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A 19-year-old, previously healthy man presented with 3 days of cough, high-grade fevers (40 °C), and dyspnea. Apart from a resolved history of seizures not requiring medications, he had no medical or surgical history. He had no known drug allergies. He took montelukast for allergies and trimethoprim-sulfamethoxazole (TMP-SMX) for 2 weeks before admission for acne, but no other medications, including over-the-counter medications and supplements. He had animal exposures to a new puppy and a friend’s bird. He had no history of smoking, vaping, or recreational drug use. His paternal grandmother had rheumatoid arthritis.

Background While specific interventions have previously demonstrated benefit in patients with the Acute Respiratory Distress Syndrome (ARDS), use of these interventions is inconsistent, and patient mortality remains high. The impact of variability in center management practices on ARDS mortality rates remains unknown. Research Question What is the impact of treatment variability on mortality in patients with moderate-to-severe ARDS in the United States (US)? Study Design and Methods We conducted a multicenter, observational cohort study of mechanically ventilated adults with ARDS and PaO2/FiO2< 150 on positive end expiratory pressure (PEEP) > 5 cm H2O, who were admitted to 29 US centers between October 1, 2016 and April 30, 2017. The primary outcome was 28-day in-hospital mortality. Center variation in ventilator management, adjunctive therapy use, and mortality were also assessed. Results A total of 2,466 patients were enrolled. Median baseline PaO2/FiO2 was 105 (IQR 78.0, 129.0). In-hospital 28-day mortality was 40.7%. Initial adherence to lung protective ventilation (tidal volume < 6.5 ml/kg predicted body weight, plateau pressure and/or peak inspiratory pressure < 30mm H2O) was 31.4% and varied between centers (0%-65%), as did rates of adjunctive therapy use (27.1%-96.4%), types of modalities used (neuromuscular blockade, prone positioning, systemic steroids, pulmonary vasodilators, and extracorporeal support), and mortality (16.7-73.3%). Center standardized mortality ratios (SMRs), calculated using baseline patient-level characteristics to derive expected mortality rate, ranged from 0.33 to 1.98. Of the treatment-level factors explored, only center adherence to early lung protective ventilation (LPV) was correlated with SMR. Interpretation Substantial center-to-center variability exists in ARDS management, suggesting that further opportunities for improving ARDS outcomes exist. Early adherence to LPV was associated with lower center mortality and may be a surrogate for overall quality of care processes. Future collaboration is needed to identify additional treatment-level factors influencing center-level outcomes. Clinical Trial Registration ClinicalTrials.gov Identifier: NCT03021824

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Through the Joint Tele-Critical Care Network (JTCCN), the U.S. military has demonstrated that tele-critical care (TCC) services can facilitate the safe delivery of critical care beyond the consulting provider's level of training. While TCC has been described in a variety of scenarios, virtual health support of adult extracorporeal membrane oxygenation (ECMO) management has not been previously reported. We present a case of a young, active duty servicemember with COVID-19 pneumonia complicated by acute hypoxemic respiratory failure refractory to conventional therapy who was cannulated for veno-venous ECMO and successfully managed for 72 hours with TCC support. CASE PRESENTATION: A 39 year-old male Active Duty Service Member (ADSM) presented to Naval Medical Center San Diego (NMCSD) with hypoxemic respiratory failure five days after a positive SARS-CoV-2 PCR test. He was given supportive oxygen therapy, Remdesivir and dexamethasone. On hospital day nine, he was intubated for refractory hypoxemia and the ratio of arterial pO2 to fraction of inspired oxygen (P/F ratio) one hour later was 74. Neuromuscular blockade and prone positioning were initiated. Three days later, the P/F ratio remained less than 100. A request to transfer the patient to a local partner facility for ECMO was declined due to lack of bed availability.The San Antonio Military Medical Center (SAMMC) ECMO Team was consulted via TCC and the patient was placed on veno-venous ECMO, as personnel at NMCSD had previously undergone cannulation training. The NMCSD critical care team had round-the-clock secure video teleconferencing connection to the perfusionists and physician ECMO specialists at SAMMC during this time. After 72 hours of tele-ECMO management without complications, a U.S. Air Force Critical Care Air Transport Team safely transferred the patient 1,276 miles by fixed-wing aircraft to SAMMC for ongoing care. DISCUSSION: As the only certified ECMO center in the Department of Defense and one of the few centers in the world with global air transport capability, SAMMC has partnered with NMCSD to provide short-term ECMO care with TCC support. Previously, this capability had not been demonstrated over a period longer than a few hours. Because this patient's clinical decompensation occurred during the peak of the COVID-19 surge in Southern California, rapid transfer to a local ECMO center was not possible. In this case, JTCCN enabled the provision of lifesaving advanced cardiopulmonary support to an ADSM until aeromedical evacuation could be arranged. CONCLUSIONS: This case serves as proof-of-concept for a hub and spoke model of tele-ECMO support to global military medical facilities, demonstrating the potential to bring sophisticated lifesaving technology to medically-austere environments anywhere in the world. REFERENCE #1: Davis K, Perry-Moseanko A, Tadlock MD, Henry N, Pamplin J. Successful Implementation of Low-Cost Tele-Critical Care Solution by the U.S. Navy: Initial Experience and Recommendations. Mil Med. 2017 May;182(5):e1702-e1707. doi: 10.7205/MILMED-D-16-00277. PMID: 29087914. REFERENCE #2: Read MD, Nam JJ, Biscotti M, Piper LC, Thomas SB, Sams VG, Elliott BS, Negaard KA, Lantry JH, DellaVolpe JD, Batchinsky A, Cannon JW, Mason PE. Evolution of the United States Military Extracorporeal Membrane Oxygenation Transport Team. Mil Med. 2020 Dec 30;185(11-12):e2055-e2060. doi: 10.1093/milmed/usaa215. PMID: 32885813. REFERENCE #3: Badulak J, Antonini MV, Stead CM, Shekerdemian L, Raman L, Paden ML, Agerstrand C, Bartlett RH, Barrett N, Combes A, Lorusso R, Mueller T, Ogino MT, Peek G, Pellegrino V, Rabie AA, Salazar L, Schmidt M, Shekar K, MacLaren G, Brodie D. ECMO for COVID-19: Updated 2021 Guidelines from the Extracorporeal Life Support Organization (ELSO). ASAIO J. 2021 Feb 26. doi: 10.1097/MAT.0000000000001422. Epub ahead of print. PMID: 33657573. DISCLOSURES: No relevant relationships by John Hunninghake, source=Web Response No relevant relationships by Phillip Mason, source=Web Res onse No relevant relationships by Jeremy Pamplin, source=Web Response No relevant relationships by Nick Rohrhoff, source=Web Response No relevant relationships by Melissa Rosas, source=Web Response No relevant relationships by Jesse Sherratt, source=Web Response No relevant relationships by Robert Walter, source=Web Response

