SESSION TITLE: Critical Care Case Report Posters 59 SESSION TYPE: Case Report Posters PRESENTED ON: 10/11/2023 12:00 pm - 12:45 pm INTRODUCTION: Enfortumab vedotin, an antibody-drug conjugate, is a newer treatment modality for patients with locally advanced or metastatic urothelial cancer who fail first-line treatment. However, despite targeting tumor cells better than systemic chemotherapy, it caused grade 3 or higher treatment-related adverse effects in >50% of patients in both phase 2 and 3 trials [1]. We present a fatal case of diabetic ketoacidosis (DKA) in a patient treated with this drug. CASE PRESENTATION: A 57-year-old male with metastatic urothelial carcinoma of the bladder was treated with enfortumab vedotin after failing treatment with intravesical Bacillus-Calmette Guérin, gemcitabine/carboplatin, and avelumab. Six days after the second dose, he presented to our hospital with a chief complaint of abdominal pain and rash for 3 days. Labs on arrival showed serum glucose >500mg/mL, elevated anion gap (18), and positive ketones consistent with DKA. Other significant labs were low white blood cells (0.6k/mm3), elevated creatinine (1.5mg/dL), elevated serum C-peptide (5ng/mL; normal <3.5ng/mL), and normal lactate. He underwent fluid resuscitation and was started on empiric broad-spectrum antibiotics. He remained persistently hyperglycemic requiring extremely high insulin infusion rates (<300u/24hrs). After 24 hours, the patient's DKA temporarily resolved, however, he rapidly decompensated and developed multiorgan failure. He was intubated for respiratory failure, started on continuous dialysis for renal failure, and needed multiple vasopressors for refractory shock. Despite aggressive supportive measures, his condition declined and he passed within 48 hours of admission to our hospital. Sepsis workup, including cultures and imaging, remained negative. DISCUSSION: While the incidence of DKA hospitalizations has been rising between 2000 to 2014, the in-hospital mortality rate over the same study period has been declining (1.1% to 0.4%) [2]. In our case, high insulin requirements in the setting of elevated C-peptide levels suggest insulin resistance as the likely pathophysiologic mechanism for DKA. Serum glucose of 510 mg/dL and HbA1c of 7.7% on presentation hints that insulin resistance developed rapidly. Despite aggressive treatment for DKA and empiric broad-spectrum antibiotics, he rapidly deteriorated and developed multiorgan failure. Point-of-care ultrasound ruled out a primary cardiogenic or obstructive shock. Hence, we hypothesize this adverse event was directly related to enfortumab vedotin. A similar clinical course was described in another patient who received enfortumab vedotin [3]. The exact mechanisms involved in the development of refractory shock and multiorgan failure and the connection to insulin resistance remain unclear. CONCLUSIONS: Enfortumab vedotin, a second-line chemotherapy option for urothelial cancer, has been reported to cause adverse events such as hyperglycemia, DKA, and metabolic acidosis. Our case highlights one such catastrophic adverse event. Therefore, clinicians treating patients at higher risk for these serious adverse events should obtain a baseline HbA1c and practice vigilance by closely monitoring blood sugars spanning weeks before and after the last dose of this drug. REFERENCE #1: Yu EY, Petrylak DP, et al. Enfortumab vedotin after PD-1 or PD-L1 inhibitors in cisplatin-ineligible patients with advanced urothelial carcinoma (EV‑201): a multicentre, single-arm, phase 2 trial. Lancet Oncol. 2021 Jun;22(6):872-882. REFERENCE #2: Benoit SR, Zhang Y, et al. Trends in Diabetic Ketoacidosis Hospitalizations and In-Hospital Mortality - United States, 2000-2014. MMWR Morb Mort Wkly Rep 2018;67:362-365. REFERENCE #3: B. Kwok 1, A. Bhatt et al. Refractory Diabetic Ketoacidosis Related to Enfortumab Vedotin Monotherapy for Metastatic Urothelial Carcinoma. Ajrccm conference.2020.201.1_MeetingAbstracts.A1736 DISCLOSURES: No relevant relationships by Dipak Chandy No relevant relationships by Anant Jain No relevant relationships by Juliet Meir No relevant relationships by Vihanga Perera No relevant relationships by Pritika Sharma

PURPOSE:Respiratory failure following mechanical thrombectomy (MT) for acute ischemic stroke (AIS) is a known complication, and requirement of tracheostomy is associated with worse outcomes. Our objective is to evaluate characteristics associated with tracheostomy timing in AIS patients treated with MT. METHODS:The National Inpatient Sample was queried for adult patients treated with MT for AIS from 2016 to 2019. Baseline demographic characteristics, comorbidities, and inpatient outcomes were analyzed for associations in patients who received tracheostomy. Timing of early tracheostomy (ETR) was defined as placement before day 8 of hospital stay. RESULTS:Of 3505 AIS-MT patients who received tracheostomy, 915 (26.1%) underwent ETR. Patients who underwent ETR had shorter length of stay (LOS) (25.39 days vs 32.43 days, p < 0.001) and lower total hospital charges ($483,472.07 vs $612,362.86, p < 0.001). ETR did not confer a mortality benefit but was associated with less acute kidney injury (OR, 0.697; p = 0.013), pneumonia (OR, 0.449; p < 0.001), and sepsis (OR, 0.536; p = 0.002). CONCLUSION:An expected increase in complications and healthcare resource utilization is seen in AIS-MT patients receiving tracheostomy, likely reflecting the severity of patients' post-stroke neurologic injury. Among these high-risk patients, ETR was predictive of shorter LOS and fewer complications.

