566. Tocilizumab: A Friend or a Foe in COVID-19 Management?

Abstract Background The emergence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has led to many proposed treatments for COVID-19 induced cytokine release syndrome (CRS). We aimed to investigate the treatment response of Tocilizumab (TZB), an Interleukin-6 (IL-6) inhibitor in this single center study. Methods A retrospective chart review in COVID-19 patients was conducted from 03/18/20 - 05/20/20. Patients with PCR confirmed COVID-19 who received TZB were included. Variables included dose and timing of TZB, trend of acute phase reactants, time to improved oxygenation and defervescence, 30-day mortality, and hospital/intensive care unit (ICU) length of stay (LOS). Descriptive statistics were used. Results Twelve patients received TZB at least once during the study period. Median patient age was 51.5 years (interquartile range (IQR), 34–87), and mean body weight of 109 kg (SD = 33.8). At time of admission, mean day of illness was 6.6 days (SD = 3.3) into their illness. All patients received a standardized TZB dose of 400 mg, and 2 patients received a second dose. Nine out of 11 patients (75%) had elevated median IL-6 baseline levels of 38.3 (IQR < 5- 96.22). The average CRS score was elevated at 3.3 at the time of TZB administration. All patients who received TZB were on supplemental oxygen, and 58% were mechanically ventilated. A decrease in oxygen requirement in 24 hours was seen in mechanically ventilated patients (71%) compared to those not on mechanical ventilation (20%). Median ICU days were 17.5 (IQR, 3–39), and median LOS days were 21.5 (IQR 8–46). All patients had sustained decreases in CRP post-TZB administration. Almost half of patients (42%) were treated for bacterial pneumonia post TZB and 3 (25%) patients were treated for herpes simplex virus (HSV) reactivation. Majority (92%) of patients received additional COVID-19 therapies such as hydroxychloroquine, convalescent plasma, or remdesivir. During the study period only one patient expired. Conclusion Our findings suggest that TZB may have a role in mechanically ventilated patients in decreasing oxygen requirement. However larger randomized studies are needed to understand which patients would benefit the most. Our study also highlights secondary infections and HSV reactivation in TZB patients. Disclosures All Authors: No reported disclosures

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Effect of gastric residual volume monitoring on incidence of ventilator-associated pneumonia in mechanically ventilated patients admitted to intensive care unit

Pakistan Journal of Medical Sciences ◽

10.12669/pjms.36.1.1321 ◽

2019 ◽

Vol 36 (1) ◽

Author(s):

Elnaz Faramarzi ◽

Ata Mahmoodpoor ◽

Hadi Hamishehkar ◽

Kamran Shadvar ◽

Afshin Iranpour ◽

...

Keyword(s):

Intensive Care Unit ◽

Mechanical Ventilation ◽

Intensive Care ◽

Ventilator Associated Pneumonia ◽

Residual Volume ◽

Gastric Residual Volume ◽

Mechanically Ventilated ◽

Mechanically Ventilated Patients ◽

Icu Length Of Stay ◽

Ventilated Patients

Objectives: The value of gastric residual volume (GRV) monitoring in ventilator-associated pneumonia (VAP) has frequently been questioned in the past years. In this trial, the effect of GRV on the frequency of VAP was evaluated in critically ill patients under mechanical ventilation. Methods: This descriptive study was carried out on 150 adult patients admitted to the intensive care unit over a 14-month period, from October 2015 to January 2017. GRV was measured every three hours, and gastric intolerance was defined as GRV>250 cc. The incidence of vomiting and VAP, GRV, length of mechanical ventilation and ICU stay, APACHE II and SOFA scores, and mortality rate were noted. Results: The mean APACHEII and SOFA scores, ICU length of stay, and duration of mechanical ventilation in the GRV>250ml group were significantly higher than in the GRV≤250 ml group (P<0.05). Also, a significantly higher number of patients in the GRV>250ml group experienced infection (62.3%) and vomiting (71.7%) compared with the GRV≤250 group (P<0.01). The highest OR was observed for SOFA score >15 and APACHE II >30, which increased the risk of GVR>250 ml by 10.09 (1.01-99.97) and 8.78 (1.49-51.58), respectively. Moreover, the increase in GVR was found to be higher in the non-survivor than in the survivor group. Conclusion: Increased GRV did not result in increased rates of VAP, ICU length of stay, and mortality. Therefore, the routine measurement of GRV as an important element of the VAP prevention bundle is not recommended in critically ill patients. How to cite this: Faramarzi E, Mahmoodpoor A, Hamishehkar H, Shadvar K, Iranpour A, Sabzevari T, et al. Effect of gastric residual volume monitoring on incidence of ventilator-associated pneumonia in mechanically ventilated patients admitted to intensive care unit. Pak J Med Sci. 2020;36(1):---------. doi: https://doi.org/10.12669/pjms.36.1.1321 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Effect of gastric residual volume monitoring on incidence of ventilator-associated pneumonia in mechanically ventilated patients admitted to intensive care unit