The prevalence of obesity is rising worldwide. Adipose tissue exerts anatomic and physiologic effects with significant implications for critical illness. Changes in respiratory mechanics cause expiratory flow limitation, atelectasis, and ventilation/perfusion mismatch with resultant hypoxemia. Altered work of breathing and obesity hypoventilation syndrome may cause hypercapnia. Challenging mask ventilation and peri-intubation hypoxemia may complicate intubation. Patients with obesity are at increased risk of acute respiratory distress syndrome and should receive lung-protective ventilation based on predicted body weight. Increased positive end expiratory pressure (PEEP), coupled with appropriate patient positioning, may overcome the alveolar decruitment and intrinsic PEEP caused by elevated baseline pleural pressure, though evidence is insufficient regarding the impact of high PEEP strategies on outcomes. Venovenous extracorporeal membrane oxygenation may be safely performed in patients with obesity. Fluid management should account for increased prevalence of chronic heart and kidney disease, expanded blood volume, and elevated acute kidney injury risk. Medication pharmacodynamics and pharmacokinetics may be altered by hydrophobic drug distribution to adipose depots and comorbid liver or kidney disease. Obesity is associated with increased risk of venous thromboembolism and infection; appropriate dosing of prophylactic anti-coagulation and early removal of indwelling catheters may decrease these risks. Obesity is associated with improved critical illness survival in some studies. It is unclear whether this reflects a protective effect or limitations inherent to observational research. Obesity is associated with increased risk of intubation and death in SARS-CoV-2 infection. Ongoing molecular studies of adipose tissue may deepen understanding of how obesity impacts critical illness pathophysiology.

Severe pulmonary edema, secondary to left ventricular afterload increment, is a common problem occurring in patients receiving venoarterial extracorporeal membrane oxygenation. No consensus is currently available for its management, but several devices/procedures have been described, including an Impella device (Abiomed), balloon atrial septostomy, intraaortic balloon counterpulsation, or an additional venous cannula, as possible adjuncts. We report the feasibility and efficacy of the atrial flow regulator device (Occlutech) for left ventricular unloading in a 58-year-old patient receiving extracorporeal membrane oxygenation. However, the benefits of this device relative to simple balloon atrial septostomy need to be further investigated.

