Virginia Research Day 2021

COVID-19 Pneumonia with ARDS Requiring Prone Therapy Shayan Anwar, DO; Kimberly Bird, MD; Ryan O’Connell, DO Sovah Health Family Medicine Residency Program, Danville, VA

Abstract # RC 7

Hospital Course: Patient was admitted for acute hypoxic respiratory failure requiring invasive mechanical ventilation secondary to COVID-19 pneumonia causing severe ARDS and sepsis related to the above, with significant improvement noted after prone therapy. Eventually was able to be extubated to nasal cannula and was discharged home with home oxygen. Patient was treated with supportive care during his hospitalization, and medications including tocilizumab, hydroxychloroquine, doxycycline, ceftriaxone, furosemide. Physical Exam: Sedated on ventilator; Temperature 101.5, HR 112, BP 148/86, 100% saturation on ventilator; RR 20-40; Coarse breath sounds throughout all lung fields; Responding to commands, able to move all 4 extremities Laboratory: Hgb 10.7, Hct 33.1, BUN 32, Cr 1.53, Blood glucose 111, Mg 2.9, AST 51, IL-6 193, CRP 12, Troponin 0.047, ABG: pH 7.49, PO2 42.4, HCO3 21.9, O2 saturation 79.9 on room air. Radiology: Chest X-ray: diffuse bilateral airspace disease

Background : SARS-COV-2 is a contagious respiratory infection currently causing a widespread pandemic throughout the world, with multiple complications including venous thromboembolism/pulmonary embolism, septic shock, and acute respiratory failure. Chief Complaint & History: A 59-year-old African American male presented to the ED with worsening chills, sweats, fever, loss of taste and loss of appetite. Of note patient presented to the ED a few days earlier and had a rapid Group A Strep that was negative. COVID-19 PCR was positive. Past Medical History: No past medical history, although reported not seeing a physician in many years; History of right knee surgery Review of Systems: Chills, fevers, sweats, loss of taste, loss of appetite, all others negative Social History : . Patient lives with wife and ambulates without assistance, no assistance with ADLs and denies tobacco, ETOH, illicit drug use. Family History: Reviewed and non- contributory

Discussion: SARS-COV-2 is a viral respiratory infection which is a strain of coronavirus causing symptoms such as cough, fever, fatigue, dyspnea, loss of taste and smell, as well as gastrointestinal symptoms like nausea and vomiting; Symptoms can range from mild to severe with complications including ARDS, acute hypoxic respiratory failure, multi-organ failure, sepsis/shock, and venous thromboembolism/pulmonary embolisms. Treatment usually is based on managing symptoms, supportive care, and all available therapies at the time. Some patients develop severe ARDS and are considered for prone therapy to improve oxygenation to their lungs. Severe ARDS is defined by the Berlin Criteria as ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (Fi02) of less than 150mm Hg, with an Fi02 of at least 0.6, a PEEP of 5 cm of H20, and a tidal-volume of approximately 6mL/kg of predicted body weight. Conclusion: The PROSEVA trial published in the NEJM showed that in patients with severe ARDS, early application of prone therapy significantly reduced mortality at 28-days and 90-days. Given this large trial the Surviving Sepsis Campaign for severe sepsis and septic shock in 2016 adopted as a strong recommendation consideration of prone therapy in adults with ARDS from sepsis with a Pa02/Fi02 ratio of less than 150.

References: 1) Guérin C, et al. "Prone positioning in severe acute respiratory distress syndrome". The New England Journal of Medicine . 2013. 368(23):2159-2168. 2) Howell MD, Davis AM. Management of Sepsis and Septic Shock. JAMA. 2017;317(8):847–848. doi:10.1001/jama.2017.0131 3) ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, Fan E, Camporota L, Slutsky AS. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012 Jun 20;307(23):2526-33. doi: 10.1001/jama.2012.5669. PMID: 22797452. 4) McIntosh, Kenneth, et al. “Coronavirus Disease 2019 (COVID - 19): Clinical Features.” UpToDate , 17 Dec. 2020, www.uptodate.com/contents/coronavirus-disease-2019-covid-19-clinical-features.

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