Tension pneumomediastinum is a rare complication of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection that has increased in incidence with the novel coronavirus disease 2019 pandemic. Although traditionally managed with conservative measures, we present the indications and methods for the first operative management of tension pneumomediastinum with concomitant SARS‐CoV‐2 infection.
Background Computerized clinical decision support systems (CDSS) have shown promising effectiveness in improving outpatient antibiotic prescribing. Methods We developed an intervention in the form of EPIC (Verona, WI, USA) order sets comprised of outpatient treatment pathways for 3 pediatric bacterial acute respiratory infections (ARIs) coupled with educational sessions. Four pediatric clinics were randomized into intervention and control arms over pre- and postimplementation study periods. In the intervention clinics, education was provided in between the 2 study periods and EPIC order sets became available at the beginning of the postimplementation period. The primary end point was the percentage of first-line antibiotic prescribing, and the secondary end points included antibiotic duration and antibiotic prescription modification within 14 days. Results A total of 2690 antibiotic prescriptions were included. During the pre-implementation phase, there was no difference in first-line antibiotic prescribing (74.9% vs 77.7%; P = .211) or antibiotic duration (9.69 ± 0.96 days vs 9.63 ± 1.07 days; P > .999) between the study arms. Following implementation, the intervention clinics had a higher percentage of first-line antibiotic prescribing (83.1% vs 77.7%; P = .024) and shorter antibiotic duration (9.28 ± 1.56 days vs 9.79 ± 0.75 days; P < .001) compared with the control clinics. The percentage of modified antibiotics was small in all clinics (1.1%–1.6%) and did not differ before and after the intervention (for all statistical comparisons, P ≤ .354). Conclusions A computerized CDSS involving treatment pathways in the form of order sets coupled with educational sessions was associated with a higher percentage of first-line antibiotic prescribing and shorter antibiotic duration for the outpatient treatment of pediatric bacterial ARIs.
Background Fluoroquinolones are antibiotics prescribed in the outpatient setting, though they have serious side effects. This study evaluates the impact of stewardship interventions on total and inappropriate prescribing of fluoroquinolones in outpatient settings in a large county hospital and health system. Methods In an effort to decrease inappropriate outpatient fluoroquinolone usage, a multimodal antimicrobial stewardship initiative was implemented in November 2016. Education regarding the risks, benefits, and appropriate uses of fluoroquinolones was provided to providers in different outpatient settings, Food and Drug Administration warnings were added to all oral fluoroquinolone orders, an outpatient order set for cystitis treatment was created, and fluoroquinolone susceptibilities were suppressed when appropriate. Charts from October 2016, 2017, and 2018 were retrospectively reviewed if the patient encounter occurred in primary care clinics, emergency departments, or urgent care centers within Parkland Health & Hospital System and a fluoroquinolone was prescribed. Inappropriate use was defined as a fluoroquinolone prescription for cystitis, bronchitis, or sinusitis in a patient without a history of Pseudomonas aeruginosa or multidrug-resistant organisms and without drug allergies that precluded use of other oral antibiotics. Results Total fluoroquinolone prescriptions per 1000 patient visits decreased significantly by 39% (P < .01), and inappropriate fluoroquinolone use decreased from 53% to 34% (P < .01). More than 90% of inappropriate fluoroquinolone prescriptions were given for cystitis, while bronchitis and sinusitis accounted for only 4.4% and 1.6% of inappropriate indications, respectively. Conclusion A multimodal stewardship initiative appears to effectively reduce both total and inappropriate outpatient fluoroquinolone prescriptions.
