Faculty Bibliography
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Therapeutic Anticoagulation with Heparin in Noncritically Ill Patients with Covid-19
BACKGROUND:Thrombosis and inflammation may contribute to the risk of death and complications among patients with coronavirus disease 2019 (Covid-19). We hypothesized that therapeutic-dose anticoagulation may improve outcomes in noncritically ill patients who are hospitalized with Covid-19. METHODS:In this open-label, adaptive, multiplatform, controlled trial, we randomly assigned patients who were hospitalized with Covid-19 and who were not critically ill (which was defined as an absence of critical care-level organ support at enrollment) to receive pragmatically defined regimens of either therapeutic-dose anticoagulation with heparin or usual-care pharmacologic thromboprophylaxis. The primary outcome was organ support-free days, evaluated on an ordinal scale that combined in-hospital death (assigned a value of -1) and the number of days free of cardiovascular or respiratory organ support up to day 21 among patients who survived to hospital discharge. This outcome was evaluated with the use of a Bayesian statistical model for all patients and according to the baseline d-dimer level. RESULTS:The trial was stopped when prespecified criteria for the superiority of therapeutic-dose anticoagulation were met. Among 2219 patients in the final analysis, the probability that therapeutic-dose anticoagulation increased organ support-free days as compared with usual-care thromboprophylaxis was 98.6% (adjusted odds ratio, 1.27; 95% credible interval, 1.03 to 1.58). The adjusted absolute between-group difference in survival until hospital discharge without organ support favoring therapeutic-dose anticoagulation was 4.0 percentage points (95% credible interval, 0.5 to 7.2). The final probability of the superiority of therapeutic-dose anticoagulation over usual-care thromboprophylaxis was 97.3% in the high d-dimer cohort, 92.9% in the low d-dimer cohort, and 97.3% in the unknown d-dimer cohort. Major bleeding occurred in 1.9% of the patients receiving therapeutic-dose anticoagulation and in 0.9% of those receiving thromboprophylaxis. CONCLUSIONS:In noncritically ill patients with Covid-19, an initial strategy of therapeutic-dose anticoagulation with heparin increased the probability of survival to hospital discharge with reduced use of cardiovascular or respiratory organ support as compared with usual-care thromboprophylaxis. (ATTACC, ACTIV-4a, and REMAP-CAP ClinicalTrials.gov numbers, NCT04372589, NCT04505774, NCT04359277, and NCT02735707.).
PMCID:8362594
PMID: 34351721
ISSN: 1533-4406
CID: 4996262
Outcomes among Hospitalized Chronic Kidney Disease Patients with COVID-19
Background/UNASSIGNED:Patients with CKD ha ve impaired immunity, increased risk of infection-related mortality, and worsened COVID-19 outcomes. However, data comparing nondialysis CKD and ESKD are sparse. Methods/UNASSIGNED:Patients with COVID-19 admitted to three hospitals in the New York area, between March 2 and August 27, 2020, were retrospectively studied using electronic health records. Patients were classified as those without CKD, those with nondialysis CKD, and those with ESKD, with outcomes including hospital mortality, ICU admission, and mortality rates. Results/UNASSIGNED:Of 3905 patients, 588 (15%) had nondialysis CKD and 128 (3%) had ESKD. The nondialysis CKD and ESKD groups had a greater prevalence of comorbidities and higher admission D-dimer levels, whereas patients with ESKD had lower C-reactive protein levels at admission. ICU admission rates were similar across all three groups (23%-25%). The overall, unadjusted hospital mortality was 25%, and the mortality was 24% for those without CKD, 34% for those with nondialysis CKD, and 27% for those with ESKD. Among patients in the ICU, mortality was 56%, 64%, and 56%, respectively. Although patients with nondialysis CKD had higher odds of overall mortality versus those without CKD in univariate analysis (OR, 1.58; 95% CI, 1.31 to 1.91), this was no longer significant in fully adjusted models (OR, 1.11; 95% CI, 0.88 to 1.40). Also, ESKD status did not associate with a higher risk of mortality compared with non-CKD in adjusted analyses, but did have reduced mortality when compared with nondialysis CKD (OR, 0.57; 95% CI, 0.33 to 0.95). Mortality rates declined precipitously after the first 2 months of the pandemic, from 26% to 14%, which was reflected in all three subgroups. Conclusions/UNASSIGNED:In a diverse cohort of patients with COVID-19, we observed higher crude mortality rates for patients with nondialysis CKD and, to a lesser extent, ESKD, which were not significant after risk adjustment. Moreover, patients with ESKD appear to have better outcom es than those with nondialysis CKD.