Abstract Aim Deep vein thrombosis (DVT) is considered a possible source of non‐infectious, non‐central fever in the intensive care unit (ICU). In the neurocritically ill, it is unknown whether lower extremity venous Doppler ultrasonography (LEVDUS) for DVT in the setting of fever leads to a higher detection rate than the baseline detection rate of DVT in this population. The aim of this study was to compare the DVT detection rate of LEVDUS performed for the indication of fever to LEVDUS performed for other indications in a neurosciences ICU. Methods Requisition forms for all LEVDUS performed in a referral neurosciences ICU were reviewed and separated into those with “fever” as the stated reason for request and those with other stated reasons. The DVT detection rate was compared between these two categories of indications. Results Five hundred eleven LEVDUS were analyzed, of which 422 had been ordered for indications other than fever. Sixteen of these tests were positive, a detection rate of 3.8%. The remaining 89 LEVDUS had “fever” as the ordering indication. Six of these tests were positive for DVT, a detection rate of 6.7%. The likelihood of positivity of a test obtained as part of fever evaluation relative to one obtained for non‐fever indications was not significantly different (OR, 1.83; 95% CI, 0.570–5.11; P = 0.246). Conclusion LEVDUS triggered by fever detected DVT at a numerically, but not statistically significantly higher rate than did LEVDUS performed for other indications in a neurocritically ill population. More rigorous investigation of this question is needed.

Background: The COVID-19 pandemic has led to a boom in the use of V-V ECMO for ARDS secondary to COVID. Comparisons of outcomes of ECMO for COVID to ECMO for influenza have emerged. Very few comparisons of ECMO for COVID to ECMO for ARDS of all etiologies are available. Objectives: To compare clinically important outcome measures in recipients of ECMO for COVID to those observed in recipients of ECMO for ARDS of other etiologies. Methods: V-V ECMO recipients between March 2020 and March 2022 consisted exclusively of COVID patients and formed the COVID ECMO group. All patients who underwent V-V ECMO for ARDS between January 2014 and March 2020 were eligible for analysis as the non-COVID ECMO comparator group. The primary outcome was survival to hospital discharge. Secondary outcomes included ECMO decannulation, ECMO duration >30 days, and serious complications. Results: Thirty-six patients comprised the COVID ECMO group and were compared to 18 non-COVID ECMO patients. Survival to hospital discharge was not significantly different between the two groups (33% in COVID vs. 50% in non-COVID; p = 0.255) nor was there a significant difference in the rate of non-palliative ECMO decannulation. The proportion of patients connected to ECMO for >30 days was significantly higher in the COVID ECMO group: 69% vs. 17%; p = 0.001. There was no significant difference in serious complications. Conclusion: This study could not identify a statistically significant difference in hospital survival and rate of successful ECMO decannulation between COVID ECMO and non-COVID ECMO patients. Prolonged ECMO may be more common in COVID. Complications were not significantly different. (C) 2022 Published by Elsevier Inc.