Pakistan Journal of Medical Sciences ◽

10.12669/pjms.36.2.1321 ◽

2019 ◽

Vol 36 (2) ◽

Author(s):

Elnaz Faramarzi ◽

Ata Mahmoodpoor ◽

Hadi Hamishehkar ◽

Kamran Shadvar ◽

Afshin Iranpour ◽

...

Keyword(s):

Intensive Care Unit ◽

Mechanical Ventilation ◽

Intensive Care ◽

Ventilator Associated Pneumonia ◽

Residual Volume ◽

Gastric Residual Volume ◽

Mechanically Ventilated ◽

Mechanically Ventilated Patients ◽

Icu Length Of Stay ◽

Ventilated Patients

Objectives: The value of gastric residual volume (GRV) monitoring in ventilator-associated pneumonia (VAP) has frequently been questioned in the past years. In this trial, the effect of GRV on the frequency of VAP was evaluated in critically ill patients under mechanical ventilation. Methods: This descriptive study was carried out on 150 adult patients admitted to the intensive care unit over a 14-month period, from October 2015 to January 2017. GRV was measured every three hours, and gastric intolerance was defined as GRV>250 cc. The incidence of vomiting and VAP, GRV, length of mechanical ventilation and ICU stay, APACHE II and SOFA scores, and mortality rate were noted. Results: The mean APACHEII and SOFA scores, ICU length of stay, and duration of mechanical ventilation in the GRV>250ml group were significantly higher than in the GRV≤250 ml group (P<0.05). Also, a significantly higher number of patients in the GRV>250ml group experienced infection (62.3%) and vomiting (71.7%) compared with the GRV≤250 group (P<0.01). The highest OR was observed for SOFA score >15 and APACHE II >30, which increased the risk of GVR>250 ml by 10.09 (1.01-99.97) and 8.78 (1.49-51.58), respectively. Moreover, the increase in GVR was found to be higher in the non-survivor than in the survivor group. Conclusion: Increased GRV did not result in increased rates of VAP, ICU length of stay, and mortality. Therefore, the routine measurement of GRV as an important element of the VAP prevention bundle is not recommended in critically ill patients. doi: https://doi.org/10.12669/pjms.36.2.1321 How to cite this: Faramarzi E, Mahmoodpoor A, Hamishehkar H, Shadvar K, Iranpour A, Sabzevari T, et al. Effect of gastric residual volume monitoring on incidence of ventilator-associated pneumonia in mechanically ventilated patients admitted to intensive care unit. Pak J Med Sci. 2020;36(2):48-53. doi: https://doi.org/10.12669/pjms.36.2.1321 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Management of sedation in the critically ill

10.1093/med/9780199600830.003.0359 ◽

2016 ◽

Author(s):

Bhakti K. Patel ◽

John P. Kress

Keyword(s):

Intensive Care Unit ◽

Patient Comfort ◽

Moving Target ◽

Ventilator Associated Pneumonia ◽

Mechanically Ventilated ◽

Mechanically Ventilated Patients ◽

Icu Length Of Stay ◽

Prolonged Sedation ◽

Frequent Assessment ◽

Ventilated Patients

Once adequate analgesia is confirmed, the need for sedation should be considered. Sedation of mechanically-ventilated patients is a common challenge in the intensive care unit (ICU). Metabolism of sedatives in critical illness can be unpredictable and achieving optimal sedation without coma is a moving target. Once adequate analgesia is achieved, the choice, depth, and duration of sedation can have major implications for the presence of delirium, the duration of mechanical ventilation, ventilator-associated pneumonia, and ICU length of stay. Therefore, goal-directed titration of sedative and frequent assessment of the depth of sedation is important to strike the delicate balance of patient comfort, while avoiding excessive prolonged sedation.

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