BACKGROUND: Pulse oximeters may produce less accurate results in non-White patients. RESEARCH QUESTION: Do pulse oximeters detect arterial hypoxemia less effectively in Black, Hispanic, and/or Asian patients than in White patients in respiratory failure and about to undergo extracorporeal membrane oxygenation (ECMO)? STUDY DESIGN AND METHODS: Data on adult patients with respiratory failure readings 6 h before ECMO were provided by the Extracorporeal Life Support Organization registry. Data was collected from 324 centers between January 2019 and July 2020. Our primary analysis was of rates of occult hypoxemia—low arterial oxygen saturation (Sao(2) ≤ 88%) on arterial blood gas measurement despite a pulse oximetry reading in the range of 92% to 96%. RESULTS: The rate of pre-ECMO occult hypoxemia, that is, arterial oxygen saturation (Sao(2)) ≤ 88%, was 10.2% (95% CI, 6.2%-15.3%) for 186 White patients with peripheral oxygen saturation (Spo(2)) of 92% to 96%; 21.5% (95% CI, 11.3%-35.3%) for 51 Black patients (P = .031 vs White); 8.6% (95% CI, 3.2%-17.7%) for 70 Hispanic patients (P = .693 vs White); and 9.2% (95% CI, 3.5%-19.0%) for 65 Asian patients (P = .820 vs White). Black patients with respiratory failure had a statistically significantly higher risk of occult hypoxemia with an OR of 2.57 (95% CI, 1.12-5.92) compared with White patients (P = .026). The risk of occult hypoxemia for Hispanic and Asian patients was equivalent to that of White patients. In a secondary analysis of patients with Sao(2) ≤ 88% despite Spo(2) > 96%, Black patients had more than three times the risk compared with White patients (OR, 3.52; 95% CI, 1.12-11.10; P = .032). INTERPRETATION: Compared with White patients, the prevalence of occult hypoxemia was higher in Black patients than in White patients about to undergo ECMO for respiratory failure, but it was comparable in Hispanic and Asian patients compared with White patients.

SESSION TITLE: Fellows' COVID-19 SESSION TYPE: Fellow Case Reports PRESENTED ON: October 18-21, 2020 INTRODUCTION: Since its discovery severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has infected millions of people worldwide causing the current coronavirus disease 2019 (Covid-19) pandemic Presenting symptoms range from asymptomatic to mild disease to respiratory failure and death Some patients develop a cytokine release like syndrome which manifests with increased markers of inflammation and is associated with acute respiratory distress syndrome (ARDS), multiorgan failure, and death Treatment with immunomodulatory agents have been proposed to attenuate disease severity and mortality However, literature is conflicting whether widespread immunosuppression is beneficial or detrimental (1,2) We report a case of a patient diagnosed with Covid-19 induced ARDS requiring extracorporeal membrane oxygenation (ECMO), initially treated with the interleukin-6 (IL-6) antagonist, tocilizumab, who later developed enteroccocus faecalis empyema CASE PRESENTATION: A 34 year-old man with no prior medical history presented to our hospital with fevers and dyspnea SARS-CoV-2 was detected via polymerase chain reaction assay On hospital day two, the patient was intubated for acute hypoxemic respiratory failure He was treated with hydroxychloroquine, azithromycin, and ceftriaxone Laboratory data showed C-reactive protein 217 61 mg/L, estimated sedimentation rate 68 mm/1h, ferritin 15,424 ng/ml, IL-6 level 46 pg/ml He received tocilizumab 400 mg on hospital days two and twenty-three Despite this he continued to deteriorate (PaO2/FiO2 ratio 0 76) and veno-venous ECMO was initiated on hospital day nine Chest x-ray performed on hospital day fourteen showed a right-sided pleural effusion which was drained via chest tube Cultures grew enterococcus faecalis and his antibiotics were narrowed to intravenous vancomycin Three weeks after his admission, he underwent tracheostomy placement He continued to improve and ECMO was discontinued on hospital day thirty-four The tracheostomy tube was eventually removed and he was discharged home on hospital day forty-two DISCUSSION: CRS-like phenomena are increasingly recognized during severe disease in Covid-19 It is characterized by a proinflammatory cascade, with upregulation of interleukins, and tumor necrosis factor resulting in cytolytic cell dysfunction (3) Covid-19 associated CRS is associated with increased mortality and therefore targeting cytokines and chemokines is of particular interest as a therapeutic approach While tocilizumab has FDA approval for treatment of rheumatoid arthritis and CRS in setting of chimeric antigen receptor T-cell therapy, the safety and efficacy in Covid-19 has yet to be established Increased SARS-CoV-2 burden and superimposed bacterial infections are worrisome adverse effects(1) CONCLUSIONS: This case highlights the need to consider secondary bacterial infections in patients with clinical deterioration despite tocilizumab use Reference #1: Ritchie AI, Singanayagam A Immunosuppression for hyperinflammation in COVID-19: a double-edged sword? Lancet 2020;395(10230):1111 doi:10 1016/S0140-6736(20)30691-7 Reference #2: Radbel J, Narayanan N, Bhatt PJ Use of Tocilizumab for COVID-19-Induced Cytokine Release Syndrome: A Cautionary Case Report [published online ahead of print, 2020 Apr 25] Chest 2020;S0012-3692(20)30764-9 doi:10 1016/j chest 2020 04 024 Reference #3: Qin C, Zhou L, Hu Z, et al Dysregulation of immune response in patients with COVID-19 in Wuhan, China [published online ahead of print, 2020 Mar 12] Clin Infect Dis 2020;ciaa248 doi:10 1093/cid/ciaa248 DISCLOSURES: No relevant relationships by Michael Bender, source=Web Response No relevant relationships by Mangalore Amith Shenoy, source=Web Response No relevant relationships by Alexandra Zavin, source=Web Response