PURPOSE:Early extubation in patients on mechanical ventilation (MV) is associated with a shorter length of ICU stay and decreased morbidity.Traditionally, extubations have taken place during the daytime when staffing is optimal.In the current era of telemedicine and increased physician staffing in the ICU throughout the day, there remains limited data regarding the distribution of extubations during the daytime and nighttime hours METHODS: We performed a retrospective analysis of all patients> 18 years of age who were liberated from MV over a period of almost 4 years (1/2016-10/2019) in eight ICUs at a tertiary care hospital.The Medical ICUs included Medical ICU (MICU), Coronary care Unit (CCU), Neuroscience ICU, Burn ICU and MidHudson ICU.The surgical ICUs included Surgical ICU (SICU), Trauma ICU (TICU) and Cardiothoracic ICU (CTICU).RESULTS: A total of 9355 extubations were performed during the study period out of which 4486 were done in Medical ICUs and 4869 in Surgical ICUs.3589 extubations (80%) in medical ICUs were executed during daytime hours (7am -7pm) with a peak time around noon and 897 extubations (20%) during the nighttime hours (7pm-7am).In contrast, extubations in surgical ICUs had a bimodal distribution.3331 extubations (68%) were executed in the surgical ICUs during the daytime (7am-7pm) with a peak around noon and 1538 extubations (32%) during nightime (7pm -7am) with a peak around late evening. CONCLUSIONS:The optimal timing for extubation, (daytime versus nighttime hours) remains unknown.Previous studies have yielded mixed results about safety of nighttime extubations.In our study, we found that most extubations occurred during the day, which is similar to other studies.The most common time for daytime extubations was around noon, likely after the ICU teams finished their morning rounds.Beyond this peak time, the medical ICUs had very few extubations throughout the day which could mean patients who could have weaned off mechanical ventilation overnight perhaps had to wait till the next morning.In comparison, surgical ICUs had substantially more extubations in the evening, probably because they had more patients who came from the operating room in the evening and were likely intubated only for the procedure.These patients may have a low reintubation risk and the physicians may be more comfortable extubating them at night.A future study demonstrating a lack of difference in reintubation rate in the medical vs surgical ICUs may be helpful to suggest that it is safe to extubate patients throughout the day with a more even temporal distribution.CLINICAL IMPLICATIONS: Personally, we recommend extubating patient once the extubating parameters have been met and appropriate personnel are available regardless of the time of the day.

We report the first quantitative systematic review of cerebrovascular disease in coronavirus disease 2019 (COVID-19) to provide occurrence rates and associated mortality. Through a comprehensive search of PubMed we identified 8 cohort studies, 5 case series, and 2 case reports of acute cerebrovascular disease in patients with confirmed COVID-19 diagnosis. Our first meta-analysis utilizing the identified publications focused on comorbid cerebrovascular disease in recovered and deceased patients with COVID-19. We performed 3 additional meta-analyses of proportions to produce point estimates of the mortality and incidence of acute cerebrovascular disease in COVID-19 patients. Patient’s with COVID-19 who died were 12.6 times more likely to have a history of cerebrovascular disease. We estimated an occurrence rate of 2.6% (95% confidence interval, 1.2–5.4%) for acute cerebrovascular disease among consecutively admitted patients with COVID-19. While for those with severe COVID-19‚ we estimated an occurrence rate of 6.5% (95% confidence interval, 4.4–9.6%). Our analysis estimated a rate of 35.5% for in-hospital mortality among COVID-19 patients with concomitant acute cerebrovascular disease. This was consistent with a mortality rate of 34.0% which we obtained through an individual patient analysis of 47 patients derived from all available case reports and case series. COVID-19 patients with either acute or chronic cerebrovascular disease have a high mortality rate with higher occurrence of cerebrovascular disease in patients with severe COVID-19.

PURPOSE: Obstructive sleep apnea (OSA) is a prevalent disorder characterized by recurrent episodes of upper airway obstruction during sleep, resulting in sleep fragmentation and intermittent hypoxemia.The gold standard for diagnosing OSA is nocturnal polysomnography (NPSG), which quantifies the frequency and severity of respiratory events using the apnea-hypopnea index (AHI) and the respiratory disturbance index (RDI).The Epworth sleepiness scale (ESS) is a validated questionnaire that assesses subjective daytime sleepiness by asking the patient to rate their likelihood of dozing off in eight different situations.However, the relationship between OSA severity and ESS score remains unclear, as previous studies have shown inconsistent results.Therefore, we conducted a large-scale study to examine the correlation between OSA severity and ESS score. METHODS:We performed a retrospective analysis of nocturnal polysomnography (NPSG) data from patients aged 18 years or older who completed both a diagnostic sleep study and a continuous positive airway pressure (CPAP) titration study between January 2013 and March 2019.We extracted data on the apnea-hypopnea index (AHI) and the Epworth sleepiness scale (ESS) from the selected patients.We applied a linear regression model to assess the correlation between AHI and ESS.We conducted simple linear regression using Stata software, version 17. RESULTS:We analyzed data from 782 patients with AHI and ESS measurements.We found a statistically significant positive correlation between AHI and ESS.For every 1 unit increase in ESS, there was a 1.9 unit increase in AHI (p¼0.021). CONCLUSIONS:We retrospectively analyzed the correlation between Epworth Sleepiness Scale (ESS) and Apnea-Hypopnea Index (AHI) in patients with suspected obstructive sleep apnea (OSA) who underwent NPSG and CPAP.We found a strong positive correlation between ESS and AHI, suggesting that more daytime sleepiness was associated with more respiratory events during sleep.The current screening tool for OSA, the STOP-BANG questionnaire, has high sensitivity but low specificity, resulting in many false positives.ESS has higher specificity than STOP-BANG for moderate-to-severe OSA, meaning that it can rule out most false positives.Our data indicate that ESS can be used as an add-on tool for screening moderate-to-severe OSA in patients with high pretest probability (>5 points on STOP-BANG).ESS also reflects the impact of OSA on patients' quality of life.CLINICAL IMPLICATIONS: Our study suggests that ESS can serve as an add-on tool for screening moderate-to-severe OSA in patients with high pretest likelihood of OSA.

