an abdominal operation were more likely to require vasopressors at diagnosis (50% vs 10%, p = 0.013). Among pediatric cancer patients, need for vasopressors at the time of PI is a marker of severe PI, with increased likelihood of requiring operative intervention. The presence of neutropenia is associated with lower rates of PI recurrence. Level III.

Presepsin: gelsolin ratio, as a promising marker of sepsis-related organ dysfunction: a prospective observational study.

We aimed to facilitate the diagnosis and prognosis of sepsis-related organ dysfunction through analyzing presepsin (PSEP) and gelsolin (GSN) levels along with a novel marker, the presepsin:gelsolin (PSEP:GSN) ratio. Blood samples were collected from septic patients at the intensive care unit (ICU) at three time points (T1-3): T1: within 12 h after admission; T2: second day morning; T3: third day morning. Sampling points for non-septic ICU patients were T1 and T3. PSEP was measured by a chemiluminescence-based POCT method while GSN was determined by an automated immune turbidimetric assay. Data were compared with routine lab and clinical parameters. Patients were categorized by the Sepsis-3 definitions. PSEP:GSN ratio was evaluated in major sepsis-related organ dysfunctions including hemodynamic instability, respiratory insufficiency and acute kidney injury (AKI). In our single center prospective observational study, 126 patients were enrolled (23 control, 38 non-septic and 65 septic patients). In contrast to controls, significantly elevated (p < 0.001) admission PSEP:GSN ratios were found in non-septic and septic patients. Regarding 10-day mortality prediction, PSEP:GSN ratios were lower (p < 0.05) in survivors than in non-survivors during follow-up, while the prognostic performance of PSEP:GSN ratio was similar to widely used clinical scores (APACHE II, SAPS II, SOFA). PSEP:GSN ratios were also higher (p < 0.001) in patients with sepsis-related AKI than septic non-AKI patients during follow-up, especially in sepsis-related AKI patients needing renal replacement therapy. Furthermore, increasing PSEP:GSN ratios were in good agreement (p < 0.001) with the dosage and the duration of vasopressor requirement in septic patients. Moreover, PSEP:GSN ratios were markedly greater (p < 0.001) in patients with septic shock than in septic patients without shock. Compared to septic patients requiring oxygen supplementation, substantially elevated (p < 0.001) PSEP:GSN ratios were observed in septic patients with demand for mechanical ventilation, while higher PSEP:GSN ratios (p < 0.001) were also associated with extended periods of mechanical ventilation requirement in septic patients. PSEP:GSN ratio could be a useful complementary marker besides the routinely used SOFA score regarding the diagnosis and short term mortality prediction of sepsis. Furthermore, the significant increase of this biomarker may also indicate the need for prolonged vasopressor or mechanical ventilation requirement of septic patients. PSEP:GSN ratio could yield valuable information regarding the extent of inflammation and the simultaneous depletion of the patient's scavenger capacity during sepsis. NIH U.S. National Library of Medicine, ClinicalTrails.gov. Trial identifier: NCT05060679, (https://clinicaltrials.gov/ct2/show/NCT05060679) 23.03.2022, Retrospectively registered.

PO-04-156 INSIGHTS REGARDING OUTCOMES FOR COVID-19 HOSPITALIZATIONS WITH ADULT CONGENITAL HEART DISEASE (ACHD)