The coronavirus disease 2019 (COVID-19) pandemic has placed unprecedented burden on the delivery of intensive care services worldwide.What is the global point estimate of deaths and risk factors for patients who are admitted to ICUs with severe COVID-19?In this systematic review and meta-analysis Medline, Embase, and the Cochrane library were searched up to August 1, 2020. Pooled prevalence of participant characteristics, clinical features, and outcome data was calculated with the use of random effects models. Subgroup analyses were based on geographic distribution, study type, quality assessment, sample size, end date, and patient disposition. Studies that reported in-hospital mortality rate of adult patients (age18 years) with confirmed COVID-19 admitted to an ICU met study eligibility criteria. Critical evaluation was performed with the Newcastle Ottawa Scale for nonrandomized studies.Forty-five studies with 16,561 patients from 17 countries across four continents were included. Patients with COVID-19 who were admitted to ICUs had a mean age of 62.6 years (95% CI, 60.4-64.7). Common comorbidities included hypertension (49.5%; 95% CI, 44.9-54.0) and diabetes mellitus (26.6%; 95% CI, 22.7-30.8). More than three-quarters of cases experienced the development of ARDS (76.1%; 95% CI, 65.7-85.2). Invasive mechanical ventilation was required in 67.7% (95% CI, 59.1-75.7) of case, vasopressor support in 65.9% (95% CI, 52.4-78.4) of cases, renal replacement therapy in 16.9% (95% CI, 12.1-22.2) of cases, and extracorporeal membrane oxygenation in 6.4% (95% CI, 4.1-9.1) of cases. The duration of ICU and hospital admission was 10.8 days (95% CI, 9.3-18.4) and 19.1 days (95% CI, 16.3-21.9), respectively, with in-hospital mortality rate of 28.1% (95% CI, 23.4-33.0; ICritically ill patients with COVID-19 who are admitted to the ICU require substantial organ support and prolonged ICU and hospital level care. The pooled estimate of global death from severe COVID-19 is 1 in 3.

The coexistence of coronavirus disease 2019 (COVID-19) and pulmonary embolism (PE), two life-threatening illnesses, in the same patient presents a unique challenge. Guidelines have delineated how best to diagnose and manage patients with PE. However, the unique aspects of COVID-19 confound both the diagnosis and treatment of PE, and therefore require modification of established algorithms. Important considerations include adjustment of diagnostic modalities, incorporation of the prothrombotic contribution of COVID-19, management of two critical cardiorespiratory illnesses in the same patient, and protecting patients and health-care workers while providing optimal care. The benefits of a team-based approach for decision-making and coordination of care, such as that offered by pulmonary embolism response teams (PERTs), have become more evident in this crisis. The importance of careful follow-up care also is underscored for patients with these two diseases with long-term effects. This position paper from the PERT Consortium specifically addresses issues related to the diagnosis and management of PE in patients with COVID-19.

Adjunctive strategies are an important part of the management of ARDS. However, their application in clinical practice remains inconsistent.We wished to determine the frequency and patterns of use of adjunctive strategies in patients with moderate to severe ARDS (PaoThe LUNG SAFE study was an international, multicenter, prospective cohort study of patients with severe respiratory failure, conducted in 2014 in 459 ICUs from 50 countries. The primary objective of this substudy was to determine the frequency of use of widely available (neuromuscular blockade, prone position) adjuncts vs adjuncts requiring specialized equipment (extracorporeal membrane oxygenation, inhaled vasodilators, high-frequency ventilation) in patients in the first 48 h of moderate to severe ARDS (P/F ratio 150).Of 1,146 patients on invasive ventilation with moderate to severe ARDS, 811 patients (71%) received no adjunct within 48 h of ARDS onset. Of 335 (29%) that received adjunctive strategies, 252 (75%) received a single strategy, and 83 (25%) receiving more than one adjunct. Of ARDS nonsurvivors, 67% did not receive any adjunctive strategy in the first 48 h. Most patients (67%) receiving specialized adjuncts did not receive prone positioning or neuromuscular blockade. Patients that received adjuncts were more likely to have their ARDS recognized, be younger and sicker, have pneumonia, be more difficult to ventilate, and be in a European high-income country than those that did not receive adjuncts.Three in 10 patients with moderate to severe ARDS, and only one-third of nonsurvivors, received adjunctive strategies over the first 48 h of ARDS. A more consistent and evidence-driven approach to adjunct use may reduce costs and improve outcomes in patients with moderate to severe ARDS.ClinicalTrials.gov; No.: NCT02010073; URL: www.clinicaltrials.gov.