Case series Patients: Female, 72-year-old • Female, 55-year-old • Female, 43-year-old Final Diagnosis: COVID provoked thromboembolism • COVID-19 • pulmonary embolism • rectus sheath hematoma Symptoms: Cough • fever • shortness of breath Medication: — Clinical Procedure: — Specialty: Critical Care Medicine • Diagnostics, Laboratory • Hematology • Infectious Diseases Objective: Unusual clinical course Background: The novel coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), often manifests a coagulopathy in severely ill patients, which may cause hemorrhage and/or thrombosis of varying severity. This report comprises the cases of 3 patients with COVID-19-associated coagulopathy who were evaluated with thromboelastography (TEG) and activated partial thromboplastin time (aPTT) to enable personalized anticoagulant therapy. Case Reports: Three patients presented with COVID-19 pneumonia, confirmed by reverse transcription-polymerase chain reaction, who developed thrombohemorrhagic coagulopathy. Case 1 : A 72-year-old woman on long-term warfarin therapy for a history of venous thromboembolism developed a right upper lobe pulmonary embolus, despite an international normalized ratio of 6.4 and aPTT of 120.7 s. TEG enabled successful anticoagulation with heparin, and her pulmonary infarct was no longer present 2 weeks later. Case 2 : A 55-year-old woman developed a rectus sheath hematoma while on heparin, and TEG demonstrated increased fibrinolysis despite COVID-19 patients more commonly undergoing fibrinolytic shutdown. Case 3 : A 43-year-old woman had significant thrombus burden while severely hypocoagulable according to laboratory testing. As the venous thrombi enlarged in a disseminated intravascular coagulopathic-like state, the heparin dose was escalated to achieve a target aPTT of 70 to 80 s, resulting in a flat line TEG tracing. Conclusions: These 3 cases of COVID-19 pneumonia with complex and varied clinical histories demonstrated the clinical value of TEG combined with the measurement of aPTT to facilitate personalized anticoagulation, resulting in good clinical outcomes.
Purpose of Review Rapidly evolving treatment paradigms of coronavirus disease 2019 (COVID-19) introduce challenges for clinicians to keep up with the pace of published literature and to critically appraise the voluminous data produced. This review summarizes the clinical evidence from key studies examining the place of therapy of recommended drugs and management strategies for COVID-19. Recent Findings The global magnitude and duration of the pandemic have resulted in a flurry of interventional treatment trials evaluating both novel and repurposed drugs targeting various aspects of the viral life cycle. Additionally, clinical observations have documented various stages or phases of COVID-19 and underscored the importance of timing for the efficacy of studied therapies. Since the start of the COVID-19 pandemic, many observational, retrospective, and randomized controlled studies have been conducted to guide management of COVID-19 using drug therapies and other management strategies. Large, randomized, or adaptive platform trials have proven the most informative to guide recommended treatments to-date. Antimicrobial stewardship programs can play a pivotal role in ensuring appropriate use of COVID-19 therapies based on evolving clinical data and limiting unnecessary antibiotics given low rates of co-infection. Summary Given the rapidly evolving medical literature and treatment paradigms, it is recommended to reference continuously updated, curated guidelines from national and international sources. While the drugs and management strategies mentioned in this review represent the current state of recommendations, many therapies are still under investigation to further define optimal COVID-19 treatment. Supplementary Information The online version contains supplementary material available at 10.1007/s11908-021-00769-8.
