The SARS-CoV2 virus is well known for causing atypical pneumonia in addition to other symptoms. Various neurological symptoms have been reported including anosmia, headaches, and stroke like symptoms. Here we report a case of a critically ill patient who developed encephalopathy with evidence of multiple bilateral acute strokes.
VERISHA KHANAM JURGENA TUSHA DANYAL TAHERI ABKOUH LAITH AL-JANABI VESNA TEGELTIJA AND SARWAN KUMAR PURPOSE: Throughout the years, several scoring systems have been established to measure disease severity in efforts to predict patient mortality and help guide management. In patients with sepsis, organ failure has been proven to worsen outcome, therefore utility of scores such as Sequential Organ Failure Assessment (SOFA) has helped determine the severity of disease and predict mortality. Patients infected with SARS COV-2 were observed to have varying disease progression with multiorgan involvement. Through this study, we intend to investigate the use of the SOFA score in predicting mortality in critically ill patients who tested positive for SARS COV-2. The aim of this study is to determine if the SOFA score is a strong predictor of mortality in critical care patients admitted with SARS-COV2 infection.
Hyperosmolar Hyperglycemic State (HHS) and Diabetic Ketoacidosis (DKA) are associated with decompensated Diabetes mellitus. On many instances' patients may present with a mixed picture of both conditions. This acute decompensation may result from infarction, medication noncompliance, or infections. With DKA and HHS, hemoconcentration is common due to dehydration. Many nonspecific enzyme values maybe elevated with these conditions, which may cause other underlying pathologies to go unnoticed. Here we report a case of post-COVID HHS/DKA with elevated lipase and features of pancreatitis.CASE PRESENTATION: 52-year-old African-American female with obesity and Type two diabetes presented with nausea, abdominal pain and dizziness of 1 day. She was in the recovery stages of COVID, past 10 days since her diagnosis at the time of admission. She stated that due to altered taste sensation, likely COVID symptom, she was not eating properly, drinking more caffeinated beverages, and less water. Her glucose was >1000 mg/dl, creatinine 1.7, anion gap > 31, elevated betahydroxybutyrate, minimal urine ketones and a bicarb of 13 on admission. Her lipase was >2000 and Amylase >1000. Lab values along with abdominal pain was enough to consider underlying pancreatitis. At that time both DKA/HHS and acute pancreatitis required aggressive fluid hydration, but the patient continued to deteriorate. Fear of fluid overload with tachypnea, along with continued abdominal pain requiring pain medications produced a 'catch 21' with her respiratory status. Ultrasound of the abdomen was unremarkable. CT abdomen did prove acute pancreatitis. Triglycerides were not elevated enough to be the culprit of pancreatitis. She denied use of alcohol or other infections. She was however recovering from SARS-CoV2 infection (>10 days since diagnosis), which may have been the inciting factor for pancreatic inflammation. Her BISAPS score was 4; very severe form of acute pancreatitis with a high mortality risk.DISCUSSION: This case shows how DKA/HHS states can mask pancreatitis. This case also presents an interesting cause of her pancreatitis. Viral etiologies like mumps or coxsackie viruses are known instigators of acute pancreatitis. Given the lack of other etiologies, COVID-19 is likely the trigger to her symptoms. COVID has been known to be a precipitator of DKA in this last year, but little is known in its' involvement in acute pancreatitis. One theory to link pancreatitis to decompensated diabetic states with COVID is cytokine mediated damage to the pancreatic beta cells, causing inflammation of the pancreas and worsening glycemic control precipitating DKA or HHS.CONCLUSIONS: An association of AP with DKA or HHS increases the risk of mortality. It's a rare phenomenon for SARS-Cov2 infection as the provoking factor. More studies should be done on the link of decompensated DM with AP, and how these conditions are affected by COVID-19.
The aim of our project is to formulate a standardized process for transfering patients from the intensive care unit to the medical wards which improves documentation, policy and puts emphasis on communication through a multidisciplinary approach by utilization of a novel hand-off template and implementation of transfer medication reconciliation.METHODS: Following the IHI model, a fishbone diagram was used to identify areas of improvement in the hand-off process. The persons involved, process, policy, and communication were identified as contributing factors in formulating a standardized Transition Of Care (TOC) process. PDSA cycles were used to test change. We measure use of proposed standardized TOC method and number of ICU re-admissions as part of adverse events. RESULTS:After observing the need for this process to become ubiquitous, using the Plan Do Study Act (PDSA) cycle, literature was reviewed, and a TOC template was formulated in PDSA1 which resulted in no significant change. In PDSA2, there was creation of a policy to utilize an existing Transfer Medication Reconciliation (Med Rec.) with our EMR prior to transferring a patient out of ICU. Internal medicine residents, faculty, ICU attendings, ICU committee, ICU Pharmacy, and EMR Department were educated on the implementation of the new procedure was initiated. 100 charts were analyzed post-intervention; of those 61 charts met inclusion criteria. Twenty seven of the 61 charts had an appropriate use of the TOC Template and use of Transfer Med Rec. in addition to communication with the primary attending (44%). Of these, there was 1 Rapid Response (RR) that warranted an ICU readmission (3.7%). There were 0 code blues after transfer from ICU. Of the 34 charts that did not abide to procedure, there were 3 RRs (8.8%).CONCLUSIONS: There were fewer RR when comparing the patients with the ICU TOC implemented compared to those without the documented communication (3.7% vs 8.8%). The ICU readmission noted, should take into account the inherit fragility of this patient population and associated morbidly. Despite our small sample size, the trends are promising that align with the impact of our implementation of ICU TOC process.The goal of this QI project was to use a multisystem approach to standardized transfer process to ensure patient safety. In our next PDSA cycle, there will be a pop-up screen when a Transfer Order out of ICU is clicked, that directs user to Transfer Med Rec. page before proceeding. With this new implementation, there will be an increased compliance to abiding to the process with integration of the EMR with Transfer Med Rec. CLINICAL IMPLICATIONS:The transition of patient care from the Intensive Care Unit (ICU) to the medical wards has been identified as a crucial time for communication and accuracy in these patients who are at high risk for potential harm due to medical errors. Proper transition process is critical, as the lack of a universal standardized hand-off could lead to detrimental consequences. Our community hospital has an "open" ICU an...
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