As of December 2022, SARS-CoV-2 coronavirus resulted in over 6 million deaths worldwide.[1] It was realized early into the pandemic, that COVID-19 significantly impacts the Cardiovascular system. [2] Patients with pre-existing cardiovascular comorbidities were particularly at higher risk of adverse outcomes during their hospitalizations. [3] Similarly, it can be safe to assume patients with adult congenital heart disease (ACHD) should considered a high-risk population for the development of severe COVID infection with increased rates of significant cardiovascular complications. Based on this reasoning and the paucity of data available on this topic using a large database, we sought to investigate the outcomes of patients with ACHD who were admitted to the hospital with COVID-19. The National Inpatient Sample database for 2020 was queried to identify adult hospitalizations with a primary diagnosis of COVID-19 and a secondary diagnosis of ACHD using International Classification of Diseases – 10 Clinical Modification (ICD-10-CM) codes. The primary outcome studied was inpatient mortality, while secondary outcomes included inpatient complications, mean length of stay (LOS), and total hospital charge (THC). Multivariate logistic and linear regression analyses were used to adjust for possible confounders and analyze the variables. Out of 1,050,045 COVID-19 hospitalizations registered, 2,425 (0.23%) had ACHD as a secondary diagnosis. Encounters with ACHD who were hospitalized with COVID-19 had significantly higher adjusted odds of inpatient mortality (Adjusted Odds Ratio [aOR]: 1.4, [95% CI: 1.05-1.88], p=0.022), Longer LOS (Mean 2.4 days, [95% CI: 1.35-3.40], p <0.001), and higher Total Hospital Charges (Mean $53,000, [95% CI: 20811-85190], p <0.001). A Forrest plot (Figure 1) demonstrates a graphical representation of the multivariate analysis of the significant in-hospital complications when adjusted for patient demographics, comorbidities, and hospital characteristics. Among COVID-19 hospitalizations, those with a history of congenital heart diseases had significantly worse outcomes in terms of in-hospital mortality, sepsis; the need for endotracheal intubation, mechanical ventilation, and vasopressors; developing acute kidney injury and pulmonary embolism, in addition to the longer length of stay, and higher total hospital charges.

Local anesthetic with monitored anesthesia care in cephalomedullary nailing of proximal femur fractures

IntroductionProximal femur fractures have high rates of morbidity, mortality, and perioperative complications. Limiting anesthesia, especially in the elderly population, is a priority from a medical perspective. The goal of the current study is to present a technique of using local anesthetic with monitored anesthesia care (MAC) for the fixation of intertrochanteric (IT) femur fractures with cephalomedullary nailing (CMN), provide early clinical results in a small series of patients, and evaluate the safety, efficiency, and anesthetic efficacy of our technique. HypothesisThe use of only local anesthetic with MAC for the fixation of IT fractures is safe and leads to decreased operative times when compared to spinal and general anesthesia. Materials and methodsPatients undergoing cephalomedullary nailing (CMN) with a long nail for IT femur fractures by a single surgeon from January 2020 to June 2021 were identified retrospectively from a prospectively-collected patient registry. Patient demographics, operative time, length of hospital stay, perioperative medication use, and complications were collected. Analysis of variance, Chi2, linear regression, and two-sampled T-tests were performed to analyze potential differences between the local anesthesia group and the general or spinal anesthesia group. ResultsThirty-seven patients were identified. Eleven patients underwent CMN using local anesthesia with MAC, 11 using spinal anesthesia, and 15 using general anesthesia. The local anesthesia group demonstrated significantly lower operating room times and anesthesia induction to incision time compared to other anesthesia techniques. The local anesthesia group also trended towards less need for vasopressors during surgery and less postoperative delirium. No differences were identified in intraoperative narcotic use, complications, patient mortality, or hospital readmissions. ConclusionsLocal anesthesia with MAC for the treatment of IT fractures with CMN was associated with decreased operating room times and had similar complication rates including blood transfusions, readmissions, and mortalities, when compared to spinal and general anesthesia. Level of evidenceIII, therapeutic.

Comparing Clinical Outcomes of COVID-19 and Influenza-Induced Acute Respiratory Distress Syndrome: A Propensity-Matched Analysis.

Acute respiratory distress syndrome (ARDS) is one the leading causes of mortality and morbidity in patients with COVID-19 and Influenza, with only small number of studies comparing these two viral illnesses in the setting of ARDS. Given the pathogenic differences in the two viruses, this study shows trends in national hospitalization and outcomes associated with COVID-19- and Influenza-related ARDS. To evaluate and compare the risk factors and rates of the adverse clinical outcomes in patients with COVID-19 associated ARDS (C-ARDS) relative to Influenza-related ARDS (I-ARDS), we utilized the National Inpatient Sample (NIS) database 2020. Our sample includes 106,720 patients hospitalized with either C-ARDS or I-ARDS between January and December 2020, of which 103,845 (97.3%) had C-ARDS and 2875 (2.7%) had I-ARDS. Propensity-matched analysis demonstrated a significantly higher in-hospital mortality (aOR 3.2, 95% CI 2.5-4.2, p < 0.001), longer mean length of stay (18.7 days vs. 14.5 days, p < 0.001), higher likelihood of requiring vasopressors (aOR 1.7, 95% CI 2.5-4.2) and invasive mechanical ventilation (IMV) (aOR 1.6, 95% CI 1.3-2.1) in C-ARDS patients. Our study shows that COVID-19-related ARDS patients had a higher rate of complications, including higher in-hospital mortality and a higher need for vasopressors and invasive mechanical ventilation relative to Influenza-related ARDS; however, it also showed an increased utilization of mechanical circulatory support and non-invasive ventilation in Influenza-related ARDS. It emphasizes the need for early detection and management of COVID-19.