One of the complications of the novel coronavirus disease 2019 (COVID-19) is hypercoagulability. For this reason, patients presenting with COVID-19 are often put on therapeutic or intermediate anticoagulation upon hospitalization. A common issue of this anticoagulation is the progression to hypocoagulability resulting in hemorrhage. Therefore, monitoring the hemostatic integrity of critically ill COVID-19 patients is of utmost importance. In this case series, we present the cases of three coagulopathic COVID-19 patients whose anticoagulation was guided by thromboelastography (TEG). In each case, TEG permitted the clinical team to simultaneously prevent thrombotic and hemorrhagic events, a difficult task for COVID-19 patients admitted to the intensive care unit. The first two cases illustrate the utility of TEG to guide anticoagulant dosing for COVID-19 patients when the activated partial thromboplastin time (aPTT) is inaccurate. The first case was a severely ill COVID-19 patient with end-stage renal disease and a falsely elevated aPTT secondary to hypertriglyceridemia. The second case was a severely ill COVID-19 patient with chronic pulmonary disease who demonstrated a falsely elevated aPTT due to polycythemia and hemoconcentration. In both cases, TEG was sensitive to the hypercoagulability caused by the metabolic derangements which enabled the goal-directed titration of anticoagulants. The last case depicts a severely ill COVID-19 patient with an inherited factor V Leiden mutation who required abnormally high dosing to achieve therapeutic anticoagulation, guided by TEG. Hypercoagulopathic COVID-19 patients are difficult to anticoagulate without development of hypocoagulopathy. Treatment of these patients demands goal-directed therapy by diligent laboratory monitoring. This can be accomplished by the use of TEG coupled with aPTT to guide anticoagulation. This case series illustrates the necessity for active hemostatic monitoring of critically ill COVID-19 patients.
<b><i>Introduction:</i></b> Cardiovascular comorbidities may predispose to adverse outcomes in hospitalized patients with coronavirus disease 2019 (COVID-19). However, across the USA, the burden of cardiovascular comorbidities varies significantly. Whether clinical outcomes of hospitalized patients with COVID-19 differ between regions has not yet been studied systematically. Here, we report differences in underlying cardiovascular comorbidities and clinical outcomes of patients hospitalized with COVID-19 in Texas and in New York state. <b><i>Methods:</i></b> We established a multicenter retrospective registry including patients hospitalized with COVID-19 between March 15 and July 12, 2020. Demographic and clinical data were manually retrieved from electronic medical records. We focused on the following outcomes: mortality, need for pharmacologic circulatory support, need for mechanical ventilation, and need for hemodialysis. Univariate and multivariate logistic regression analyses were performed. <b><i>Results:</i></b> Patients in the Texas cohort (<i>n</i> = 296) were younger (57 vs. 63 years, <i>p</i> value <0.001), they had a higher BMI (30.3 kg/m<sup>2</sup> vs. 28.5 kg/m<sup>2</sup>, <i>p</i> = 0.015), and they had higher rates of diabetes mellitus (41 vs. 30%; <i>p</i> = 0.014). In contrast, patients in the New York state cohort (<i>n</i> = 218) had higher rates of coronary artery disease (19 vs. 10%, <i>p</i> = 0.005) and atrial fibrillation (11 vs. 5%, <i>p</i> = 0.012). Pharmacologic circulatory support, mechanical ventilation, and hemodialysis were more frequent in the Texas cohort (21 vs. 13%, <i>p</i> = 0.020; 30 vs. 12%, <i>p</i> < 0.001; and 11 vs. 5%, <i>p</i> = 0.009, respectively). In-hospital mortality was similar between the 2 cohorts (16 vs. 18%, <i>p</i> = 0.469). After adjusting for differences in underlying comorbidities, only the use of mechanical ventilation remained significantly higher in the participating Texas hospitals (odds ratios [95% CI]: 3.88 [1.23, 12.24]). Median time to pharmacologic circulatory support was 8 days (interquartile range: 2, 13.8) in the Texas cohort compared to 1 day (0, 3) in the New York state cohort, while median time to in-hospital mortality was 16 days (10, 25.5) and 7 days (4, 14), respectively (both <i>p</i> < 0.001). In-hospital mortality was higher in the late versus the early study phase in the New York state cohort (24 vs. 14%, <i>p</i> = 0.050), while it was similar between the 2 phases in the Texas cohort (16 vs. 15%, <i>p</i> = 0.741). <b><i>Conclusions:</i></b> Geographical differences, including practice pattern variations and the impact of disease burden on provision of health care, are important for the evaluation of COVID-19 outcomes. Unadjusted data may cause bias affecting future regulatory policies and proper allocation of resources.
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