Since the outbreak of coronavirus disease 2019 (COVID-19) in China in December 2019, considerable attention has been focused on its elucidation. However, it is also important for clinicians and epidemiologists to differentiate COVID-19 from other respiratory infectious diseases such as influenza viruses.The aim of this study was to explore the different clinical presentations between COVID-19 and influenza A (H1N1) pneumonia in patients with ARDS.This analysis was a retrospective case-control study. Two independent cohorts of patients with ARDS infected with either COVID-19 (n = 73) or H1N1 (n = 75) were compared. Their clinical manifestations, imaging characteristics, treatments, and prognosis were analyzed and compared.The median age of patients with COVID-19 was higher than that of patients with H1N1, and there was a higher proportion of male subjects among the H1N1 cohort (P .05). Patients with COVID-19 exhibited higher proportions of nonproductive coughs, fatigue, and GI symptoms than those of patients with H1N1 (P .05). Patients with H1N1 had higher Sequential Organ Failure Assessment (SOFA) scores than patients with COVID-19 (P .05). The PaoThere were many differences in clinical presentations between patients with ARDS infected with either COVID-19 or H1N1. Compared with H1N1 patients, patients with COVID-19-induced ARDS had lower severity of illness scores at presentation and lower SOFA score-adjusted mortality.

Case Presentation A 24-year-old woman with ΔF508/Y1092X cystic fibrosis (CF) complicated by severe obstructive lung disease (FEV1 of 30% predicted) was admitted for IV antibiotics for planned sinus surgery resulting from severe chronic sinusitis causing frequent exacerbations and declining lung function. She had persistent airway infection with multidrug-resistant Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus, and growth of a fungus presumed to be an airway colonizer, identified as Stephanoascus ciferrii 1 year before presentation. Two days after surgery, she developed acute respiratory failure requiring mechanical ventilation. On day 4 of mechanical ventilation, venovenous-extracorporeal membrane oxygenation (VV-ECMO) was initiated for refractory respiratory failure. The following day, she was listed for bilateral lung transplant and was transplanted 4 days later. Following transplantation, she was decannulated from ECMO; however, over the next 12 hours, oxygenation deteriorated requiring reinstitution of VV-ECMO for presumed severe primary graft dysfunction. Despite treatment with broad spectrum antimicrobial coverage with piperacillin/tazobactam, ciprofloxacin, linezolid, micafungin, voriconazole, and ganciclovir, she failed to improve and developed complex bilateral pleural effusions.

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Multisystem Inflammatory Syndrome is a rare condition characterized by fever and multisystem organ failure that presents in those with a history of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We present a case of a 37-year-old man with multisystem inflammatory syndrome in adults (MIS-A) to portray this complication of SARS-CoV-2 infection. CASE PRESENTATION: A 37-year-old man with a prior medical history of obesity and mild COVID-19 infection one month prior to admission was evaluated for persistent headaches, fever, and myalgias. The patient presented with leukocytosis, elevated inflammatory markers, a positive COVD-19 PCR, and a chest x-ray that was negative for pulmonary disease. Once admitted, he developed hypotension due to cardiogenic shock with vasoplegia, and decompensated into multiorgan system failure requiring vasopressor and ventilatory support. Corticosteroids and antibiotics were started, and transthoracic echocardiogram (TTE) revealed an ejection fraction (EF) of 30% with global hypokinesis. The patient was transferred to a tertiary care center, where a follow up TTE revealed an EF of 20%, requiring ionotropic therapy and left ventricular mechanical support with an Impella. The patient's inflammatory markers continued to rise, with a D-Dimer greater than 20 ug/mL, lactate dehydrogenase greater than 4,000 U/L, and ferritin greater than 40,000 U/L, and progressed to acute renal failure. The patient underwent continuous veno-venous hemofiltration, plasma exchange, and tocilizumab, eventually requiring veno-arterial extracorporeal membrane oxygenation for further hemodynamic support. However, due to continued decompensation, the patient expired despite maximal mechanical and pharmacologic support. DISCUSSION: Multisystem inflammatory syndrome in adults (MIS-A) has been described as cardiogenic shock with elevated inflammatory markers in the setting of a positive SARS-CoV-2 test without severe respiratory illness(1). While SARS-CoV-2 infections have been known to cause myocarditis on initial presentation(2), such a significant cardiogenic and vasodilatory shock refractory to both mechanical and pharmacologic support 1-month post-infection is extremely rare in adults, especially in this acuity. However, this presentation has been documented in children (MIS-C) who have had prior SARS-CoV-2 infection (3) with multi-organ inflammation. Treatment is supportive, including the use of corticosteroids, tocilizumab, intravenous immunoglobulin, and circulatory support, but further research is necessary to determine the pathophysiology behind this inflammatory response. CONCLUSIONS: Multisystem inflammatory syndrome in adults is a rare and severe inflammatory complication for those post-SARS-CoV-2 infection. Further research needs to be completed to distinguish the pathophysiology behind this response to optimize treatment. REFERENCE #1: Morris SB, Schwartz NG, Patel P, et al. Case Series of Multisystem Inflammatory Syndrome in Adults Associated with SARS-CoV-2 Infection - United Kingdom and United States, March-August 2020. MMWR Morb Mortal Wkly Rep. 2020;69(40):1450-1456. Published 2020 Oct 9. doi:10.15585/mmwr.mm6940e1 REFERENCE #2: Siripanthong B, Nazarian S, Muser D, et al. Recognizing COVID-19-related myocarditis: The possible pathophysiology and proposed guideline for diagnosis and management. Heart Rhythm. 2020;17(9):1463-1471. doi:10.1016/j.hrthm.2020.05.001 REFERENCE #3: Abrams JY, Oster ME, Godfred-Cato SE, et al. Factors linked to SEVERE outcomes IN multisystem Inflammatory syndrome in children (MIS-C) in the USA: A retrospective surveillance study. The Lancet Child & Adolescent Health. 2021;5(5):323-331. doi:10.1016/s2352-4642(21)00050 DISCLOSURES: No relevant relationships by Wahaaj Khan, source=Web Response No relevant relationships by Pedro Mogrovejo, source=Web Response No relevant relationships by Christian von Gizycki, source=Web Response