PURPOSE: OSA is a common condition characterized by recurrent episodes of upper airway collapse during sleep.Body mass index (BMI) is a major risk factor for OSA, as excess weight can cause or worsen upper airway obstruction.Obesity also increases the cardiometabolic risk associated with OSA by impairing adipose tissue function and metabolism.The standard treatment for OSA is CPAP, which delivers pressurized air through a mask to prevent upper airway collapse.Previous studies have suggested a positive correlation between BMI and OSA severity, as measured by the apnea-hypopnea index (AHI).However, the relationship between BMI and CPAP levels, which reflect the degree of upper airway obstruction, has not been well established in large populations. METHODS:We conducted a retrospective analysis of nocturnal polysomnography (NPSG) data from January 2013 to March 2019.We included only adult patients ($18 years) who had both a diagnostic sleep study and a CPAP titration study available.We used a linear regression model to examine the correlation between BMI and CPAP pressures.We performed simple linear regression using Stata software, version 17. RESULTS:Our study examined the association between body mass index (BMI) and continuous positive airway pressure (CPAP) levels in 782 patients with obstructive sleep apnea (OSA).We found a strong positive correlation between BMI and CPAP levels.For every one unit increase in BMI, there was a 0.160 increase in CPAP pressure (p<0.001;95% confidence interval [CI] 0.130-0.190). CONCLUSIONS:This retrospective analysis of BMI in relation to CPAP showed a strong positive correlation between BMI and CPAP, indicating that higher BMI was associated with higher CPAP requirements.We propose that patients with higher BMI may benefit from starting at higher CPAP pressures or increasing the pressure more quickly during titration studies to avoid nondiagnostic results.We also suggest that patients with higher BMI be informed of their likely need for higher CPAP pressures which may improve their adherence to treatment.Furthermore, we advise that inpatients with obesity and unknown CPAP pressure who need empiric CPAP therapy should be given a higher pressure than non-obese patients.CLINICAL IMPLICATIONS: We found a strong positive correlation between BMI and CPAP levels, indicating that higher BMI was associated with higher CPAP requirements.This finding has implications for CPAP titration protocols, patient education, and empiric CPAP use.

SESSION TITLE: Impact of Health Disparities and DifferencesSESSION TYPE: Rapid Fire Original InvPRESENTED ON: 10/19/2022 11:15 am - 12:15 pmPURPOSE: As of March 25, 2022, age-standardized data reported by the Centers for Disease Control and Prevention showed that Hispanic, Black and American Indian or Alaska Native are about twice as likely to die from coronavirus disease 2019 (COVID-19) as their White and Asian counterparts. However, there is paucity of data regarding the effect of race on outcomes in COVID-19 related acute respiratory distress syndrome (ARDS) patients managed with extracorporeal membrane oxygenation (ECMO). Our study aims to understand the differences in the outcome between White/Asian and other ethnically minority COVID-19 patients treated with ECMO in our intensive care unit (ICU).METHODS: Retrospective analysis of adult patients with COVID-19 related ARDS treated with ECMO in the ICUs of a quaternary care hospital between 03/01/2020 and 03/31/2022. Patients were divided into two groups: White/Asian (WA) and Other Minorities (OM). Demographics, clinical characteristics, and outcomes of the two groups were compared.RESULTS: Of the 36 COVID-19 patients managed with ECMO during the study period, 18 (50%) patients belonged to the WA group while 18 (50%) patients belonged to the OM group. In the WA group, 16 (89%) were white and 2 (11%) were Asians whereas in the OM group, 16 (89%) patients were Hispanics and 2 (11%) patients were African-American. Both groups were similar in terms of age, gender, comorbidity burden (measured by Charlson Comorbidity Index), and severity of illness at the time of ICU admission (assessed by APACHE-IV score). Mean RESP score was lower in the OM group but was not statistically significant (1.3 ± 3.9 vs 2.9 ± 2.3, p= 0.157). This was reflected in the higher hospital mortality in the OM group compared to the WA group [n= 9 (50%) vs. 15 (83%), p=0.075]. There was no significant difference between the groups in the rate of ECMO-related complications, including major bleeding requiring transfusion, transaminitis (alanine transaminase greater than 5 times of upper normal limit), stroke, myocardial