Introduction: Coronaviruses are a large family of viruses that have been around for many years and may cause illness in humans or animals. In early December 2019, the first pneumonia cases related to the coranoavirus were found which has since led a pandemic. Coronaviruses bind to their target cells through angiotensin-converting enzyme 2 (ACE2), which is expressed by epithelial cells of the lung, intestine, kidney, and blood vessels. Hypothesis: Hypothetically, the increased expression of ACE2 would facilitate infection with COVID-19 and treatment with ACE2-stimulating drugs may worsen the infection with COVID-19. The goal of this study was to analyze the severity of COVID-19 in patients who are on ACEi and ARB therapy. Methods: All adult patients admitted with the confirmed diagnosis of COVID 19 pneumonia between March to April 2020 in our community hospital were included in the study. Patients were then be divided into two groups, one group who received ACEi or ARBs and a second group who did not. The baseline characteristics of two groups were compared. Primary outcome was the in-hospital mortality between two groups. Secondary outcomes were severity of pneumonia including rate of intubation, requirement for ICU admission and total length of hospital stay. Results: A total of 200 patients were admitted with the time frame studied. After removing for missing data 194 patients were included in the study of which 64 patients received either ACEi or ARB during the hospital stay. There was no difference in the rate of inpatient mortality in patients who received or did not received the drug (32.3% vs 23.5% p- value 0.19). Similarly, there was no difference in the other outcomes including rate of intubation(22.6% vs 24.4% p- value 0.79), requirement for ICU admission(21% vs 33.3% p-value 0.07) and mean total length of hospital stay between the two groups (9.5 days vs 8.4 days p-value 0.34). Conclusion: There was no difference in the outcomes. Patients who received ACEi or ARBs did not have worse outcomes. Thus, if indicated for other reasons, these drugs can safely be continued in patients with COVID 19 pneumonia. Further large center studies are however, required to confirm our findings.
Malignant hyperthermia is a rare reaction of extreme fever and muscle rigidity to agents used for sedation and anesthesia. Typically, the reaction is within minutes of anesthesia administration. In this case report, we will discuss a 35year-old male who had a reaction 11 hours postoperatively. CASE PRESENTATION:A 35-year-old male with a history of HIV, anemia, and alcohol abuse came to the hospital due to right hip fracture sustained during a seizure episode at home, he was also found to be in alcohol withdrawal. On day 2 early morning, he underwent total hip replacement and was extubated post-op successfully. Sevoflurane and Rocuronium were used to achieve anesthesia. Post op, patient was hemodynamically stable with hydromorphone for pain control along with dexmedetomidine for withdrawal. In the evening at 2000h, the patient became agitated with muscular rigidity. His rectal temperature was 107 F. His labs were CK-1000, K-4.4, Mg-1.2. Peripheral smear showed no hemolysis. Rectal acetaminophen and dantrolene and cool saline were administered while blood cultures drawn and empiric antibiotics were started for suspected infection. The patient responded to therapy promptly and remained afebrile throughout the night. Due to improving symptoms, empiric antibiotics were discontinued. The patient remained afebrile after 24 hours and was transferred out of the ICU.DISCUSSION: Malignant hyperthermia is a rare but life-threatening reaction to commonly used inhaled anesthetics and depolarizing muscle relaxants. It is mediated by an autosomal dominant mutation in the gene RYR1 (ryanodine receptor), heterozygous mutation for RYR1 receptor has been associated with delayed onset of malignant hyperthermia.CONCLUSIONS: Cases of malignant hyperthermia have been reported to occur as late as four days after depolarizing muscle relaxant administration. Therefore, it is important to consider malignant hyperthermia as a cause of hyperpyrexia in patients who have undergone recent surgery.
Background: Antibiotic overuse leading to increasing antibiotic resistance has been a growing concern. Patients presenting with acute respiratory tract infections (RTI) are often started empirically on antibiotics and continued for days, unless confirmatory results are reported by microbiological testing. Procalcitonin is a serum inflammatory marker that increases in bacterial infections and is utilized as an adjunct to help differentiate viral versus bacterial pneumonia. Procalcitonin-guided management is associated with significantly lower antibiotic exposure and mortality. No studies exist in literature that assess the appropriate utilization of negative procalcitonin test for antibiotic discontinuation. This study assesses utilization of a negative PCT (<0.25 ng/ml) to guide antibiotic discontinuation in patients with pneumonia in a community hospital. Methods:Retrospective observational study including adult patients admitted to our community hospital in 1 year (July 2019-June 2020) with diagnosis of community acquired pneumonia and started on empiric antibiotic therapy and had procalcitonin levels checked. Our hypothesis was that PCT is not being appropriately used for discontinuation of antibiotics and that rate of discontinuation of antibiotics will be less despite a negative PCT. Statistical analysis was performed using XLSTAT. Categorical variables were represented by frequencies and proportions and compared using Chi-square and z test for two proportions. Results: 516 charts were reviewed. After excluding missing data, 176 patients were included. 100 patients had negative PCT. Antibiotics were discontinued in 16% of patients with negative PCT, compared to 58% (p<0.0001), in whom antibiotics were continued without any other indication (including UTI, severe COPD exacerbation, COVID pneumonia) despite a negative PCT. The difference between the percentage of antibiotic discontinuation in our PCT guided treatment sample (9%, n=16/176) was also found to be statistically significant (p< 0.001) compared to percentage of antibiotic discontinuation in population using data from a meta-analysis of 7 RCTs (42%, n=698/1658). 1 Conclusion:Previous studies have shown that procalcitonin guided treatment aids in decreasing antibiotic exposure. In lower respiratory tract infections, clinicians order PCT test to aid in differentiating viral versus bacterial etiology and ultimately help guide antibiotic therapy. Our data analysis reveals that despite negative PCT, thus indicating a likely viral etiology, clinicians are not consistently making changes to empiric antibiotic use. This study addresses need for further recommendations from antibiotic stewardship programs regarding procalcitonin-guided antibiotic use and prevent unnecessary ordering of PCT test. 1. Li H, Luo Y-F, Blackwell TS, Xie C-M. Procalcitonin-guided therapy in respiratory tract infections: a meta-analysis and systematic review. Antimicrob Agents Chemother
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