PMCID:8786103
PMID: 35368350
ISSN: 2641-7650
CID: 5219372
Low-Dose Tocilizumab With High-Dose Corticosteroids in Patients Hospitalized for COVID-19 Hypoxic Respiratory Failure Improves Mortality Without Increased Infection Risk
BACKGROUND:Severe hypoxic respiratory failure from COVID-19 pneumonia carries a high mortality risk. There is uncertainty surrounding which patients benefit from corticosteroids in combination with tocilizumab and the dosage and timing of these agents. The balance of controlling inflammation without increasing the risk of secondary infection is difficult. At present, dexamethasone 6 mg is the standard of care in COVID-19 hypoxia; whether this is the ideal choice of steroid or dosage remains to be proven. OBJECTIVES/OBJECTIVE:The primary objective was to assess the impact on mortality of tocilizumab only, corticosteroids only, and combination therapy in patients with COVID-19 respiratory failure. METHODS:A multihospital, retrospective study of adult patients with severe respiratory failure from COVID-19 who received supportive therapy, corticosteroids, tocilizumab, or combination therapy were assessed for 28-day mortality, biomarker improvement, and relative risk of infection. Propensity-matched analysis was performed between corticosteroid alone and combination therapies to further assess mortality benefit. RESULTS:= 0.005] without increasing the risk of infection. CONCLUSION AND RELEVANCE/UNASSIGNED:Combination of tocilizumab and corticosteroids was associated with improved 28-day survival when compared with corticosteroids alone. Modification of steroid dosing strategy as well as steroid type may further optimize therapeutic effect of the COVID-19 treatment.
PMID: 34180274
ISSN: 1542-6270
CID: 4926192
A proposed classification for CPR-related cognitive activity, consciousness, awareness and recall [Letter]
PMID: 34146621
ISSN: 1873-1570
CID: 4917952
Decreasing Incidence of AKI in Patients with COVID-19 critical illness in New York City
Introduction/UNASSIGNED:Reports from the United States suggest that acute kidney injury (AKI) frequently complicates COVID-19, but understanding of AKI risks and outcomes is incomplete. Additionally, whether kidney outcomes have evolved during the course of the pandemic is unknown. Methods/UNASSIGNED:We used electronic records to identify COVID-19 patients with and without AKI admitted to 3 New York Hospitals between March 2 and August 25, 2020. Outcomes included AKI overall and according to admission week, AKI stage, the requirement for new renal replacement therapy (RRT), mortality and recovery of kidney function. Logistic regression was utilized to assess associations of patient characteristics and outcomes. Results/UNASSIGNED:Out of 4732 admissions 1386 (29.3%) patients had AKI. Among those with AKI, 717 (51.7%) had Stage 1, 132 (9.5%) Stage 2, 537 (38.7%) stage 3, and 237 (17.1%) required RRT initiation. In March 536/1648 (32.5%) of patients developed AKI compared with 15/87 (17.2%) in August (P<0.001 for monthly trend) whereas RRT initiation was required in 6.9% and 0% of admission, in March and August respectively. Mortality was higher with than without AKI (51.6% vs 8.6%) and was 71.9% in individuals requiring RRT. However, most patients with AKI who survived hospitalization (77%) recovered to within 0.3 mg/dL of baseline creatinine. Among those surviving to discharge, 62% discontinued RRT. Conclusions/UNASSIGNED:AKI impacts a high proportion of admitted COVID-19 patients and is associated with high mortality, particularly when RRT is required. AKI incidence appears to be decreasing over time and kidney function frequently recovers in those who survive.
PMCID:7857986
PMID: 33558853
ISSN: 2468-0249
CID: 4779502
The impact of extracorporeal membrane oxygenation on cerebral oxygen delivery during cardiac arrest: a case series [Case Report]
Aim/UNASSIGNED:To describe the impact of extracorporeal membrane oxygenation (ECMO) assisted CPR (E-CPR) on cerebral oxygen delivery during in-hospital cardiac arrest (IHCA). Methods/UNASSIGNED:Retrospective case series from a tertiary academic medical center. Regional cerebral oxygen saturation (rSO2) was measured continuously using cerebral oximetry in six patients who experienced IHCA. During CPR, the time of E-CPR initiation was recorded, and rSO2 values were subsequently analyzed for a period beginning 5Â min before and ending 2.5Â min after the initiation of E-CPR. Results/UNASSIGNED:value in the 2.5Â min period following E-CPR initiation increased by 20.8% as compared to the 5-min period before E-CPR initiation. Conclusions/UNASSIGNED:ECMO can be employed in parallel with cerebral rSO2 monitoring during CPR for adult IHCA patients. E-CPR is associated with rapid and significant increases in brain oxygen delivery.