dysfunction (defined as an ejection fraction < 30%), acute kidney injury requiring dialysis and positive sterile fluid cultures.CONCLUSIONS: Our study showed higher mortality in ethnically minority patients compared to the white and Asian population but the difference was not statistically significant. It is possible that the relatively small number of patients in our study led to a beta error. Higher mortality rates among people of color have been attributed to low socio-economic status, structural inequities in health care and differences in vaccination rates.CLINICAL IMPLICATIONS: Larger studies are needed to further explore differences in clinical characteristics and outcomes of COVID-19 patients of different races and ethnicities treated with ECMO.DISCLOSURES: No relevant relationships by ALEENA ARSHADNo relevant relationships by Dipak ChandyNo relevant relationships by Subo DeyNo relevant relationships by Oleg EpelbaumNo relevant relationships by Daniel GreenbergNo relevant relationships by Theresa HensonNo relevant relationships by Lawrence HuangNo relevant relationships by Daniel PeneyraNo relevant relationships by Areen PitaktongNo relevant relationships by Hamid Yaqoob SESSION TITLE: Impact of Health Disparities and Differences SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: As of March 25, 2022, age-standardized data reported by the Centers for Disease Control and Prevention showed that Hispanic, Black and American Indian or Alaska Native are about twice as likely to die from coronavirus disease 2019 (COVID-19) as their White and Asian counterparts. However, there is paucity of data regarding the effect of race on outcomes in COVID-19 related acute respiratory distress syndrome (ARDS) patients managed with extracorporeal membrane oxygenation (ECMO). Our study aims to understand the differences in the outcome between White/Asian and other ethnically minority COVID-19 patients treated with ECMO in our intensive care unit (ICU). METHODS: Retrospective analysis of adult patients with COVID-19 related ARDS treated with ECMO in the ICUs of a quaternary care hospital between 03/01/2020 and 03/31/2022. Patients were divided into two groups: White/Asian (WA) and Other Minorities (OM). Demographics, clinical characteristics, and outcomes of the two groups were compared. RESULTS: Of the 36 COVID-19 patients managed with ECMO during the study period, 18 (50%) patients belonged to the WA group while 18 (50%) patients belonged to the OM group. In the WA group, 16 (89%) were white and 2 (11%) were Asians whereas in the OM group, 16 (89%) patients were Hispanics and 2 (11%) patients were African-American. Both groups were similar in terms of age, gender, comorbidity burden (measured by Charlson Comorbidity Index), and severity of illness at the time of ICU admission (assessed by APACHE-IV score). Mean RESP score was lower in the OM group but was not statistically significant (1.3 ± 3.9 vs 2.9 ± 2.3, p= 0.157). This was reflected in the higher hospital mortality in the OM group compared to the WA group [n= 9 (50%) vs. 15 (83%), p=0.075]. There was no significant difference between the groups in the rate of ECMO-related complications, including major bleeding requiring transfusion, transaminitis (alanine transaminase greater than 5 times of upper normal limit), stroke, myocardial dysfunction (defined as an ejection fraction < 30%), acute kidney injury requiring dialysis and positive sterile fluid cultures. CONCLUSIONS: Our study showed higher mortality in ethnically minority patients compared to the white and Asian population but the difference was not statistically significant. It is possible that the relatively small number of patients in our study led to a beta error. Higher mortality rates among people of color have been attributed to low socio-economic status, structural inequities in health care and differences in vaccination rates. CLINICAL IMPLICATIONS: Larger studies are needed to further explore differences in clinical characteristics and outcomes of COVID-19 patients of different races and ethnicities treated with ECMO. DISCLOSURES: No relevant relationships by ALEENA ARSHAD No relevant relationships by Dipak Chandy No relevant relationships by Subo Dey No relevant relationships by Oleg Epelbaum No relevant relationships by Daniel Greenberg No relevant relationships by Theresa Henson No relevant relationships by Lawrence Huang No relevant relationships by Daniel Peneyra No relevant relationships by Areen Pitaktong No relevant relationships by Hamid Yaqoob