COVID-19 Related Predisposition to Diabetic Ketoacidosis.

Background and aims Severe acute respiratory syndromecoronavirus 2(SARS-CoV-2) can exacerbate hyperglycemia and can cause life-threatening diabetic ketoacidosis (DKA) in patients with diabetes mellitus (DM). The objective of this study is to compare the characteristics of diabetic COVID-19 patients with and without DKA and to determine the predictors of mortality in the setting of COVID-19 and DKA. Methods This is a retrospective single-center cohort study including patients admitted to our hospital with COVID-19 and DM from March 2020 to June 2020. Patients with DKA were filtered as per the diagnostic criteria set by the American Diabetes Association (ADA). Patients with hyperosmolar hyperglycemic state (HHS) were excluded. A retrospective analysis was performed, which included those who developed DKA and those with neither DKA nor HHS. The primary outcome measurement was mortality rate and predictors of mortality for DKA. Results Out of 301 patients with COVID-19 and DM, 30 (10%) had DKA and five (1.7%) had HHS. Mortality was significantly higher in the DKA group compared to the non-DKA/HHS group (36.6% vs 19.5%; OR: 2.38; p=0.03). After adjusting for parameters used for multivariate logistic model for mortality, DKA was no longer associated with mortality (OR: 2.08, p=0.35). The independent predictors for mortality were age, platelet count, serum creatinine, C-reactive protein, hypoxic respiratory failure, need for intubation, and need for vasopressors. Conclusion Our study demonstrates higher mortality rate in diabetic COVID-19 patients with DKA. Though direct and independent statistical association of mortality with DKA could not be proven in our multivariate logistic model, physicians must be vigilant in risk-stratifying and managing these patients in a timely manner.

Effect of zinc supplementation on symptom reduction and length of hospital stay among pediatric patients with Coronavirus disease 2019 (COVID-19)

ObjectivesZinc is considered an essential multipurpose trace element because of its ability to act as a cofactor and signaling molecule. As reported in earlier studies of pediatric respiratory infection management, zinc exhibits potent immunoregulatory and antiviral properties, but its effects on pediatric patients with COVID-19 remain unknown. The aim of this study was to determine the extent to which zinc supplementation improves COVID-19 symptoms, length of hospitalization and, to determine how zinc supplementation impacts ICU admission, in-hospital mortality, need for ventilation, duration of ventilation, need for vasopressors, development of liver injury, or respiratory failure. MethodsPediatric patients younger than 18 years with confirmed COVID-19 infection during the study period (March 1, 2020, to December 31, 2021) were recruited for this retrospective cohort study. The study population was divided into two arms (zinc/no zinc supplementation as an adjunct to standard therapy). ResultsOf 169 hospitalized patients who were screened, 101 met the inclusion criteria. No statistically significant association was found between the administration of zinc as adjunctive therapy and symptom reduction, intensive care unit (ICU) admission, or mortality (p = 0.105; p = 0.941, and p = 0.073, respectively). However, zinc supplementation was associated with a statistically significant reduction in respiratory failure and length of hospitalization (p = 0.004 and p = 0.017, respectively), also, zinc administration was associated with elevated serum creatinine (p = 0.01*) ConclusionsAmong pediatric patients with COVID-19, zinc supplementation was associated with shorter hospital stay. However, there was no significant difference between the two groups in terms of symptom improvement, in-hospital mortality, or ICU admission. In addition, the study raises question about the possibility of kidney injury as indicated by high levels of serum creatinine.

High-Dose vs. Low-Dose Dexamethasone in Patients With COVID-19: A Cohort Study in Rural Central America.