PMCID:8244461
PMID: 34223338
ISSN: 2666-5204
CID: 4932922
Use of a QR Code Accessed Debrief Tool is Associated With Higher Rates of Debrief After In-Hospital Cardiac Arrest [Meeting Abstract]
ISI:000750132100112
ISSN: 0009-7322
CID: 5263722
Association of Post-Resuscitation Inflammatory Response with Favorable Neurologic Outcomes in Adults with In-Hospital Cardiac Arrest
BACKGROUND:Early prediction of mortality in adults after in-hospital cardiac arrest (IHCA) remains vital to optimizing treatment strategies. Inflammatory cytokines specific to early prognostication in this population have not been well studied. We evaluated whether novel inflammatory cytokines obtained from adults with IHCA helped predict favorable neurologic outcome. METHODS:The study population included adults with IHCA who underwent ACLS-guided resuscitation between March 2014 and May 2019 at an academic tertiary medical center. Peripheral blood samples were obtained within 6, 24, 48, 72, and 96 hours of IHCA and analysis of 15 cytokines were performed. The primary outcome of interest was presence of favorable neurologic outcome at hospital discharge, defined as a Glasgow Outcome Score of 4 or 5. RESULTS:Of the 105 adults with IHCA studied, 27 (25.7%) were noted to have survival with a favorable neurologic outcome while 78 (74.3%) did not. Patients who survived with favorable neurologic outcome were more often men (88.9% vs 61.5%, p = 0.008) and had higher rates of ventricular tachyarrhythmias as their initial rhythm (34.6% vs 11.7%, p = 0.018). Levels of interleukin (IL)-6, IL-8, IL-10, and Tumor Necrosis Factor (TNF)-R1 within 6 or 24 hours were significantly lower in patients with favorable neurologic outcome compared with those who had unfavorable neurologic outcome. In multivariable analysis, IL-10 levels within 6 hours was the only independent predictor of favorable neurologic outcomes [odds ratio (OR) 0.895, 95% confidence interval 0.805-0.996, p = 0.041]. CONCLUSION/CONCLUSIONS:In this contemporary observational study of adults with IHCA receiving ACLS-guided resuscitative and post-resuscitative care, inflammatory cytokines specific to early prognostication in adults with IHCA exist. Further larger scale studies examining the association of these inflammatory cytokines with prognosis are warranted.
PMID: 33385467
ISSN: 1873-1570
CID: 4731992
Clinical characteristics and outcomes of in-hospital cardiac arrest among patients with and without COVID-19
Aims/UNASSIGNED:To define outcomes of patients with COVID-19 compared to patients without COVID-19 suffering in-hospital cardiac arrest (IHCA). Materials and methods/UNASSIGNED:We performed a single-center retrospective study of IHCA cases. Patients with COVID-19 were compared to consecutive patients without COVID-19 from the prior year. Return of spontaneous circulation (ROSC), 30-day survival, and cerebral performance category (CPC) at 30-days were assessed. Results/UNASSIGNED:Fifty-five patients with COVID-19 suffering IHCA were identified and compared to 55 consecutive IHCA patients in 2019. The COVID-19 cohort was more likely to require vasoactive agents (67.3% v 32.7%, p = 0.001), invasive mechanical ventilation (76.4% v 23.6%, p < 0.001), renal replacement therapy (18.2% v 3.6%, p = 0.029) and intensive care unit care (83.6% v 50.9%, p = 0.001) prior to IHCA. Patients with COVID-19 had shorter CPR duration (10 min v 22 min, p = 0.002). ROSC (38.2% v 49.1%, p = 0.336) and 30-day survival (20% v 32.7%, p = 0.194) did not differ. A 30-day cerebral performance category of 1 or 2 was more common among non-COVID patients (27.3% v 9.1%, p = 0.048). Conclusions/UNASSIGNED:Return of spontaneous circulation and 30-day survival were similar between IHCA patients with and without COVID-19. Compared to previously published data, we report greater ROSC and 30-day survival after IHCA in COVID-19.
PMCID:7680084
PMID: 33403368
ISSN: 2666-5204
CID: 4738852
The Association between Post-Cardiac Arrest Cerebral Oxygenation and Survival with Favorable Neurological Outcomes: A Multicenter Study
OBJECTIVE:following IHCA is associated with survival and favorable neurological outcomes. DESIGN/METHODS:Prospective study from nine acute care hospital in the United States and United Kingdom. PATIENTS/METHODS:Convenience sample of IHCA patients admitted to the intensive care unit with post-cardiac arrest syndrome. INTERVENTIONS/METHODS:Cerebral oximetry monitoring (Equanox 7600, Nonin Medical, MN, USA) during the first 48 hours after IHCA. MEASUREMENTS AND MAIN RESULTS/RESULTS:, and hemoglobin levels between two groups. CONCLUSIONS:in the first two hours after ROSC in IHCA patients who achieve favorable neurological outcomes, however, this difference may not be clinically significant.
PMID: 32544414
ISSN: 1873-1570
CID: 4484722