A 26-year-old woman from Pakistan presented to our institution in New York with episodic right-sided weakness and expressive aphasia. She was at 36 weeks’ gestation of an uncomplicated third pregnancy. On presentation, the patient appeared well, had normal vital signs and was afebrile. Her neurological examination was normal between recurrences. The patient reported usual fetal movement, and fetal monitoring displayed a reassuring tracing. MRI of the brain without gadolinium revealed numerous ring-like hyperintense lesions most consistent with an inflammatory or infectious aetiology (figure 1A). CT of the chest demonstrated multiple bilateral lung nodules with areas of coalescence (figure 1B). The patient denied respiratory symptoms. HIV and vasculitis testing was negative. Interferon gamma release assay had been positive earlier in the pregnancy. Lumbar puncture was performed: there was an elevated opening pressure, lymphocytic pleocytosis, low glucose and high protein. Cerebrospinal fluid smear for acid-fast bacilli (AFB) was …

SESSION TITLE: ECMO and ARDS in COVID-19 Infections SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/17/2022 12:15 pm - 1:15 pm PURPOSE: Before the Coronavirus disease 2019 (COVID-19) pandemic, the use of extracorporeal membrane oxygenation (ECMO) specific scoring systems have been shown to predict survival better compared to general risk scores used in the intensive care unit (ICU). However, data is lacking on the utility of these scores in predicting mortality in COVID-19 patients managed with ECMO. Also, inflammatory markers have been reported to be predictors of mortality in patients with COVID-19 but have not been studied well in ECMO patients. Our study aims to assess the utility of standard ICU [Acute Physiology And Chronic Health Evaluation (APACHE-IV)] and ECMO specific [Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP)] risk calculators along with inflammatory markers in COVID-19 patients treated with ECMO. METHODS: This study is a retrospective analysis of all adult patients with COVID-related acute respiratory distress syndrome (ARDS) admitted to the ICUs of a quaternary care hospital between 03/01/2020 and 03/31/2022 who were managed with ECMO. Demographic and clinical characteristics, inflammatory markers at the time of hospital admission, and respiratory parameters at the time of ECMO cannulation of the patients who survived were compared and analyzed with patients who did not survive. RESULTS: Of the 36 COVID-19 patients managed with ECMO during the study period, 12 (33%) patients survived. Both groups were similar in terms of age, gender, and comorbidity burden (measured by Charlson Comorbidity Index). The severity of illness at the time of ICU admission (assessed by APACHE IV score) was not significantly different between two groups [Median (IQR) = 58 (50-67) vs. 60 (52-71), p= 0.627]. D-dimers at the time of ICU admission were significantly lower in the survivor group as compared to their counterpart [Median (IQR) ng/ml = 1238 (1021-1830) vs. 2990 (1298-16583), p= 0.031]. RESP score at the time of ECMO cannulation was significantly higher among the survivors as compared to non-survivors (Mean ± SD = 3.7 ± 2.2 vs. 1.3 ± 3.5, p= 0.042). CONCLUSIONS: Our study showed that higher D-dimers at the time of hospital admission and lower RESP score at the time of ECMO cannulation are associated with increased morality in patients with COVID-19 related ARDS placed on ECMO. Knowledge of these factors may assist with determining appropriate candidates for this limited resource as well as may enhance outcome predictions. Our study is limited by a relatively small sample size and therefore larger studies will be needed to validate our findings. CLINICAL IMPLICATIONS: This study shows that similar to pre-COVID studies, RESP score be useful in risk stratification of COVID-19 patients treated with ECMO. DISCLOSURES: No relevant relationships by ALEENA ARSHAD No relevant relationships by Dipak Chandy No relevant relationships by Oleg Epelbaum No relevant relationships by Daniel Greenberg No relevant relationships by Theresa Henson No relevant relationships by Areen Pitaktong No relevant relationships by Hamid Yaqoob