To compare the clinical outcomes of a low dose dexamethasone strategy vs. a high-dose dexamethasone strategy in hypoxemic COVID-19 patients. A retrospective observational study comparing low-dose (8 mg) and high-dose dexamethasone (24 mg) of COVID-19 patients admitted from September 1, 2020 to October 31, 2020 in a hospital in Honduras. We included 81 patients with confirmed COVID-19 who required oxygen therapy. The mean age was similar between groups (57.49 vs. 56.95 years). There were more male patients in the group of 24 mg ( p = 0.01). Besides, patients on the 24 mg dose had more prevalence of hypertension ( p = 0.052). More patients in the 24 mg group had a higher rate of invasive mechanical ventilation (15.00% vs. 2.56%, p = 0.058). When evaluating the association between the high dose group and outcomes, we find no significant association with mortality, nosocomial infections, high flow mask, invasive mechanical ventilation, or the need for vasopressors. We find no significant differences in the Kaplan-Meier analysis regarding the survival (log-rank p -value = 0.315). We did not find significant differences between the use of 24 mg and 8 mg of dexamethasone in hypoxemic COVID-19 patients.

Dysautonomia and related outcomes in Guillain-Barre syndrome

Guillain-Barre syndrome (GBS) presents an annual incidence of 1.2-2.3 per 100,000. Sympathetic and parasympathetic nervous systems' peripheral control of visceral organs is affected by GBS aberrant immune response. Associated cardiovascular, gastrointestinal, sudomotor, pupillary, and other systems disturbances cause significant morbidity and mortality. This study aims to evaluate the dysautonomia spectrum in GBS patients, its relationship with patient outcomes, and compare it with those without autonomic disturbances. We performed an ambispective review study of patients with GBS and dysautonomia admitted to the Institute of Neurology from 2017 to 2021. We recorded demographics, comorbidities, nerve conduction studies, clinical course, hospital complications, and functional outcomes. We included 214 patients, mean age 46.44±16.49years, 51 (31%) presented dysautonomia, hypertension in most of the patients 39 (84.8%), hypotension 35 (76.1%), tachycardia 35 (76.1%), enteric dysmotility 35 (76.1%), and need for vasopressor 27 (58.7%) were common characteristics. Twenty (39.2%) with a demyelinating form and twenty (39.2%) with an axonal motor form. The bivariate analysis report factors associated with dysautonomia, were lower cranial nerves (VII, IX, X) involvement (p=0.002), need for mechanical ventilation (p=0.0001) and intensive care (p=0.0001), higher mEGOS (p=0.05), EGRIS (p=0.004), GBS disability score (p=0.004), and delirium presence (p=0.001). Kaplan-Meier survival analysis showed that dysautonomic patients needed more days for the independent walk (p=0.004). There was no associated mortality. Autonomic dysfunction in GBS significantly affects the peripheral nervous system. With consequently worse functional results. Further investigation needs to clarify whether more aggressive treatment is beneficial in this category of GBS.

Abstract Number ‐ 101: Blood Pressure Interventions Are Most Common Reason for ICU Admission After MMA Embolization

Introduction Middle meningeal artery embolization (MMAE) is a minimally invasive technique that is increasingly performed for the treatment of chronic subdural hematomas. In comparison to prior surgical interventions, which often resulted in complications such as insufficient drainage or recurrence of rebleeding, MMAE has greatly reduced the need for multiple inpatient hospitalizations. Some authors have described managing minimally symptomatic patients with MMAE in the outpatient setting. Our practice, however, has been routinely admitting patients to the neuro‐intensive care setting after MMAE. The objective of this research is to analyze the frequency of ICU level interventions that were administered to patients after MMAE in the neuro‐intensive care unit in order to gain a better understanding of postoperative management and assess the potential for future management in the outpatient setting. Methods A consecutive series of MMA embolizations for cSDH were retrospectively reviewed from 2020 to 2022 at Valley Baptist Medical Center in Harlingen, TX, USA. Frequency of ICU specific interventions such as need for post procedural mechanical ventilation, need for intravenous vasopressor or antihypertensive medications was recorded. Additional data collected included patient clinical presentations, indications for treatment, additional neurosurgical intervention, length of ICU stay, and blood pressure parameters. Results A total of 50 MMA embolizations were performed during the study period. The average age of patients included in the study was 63 years old +/‐ 16 years with 30% being female. 34% patients did not receive any sort of ICU level intervention at all. Among the remaining who did, 32% required mechanical ventilation post procedurally. 14% needed a vasopressor and 48% required intravenous antihypertensives to maintain systolic blood pressure within goal parameters. Conclusions The most common reason for an ICU intervention after MMAE was for correction of blood pressure to maintain within specified goal. 34% of patients who underwent MMAE did not require any ICU level interventions afterwards. Further investigation is warranted, but current data suggests that liberalizing blood pressure parameters could potentially reduce the need for ICU utilization after MMAE. Assessment of various components of ICU level interventions administered to patients post‐MMAE allows for a better understanding on preventive measures that can be taken in the future to reduce length of inpatient stay post procedurally, which would reduce risk of iatrogenic complications, minimize spread of nosocomial infections, andoverall increase patient comfort.