TOPIC: Transplantation TYPE: Fellow Case Reports INTRODUCTION: SARS-CoV2, commonly known as COVID-19, has been noted to manifest severe illness in certain patient populations. The clinical manifestations of this coronavirus in solid organ transplant recipients is just beginning to be described, and is not well understood. SARS-CoV2 and associated illness have been described in multiple patient populations, so far limited data has been published on the course of illness in lung transplant recipients. Here we present a case series of 26 patients who were unfortunately infected with SARS-CoV2. CASE PRESENTATION: We conducted a single-center, retrospective review of 26 lung transplant recipients infected with SARS-CoV2. Data collection and patient consent were covered by OSU IRB protocol. DISCUSSION: 15 of these patients (55.5%) required admission for hypoxemia, and 4 required intubation and mechanical ventilation. 1 patient required extracorporeal membrane oxygenation (ECMO). 46% (12/26) patients received dexamethasone and remdesivir, 27% (7/26) received convalescent plasma, 1 received hydroxychloroquine, and 2 received azithromycin as part of their treatments. Prior to COVID-19 infection all patients but 1 were on a standard triple immune suppression regimen with calcineurin inhibitors, steroids, and cell cycle inhibitors. Calcineurin dosing was decreased in 2 patients with severe COVID-19 and cell cycle inhibitors were reduced by 50% or held for 2 weeks 50% patients. 1 patient succumbed to COVID-19 ARDS despite ECLS support and a second 3 months after initial diagnosis due to a massive CVA. Mortality 3 months after initial diagnosis was 7.6% which is lower than other reported series. The average change in FEV1 was a loss of 0.52 liters. An average loss of 0.69 liters of FVC was noted in survivors. CONCLUSIONS: To our knowledge this is one of the largest currently reported case series of lung transplant recipients with SARS-CoV2. Overall, mortality was higher in this group than in the general population but at 7.6% 3 months after diagnosis is lowest of the single center reports published. As expected, a decrease in lung function was noted in survivors. Three was no general difference in lung function in patients who received certain treatments over others. REFERENCE #1: Tsuang WM, Budev MM. COVID-19 and lung transplant patients. Cleve Clin J Med. 2020. REFERENCE #2: Aigner C, Dittmer U, Kamler M, Collaud S, Taube C. COVID-19 in a lung transplant recipient. J Heart Lung Transplant. 2020;39(6):610-611. REFERENCE #3: Keller BC, Le A, Sobhanie M, et al. Early COVID-19 infection after lung transplantation. Am J Transplant. 2020;20(10):2923-2927. DISCLOSURES: No relevant relationships by Mena Botros, source=Web Response No relevant relationships by Molly Howsare, source=Web Response