SESSION TITLE: ECMO and ARDS in COVID-19 InfectionsSESSION TYPE: Rapid Fire Original InvPRESENTED ON: 10/17/2022 12:15 pm - 1:15 pmPURPOSE: The role of extracorporeal membrane oxygenation (ECMO) for patients with coronavirus disease 2019 (COVID-19) related acute respiratory distress syndrome (ARDS) is evolving. Data from different waves of the pandemic has shown that mortality of COVID-19 patients treated with ECMO ranges from 40-94%. Pre-COVID studies have shown that ECMO is associated with bleeding in 30-50% of patients, thrombotic complications in about 10% and secondary infections in 40% of patients. However, there is a paucity of data regarding complications with the use of ECMO in COVID-19 patients. In this study, we describe the hospital course and complications seen in the COVID-19 patients admitted to our Intensive Care Unit (ICU) treated with ECMO.METHODS: Retrospective cohort analysis of adult patients with COVID-19 related ARDS admitted to the ICUs of a quaternary care hospital between 03/01/2020 and 03/31/2022 who were managed with ECMO.RESULTS: Of the 36 COVID-19 patients treated with ECMO, 23 (64%) patients were male. Median age was 48 years (IQR 36-59). Patients had a mean BMI of 36 ± 12. Median Charlson Comorbidity Index (assesses comorbidities) was 1 (0-2) and median APACHE-IV score (assesses severity of illness at the time of ICU admission) was 60 (51-72). Prior to initiation of ECMO, 14 (39%) patients were proned and 29 (81%) patients received a trial of neuromuscular blockade. Patients had high plateau pressures (mean 31 ± 8 cm H20) with pO2/FiO2 ratios consistent with severe ARDS (mean 63 ± 17) at the time of ECMO cannulation. Mean Respiratory ECMO Survival Prediction (RESP) score was 2.1 ± 3.3. The most common complications were bleeding requiring transfusion seen in 94% of patients and positive sterile fluid cultures (53% patients). Hemorrhagic stroke was seen in 3 patients (8%). None of the patients had limb ischemia or clotting of the cannula requiring catheter exchange. Withdrawal of care occurred in 3 patients (8%). 13 (35%) patients were successfully decannulated from ECMO; however only 12 (33%) patients were discharged alive.CONCLUSIONS: Our study shows a survival rate in COVID-19 patients treated with ECMO that is comparable to previously reported studies. High bleeding and infection rates can possibly be explained by steroid use and COVID-19 disease specific characteristics.CLINICAL IMPLICATIONS: Our study describes the hospital course of the COVID-19 patients treated with ECMO and can be used to evaluate it's role in the management of severe COVID-19 patients refractory to conventional ventilatory management.DISCLOSURES: No relevant relationships by ALEENA ARSHADNo relevant relationships by Dipak ChandyNo relevant relationships by Oleg EpelbaumNo relevant relationships by Daniel GreenbergNo relevant relationships by Theresa HensonNo relevant relationships by Lawrence HuangNo relevant relationships by Daniel PeneyraNo relevant relationships by Areen PitaktongNo relevant relationships by Hamid Yaqoob SESSION TITLE: ECMO and ARDS in COVID-19 Infections SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/17/2022 12:15 pm - 1:15 pm PURPOSE: The role of extracorporeal membrane oxygenation (ECMO) for patients with coronavirus disease 2019 (COVID-19) related acute respiratory distress syndrome (ARDS) is evolving. Data from different waves of the pandemic has shown that mortality of COVID-19 patients treated with ECMO ranges from 40-94%. Pre-COVID studies have shown that ECMO is associated with bleeding in 30-50% of patients, thrombotic complications in about 10% and secondary infections in 40% of patients. However, there is a paucity of data regarding complications with the use of ECMO in COVID-19 patients. In this study, we describe the hospital course and complications seen in the COVID-19 patients admitted to our Intensive Care Unit (ICU) treated with ECMO. METHODS: Retrospective cohort analysis of adult patients with COVID-19 related ARDS admitted to the ICUs of a quaternary care hospital between 03/01/2020 and 03/31/2022 who were managed with ECMO. RESULTS: Of the 36 COVID-19 patients treated with ECMO, 23 (64%) patients were male. Median age was 48 years (IQR 36-59). Patients had a mean BMI of 36 ± 12. Median Charlson Comorbidity Index (assesses comorbidities) was 1 (0-2) and median APACHE-IV score (assesses severity of illness at the time of ICU admission) was 60 (51-72). Prior to initiation of ECMO, 14 (39%) patients were proned and 29 (81%) patients received a trial of neuromuscular blockade. Patients had high plateau pressures (mean 31 ± 8 cm H20) with pO2/FiO2 ratios consistent with severe ARDS (mean 63 ± 17) at the time of ECMO cannulation. Mean Respiratory ECMO Survival Prediction (RESP) score was 2.1 ± 3.3. The most common complications were bleeding requiring transfusion seen in 94% of patients and positive sterile fluid cultures (53% patients). Hemorrhagic stroke was seen in 3 patients (8%). None of the patients had limb ischemia or clotting of the cannula requiring catheter exchange. Withdrawal of care occurred in 3 patients (8%). 