A multicenter, randomized feasibility analysis comparing restrictive fluids to standard therapy for people with sepsis in the emergency department (REFACED)

Aim: Sepsis presents a problem for fluid management, and clinical consensus exists about intravenous (IV) volume requirements. When adult patients with sepsis who were not in shock presented to the emergency room, our goal was to assess if a 24-hour strategy restricting IV fluid was possible (ED). Methods: The REFACED Sepsis trial is an investigator-initiated, multicenter, randomised, open-label, feasibility study in which sepsis patients who are not in shock are randomly assigned to receive either conventional therapy or 24 hours of restrictive, crystal IV fluid delivery. Fluid boluses were only allowed in the IV fluid restriction group when certain conditions for hypoperfusion were met. The treating team determined the standard of care. Total IV crystalloid fluid volumes were the main result 24 hours after randomization. Total fluid volumes, feasibility tests, and patient-centered outcomes were also considered secondary outcomes. Results: In the initial analysis, we included 123 patients (61 patients under restrictive care and 62 patients under normal treatment). The proportion of eligible patients who met all inclusion criteria and no exclusion criteria was 32% (95% confidence interval [CI] 28%-37%). At 24hrs, the restriction versus standard care groups had mean (± SD) IV crystalloid fluid amounts of 562 (1076) ml and 1370 (1438) ml, respectively (mean difference -801 ml, 95% CI - 1257 to - 345 ml, p = 0.001). In the fluid-restrictive group, 21 (34%) of the patients experienced protocol violations. Adverse events, the need for mechanical breathing or vasopressors, acute renal failure, length of stay, or mortality did not differ across groups. Conclusions: In comparison to normal care, a regimen restricting IV crystalloid fluids in ED patients with sepsis resulted in lower 24-hour fluid amounts. It is possible that a future experiment may focus on patient-centered outcomes.

Ventilator-Associated Pneumonia in COVID-19 Patients Admitted in Intensive Care Units: Relapse, Therapeutic Failure and Attributable Mortality—A Multicentric Observational Study from the OutcomeRea Network

Introduction: Ventilator-associated pneumonia (VAP) incidence is high among critically ill COVID-19 patients. Its attributable mortality remains underestimated, especially for unresolved episodes. Indeed, the impact of therapeutic failures and the determinants that potentially affect mortality are poorly evaluated. We assessed the prognosis of VAP in severe COVID-19 cases and the impact of relapse, superinfection, and treatment failure on 60-day mortality. Methods: We evaluated the incidence of VAP in a multicenter prospective cohort that included adult patients with severe COVID-19, who required mechanical ventilation for ≥48 h between March 2020 and June 2021. We investigated the risk factors for 30-day and 60-day mortality, and the factors associated with relapse, superinfection, and treatment failure. Results: Among 1424 patients admitted to eleven centers, 540 were invasively ventilated for 48 h or more, and 231 had VAP episodes, which were caused by Enterobacterales (49.8%), P. aeruginosa (24.8%), and S. aureus (22%). The VAP incidence rate was 45.6/1000 ventilator days, and the cumulative incidence at Day 30 was 60%. VAP increased the duration of mechanical ventilation without modifying the crude 60-day death rate (47.6% vs. 44.7% without VAP) and resulted in a 36% increase in death hazard. Late-onset pneumonia represented 179 episodes (78.2%) and was responsible for a 56% increase in death hazard. The cumulative incidence rates of relapse and superinfection were 45% and 39.5%, respectively, but did not impact death hazard. Superinfection was more frequently related to ECMO and first episode of VAP caused by non-fermenting bacteria. The risk factors for treatment failure were an absence of highly susceptible microorganisms and vasopressor need at VAP onset. Conclusions: The incidence of VAP, mainly late-onset episodes, is high in COVID-19 patients and associated with an increased risk of death, similar to that observed in other mechanically ventilated patients. The high rate of VAP due to difficult-to-treat microorganisms, pharmacokinetic alterations induced by renal replacement therapy, shock, and ECMO likely explains the high cumulative risk of relapse, superinfection, and treatment failure.