TOPIC: Disorders of the Mediastinum TYPE: Medical Student/Resident Case Reports INTRODUCTION: Lymphoma is the fourth most common malignancies in pregnancy, and a high portion is primary mediastinal (thymic) large B-cell lymphoma (PMBCL). It presents many challenges to diagnose lymphoma during pregnancy while avoiding fetal harm. CASE PRESENTATION: 41-year-old G2P1 female without significant past medical history experienced shortness of breath starting in her second trimester. She only had a telehealth appointment amid the COVID19 pandemic. The patient was offered a chest X-ray (CXR) but declined due to her concern of radiation. She was empirically managed as asthma triggered by acid reflux. At 39W of gestation, she presented to the hospital for labor and delivery. She was hypoxic and required three liters of oxygen. The physical exam was unremarkable. Lab were pertinent for mild leukocytosis and anemia. The patient still declined CXR. She was taken for C-section after failing trial of vacuum. The newborn was healthy. After delivering, she developed profound hypoxia in the OR requiring intubation. Tracheal compression was noted during intubation. CXR after intubation showed mediastinal widening. Following intubation, patient developed tachycardia, hypotension and ultimately cardiac arrest requiring CPR. Extracorporeal membrane oxygenation was activated. CT angiogram of the chest showed a 15 cm x 12 cm x 13 cm mass in the superior mediastinum that encases the aorta and great branches and was associated with direct extension into the sternum and invasion of the pericardium. The tumor also encased the trachea and left main bronchus. During her hospitalization, no neurological recovery was observed. The family decided to transition to comfort. The patient unfortunately passed away. The autopsy revealed neoplastic medium to large-size lymphoid cells in mediastinal mass, positive for CD45, CD20, BCL2, PAX-5, MUM-1, and MYC rearrangement negative for other markers. The final diagnosis was PMBCL. DISCUSSION: PMBCL is an aggressive B cell lymphoma arises from the thymus. Airway obstruction and superior vena cava syndrome are common due to local invasion. Dyspnea, B symptoms (fever, night sweats, weight loss) are possible symptoms. Labs may reveal elevated lactate dehydrogenase. Imaging studies typically illustrate an anterior mediastinal mass originating in the thymus. Final diagnosis can be made with biopsy and immunohistochemistry or flow cytometry analysis. Early recognition is important since these patients are at risk of cardiac and respiratory arrest during general anesthesia due to the mass location in the mediastinum. Pregnant patients should be informed that there is no evidence of fetal adverse outcome with imaging studies that expose the fetus to less than 50 mGy (CXR fetal dose: 0.0005 to 0.01 mGY). CONCLUSIONS: PMBCL should be identify early in pregnancy due to increased risk of cardiac and respiratory arrest. CXR is safe and harmless to the fetus. REFERENCE #1: Brenner B, Avivi I, Lishner M. Haematological cancers in pregnancy. Lancet. 2012;379(9815):580-587. REFERENCE #2: Dunleavy K, McLintock C. How I treat lymphoma in pregnancy. Blood. 2020 Nov 5;136(19):2118-2124. doi: 10.1182/blood.2019000961. PMID: 32797210. REFERENCE #3: Brent RL. The effect of embryonic and fetal exposure to x-ray, microwaves, and ultrasound: counseling the pregnant and nonpregnant patient about these risks. Semin Oncol. 1989 Oct;16(5):347-68. PMID: 2678486. DISCLOSURES: No relevant relationships by John Chronakas, source=Web Response No relevant relationships by Patrice Gillotti, source=Web Response No relevant relationships by Tien-Chan Hsieh, source=Web Response No relevant relationships by Oluwaseyi Olayinka, source=Web Response No relevant relationships by Nusrat Pathan, source=Web Response No relevant relationships by Akash Shah, source=Web Response No relevant relationships by Amanda Tissot, source=Web Response

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Endobronchial obstruction can be a potentially life-threatening condition leading to respiratory failure. A significant cause includes endobronchial blood clots. The presence of blood clots in a patient with SARS COV 2 pneumonia and ARDS is even more detrimental. If the clot burden is obstructing central airways, it may result in fatal respiratory failure. This report will describe a case where removing endobronchial clots was unsuccessful by suctioning during bronchoscopy;therefore, endobronchial tPA was administered to reduce the clot burden successfully. CASE PRESENTATION: Fifty-six-year-old African American male with a past medical history of multiple myeloma;on chemotherapy, was positive for SARS COV 2 by rapid PCR. He presented with severe respiratory failure. He was intubated, and due to the severity of ARDS not responding to salvage techniques, he was started on ECMO via Avalon catheter.Thirty days into ECMO treatment, patients' tidal volumes suddenly dropped to 40mL/breath. Bronchoscopy revealed extensive clot burden extending from the endotracheal tube distally. After two unsuccessful attempts at clot extraction, endobronchial tPA for thrombolysis was administered. The patient received three such treatments. There was no evidence of acute pulmonary hemorrhage or other adverse effects throughout and between each procedure due to tPA administration. The patient showed significant improvement in tidal volumes. DISCUSSION: The presence of large clots in the bronchial tree can lead to compromised oxygenation. The presence of ARDS requiring ECMO highlights the severity of illness in a patient. Conservative management is reasonable in a patient without instability. Otherwise, more aggressive management will be needed. The gold standard therapy includes bronchoscopy with suction, forceps, and basket extraction. When these strategies do not give desired results, administering tPA is another option.Other invasive methods to dissolve the bronchial blood clots have been described in literature including cryo-adhesion and topical thrombolysis with streptokinase or urokinase. CONCLUSIONS: Management of endobronchial blood clots using tPA appears to be safe and effective, clearing the blot burden from the larger airways without resulting in any acute or worsening pulmonary hemorrhage. REFERENCE #1: Anderson, D., De la Cruz, P., Dellavolpe, J., & Walter, R. (2016). Endobronchial blood Clot extraction with Tissue plasminogen activator. Chest, 150(4). doi:10.1016/j.chest.2016.08.1102 REFERENCE #2: Veress, L. A., Anderson, D. R., Hendry-Hofer, T. B., Houin, P. R., Rioux, J. S., Garlick, R. B.,… White, C. W. (2014). Airway tissue plasminogen activator prevents acute mortality due to lethal sulfur mustard inhalation. Toxicological Sciences, 143(1), 178-184. doi:10.1093/toxsci/kfu225 DISCLOSURES: No relevant relationships by Muhammad Ehtesham, source=Web Response No relevant relationships by Waseem Farra, source=Web Response No relevant relationships by Elise Landa, source=Web Response

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Amniotic fluid embolism (AFE) is a life-threatening obstetrical emergency. Despite its clinical significance there is little guidance on diagnosis and management[1, 2, 3]. In the absence of more specific diagnostic guidelines, point-of-care ultrasound (POCUS) in combination with rotational thromboelastometry (ROTEM) can aid in the diagnosis and management of AFE and have a significant impact on clinical outcomes[4]. CASE PRESENTATION: A 29-year-old, previously healthy, gravida 1 female presented at 39 weeks' gestation for induction of labor due to gestational diabetes and concerns surrounding the COVID-19 pandemic. The patient was laboring for approximately 10 hours when she suddenly started to feel nauseous, lightheaded, and subsequently suffered a syncopal episode complicated by fetal bradycardia. She was tachycardic, poorly responsive and in respiratory distress. She was transferred to the operating room (OR) for emergency Cesarean section. After the uterine incision, the intubated patient developed circulatory collapse followed by a sinus tachycardia pulseless electrical activity (PEA) arrest. Chest compressions were initiated, and the hospital code/resuscitation team was called to the OR. The patient started bleeding from her incision leading to an initial diagnosis of hemorrhagic shock. The code team, equipped with point-of-care ultrasound skill obtained an apical 4-chamber view (Figure 1) that revealed a severely dilated and hypokinetic right ventricle, and a hyperdynamic, underfilled left ventricle. The ultrasound findings in combination with significant bleeding were felt to be consistent with AFE not hemorrhagic shock and the extracorporeal membrane oxygenation (ECMO) team was activated for bedside cannulation. ROTEM (Figure 2) demonstrated markedly prolonged clotting time, prolonged clotting formation time and very low clot amplitude consistent with DIC, further supporting the diagnosis of AFE and prompted the difficult decision to withhold heparin after VA-ECMO cannulation. Following stabilization, patient was transferred to the intensive care unit with a diagnosis of AFE complicated by DIC and post-partum hemorrhage. She left the hospital with no physical or neurologic deficits 31 days later with her healthy baby boy. DISCUSSION: The description of POCUS use during cardiovascular resuscitation in the setting of AFE and other obstetric emergencies is rare. Identifying a dilated right ventricle on ultrasound can narrow the diagnosis of circulatory collapse in the peripartum patient to pulmonary embolism (PE) and AFE. ROTEM can help differentiate AFE from PE by identifying DIC with one study estimating the occurrence of DIC in PE at 1 % compared to 30-77% in AFE[5]. CONCLUSIONS: The use of POCUS and ROTEM in the diagnosis and management of AFE can guide lifesaving clinical decision making in the peripartum patient who develops circulatory collapse followed by cardiac arrest. REFERENCE #1: Sitaula S, Das D, Sitaula S, Chhetry M. Amniotic fluid embolism: A rare cause of maternal collapse-A case report. Clin Case Rep. 2020;8(12):3359-3361. Published 2020 Oct 26. doi:10.1002/ccr3.3433 REFERENCE #2: Loughran JA, Kitchen TL, Sindhakar S, Ashraf M, Awad M, Kealaher EJ. Rotational thermoelectrometry (ROTEM®)-guided diagnosis and management of amniotic fluid embolism. Int J Obstet Anesth. 2019;38:127-130. doi:10.1016/j.ijoa.2018.09.001 REFERENCE #3: Rath WH, Hoferr S, Sinicina I. Amniotic fluid embolism: an interdisciplinary challenge: epidemiology, diagnosis and treatment. Dtsch Arztebl Int. 2014;111(8):126-132. doi:10.3238/arztebl.2014.0126 DISCLOSURES: No relevant relationships by Angela Phillips, source=Web Response No relevant relationships by David Tierney, source=Web Response