13 (35%) patients were successfully decannulated from ECMO; however only 12 (33%) patients were discharged alive. CONCLUSIONS: Our study shows a survival rate in COVID-19 patients treated with ECMO that is comparable to previously reported studies. High bleeding and infection rates can possibly be explained by steroid use and COVID-19 disease specific characteristics. CLINICAL IMPLICATIONS: Our study describes the hospital course of the COVID-19 patients treated with ECMO and can be used to evaluate it's role in the management of severe COVID-19 patients refractory to conventional ventilatory management. DISCLOSURES: No relevant relationships by ALEENA ARSHAD No relevant relationships by Dipak Chandy No relevant relationships by Oleg Epelbaum No relevant relationships by Daniel Greenberg No relevant relationships by Theresa Henson No relevant relationships by Lawrence Huang No relevant relationships by Daniel Peneyra No relevant relationships by Areen Pitaktong No relevant relationships by Hamid Yaqoob

Spontaneous Pneumothorax (PTX) has received increasing attention as a complication of Coronavirus disease 2019 (COVID-19).1.Martinelli A.W. Ingle T. Newman J. et al.COVID-19 and pneumothorax: a multicentre retrospective case series.Eur Respir J. 2020; 56 (Print 2020 Nov. doi: 2002697 [pii])https://doi.org/10.1183/13993003.02697-2020Crossref PubMed Scopus (200) Google Scholar,2.Wang D. Hu B. Hu C. et al.Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china.JAMA. 2020; https://doi.org/10.1001/jama.2020.1585Crossref Scopus (16310) Google Scholar In the January article, Ekanem et al. identified PTX in 1.4% of 1619 COVID-19 who had no evidence of trauma during hospitalization.3.Ekanem E. Podder S. Donthi N. Khandhar S. Mahajan A. Desai M. Spontaneous pneumothorax: an emerging complication of COVID-19 pneumonia.Heart Lung: J Acute Crit Care. January 29, 2021; https://doi.org/10.1016/j.hrtlng.2021.01.020Abstract Full Text Full Text PDF Scopus (19) Google Scholar Here, we describe our tertiary care center's experience with spontaneous PTX and pneumomediastinum (PTM) among patients hospitalized from March to October 2020 with laboratory confirmed COVID-19 in suburban New York. PTX and/or PTM cases were categorized as either spontaneous (primary or secondary) or as other events (present in close temporal association with trauma or a medical procedure) using prior definitions.4.Zarogoulidis P. Kioumis I. Pitsiou G. et al.Pneumothorax: from definition to diagnosis and treatment.J Thorac Dis. 2014; 6: S372-S376https://doi.org/10.3978/j.issn.2072-1439.2014.09.24Crossref PubMed Google Scholar Outcomes were PTX/PTM events, radiological resolution, recurrence, and overall mortality. During the study period, PTX and/or PTM was documented in 25/1260 (2%) of all hospitalized adult patients with COVID-19. Ten of twenty-five patients had spontaneous PTX, 1/25 had spontaneous PTM and 7/25 had spontaneous PTX and PTM. In the remaining 7/25 patients, PTX/PTM occurred in close temporal relation to: a medical procedure (3/7), blunt trauma (2/7), a stab wound to the chest (1/7) and intubation (1/7). The mean duration from COVID-19 symptoms to PTX/PTM was 16 (0–46) days. Mechanical ventilation preceded PTX/PTM in 18/25 (72%) of patients by a mean of 9 (0–33) days. A low tidal volume ventilation strategy (4–8 mL/kg) was utilized for all except one study patient. Of the study patients, 52% died (13/25) at a mean of 17 (0–61) days after PTX/PTM. Two patients died shortly after development of tension PTX. The mean duration of hospital stay was 31 (2–104) days. Further details are available in the Table 1.Table 1Clinical Course and Charactersitics of Patients Hospitalized with COVID-19 and Pneumothorax and/or PneumomediastinumCharacteristics of PatientsNumber, PercentPatients Hospitalized with COVID-19 (March 2020 – October 2020)Total n = 1260Pneumothorax / PneumomediastinumTotal events25/1260 (1.98%)Spontaneous events18/1260 = (1.4%)Hospital CourseAll-Cause Mortality13/25 (52%)Length of Stay; (mean/days, range)31 (2–104)DemographicsAge (mean/years)55 (23–83)Sex (Male)19/25 (76%)Body Mass Index (Mean, range)30 (20–48)Chronic Medical ConditionsNone8/25 (32%)Cardiovascular Disease7/25 (28%)Chronic Lung Disease1/25 (4%)Imaging Findings at PresentationClear Chest X-ray or Computed Tomography2/25 (8%)Bilateral Airspace Opacities17/25 (68%)Chronic lung disease1/25 (4%)Events and TypeType of EventSpontaneous PTX10/25 (40%)Spontaneous PTM1/25 (4%)Spontaneous PTX and PTM7/25 (28%)Other (Events with Preceding Factors)7/25 (28%)Medical procedure(s)3/7 (43%)Intubation1/7 (14%)Blunt Trauma2/7 (29%)Sharp Trauma1/7 (14%)ManagementChest Tube15/25 (60%)Resolution21/25 (84%)Recurrence7/23 (30%) Open table in a new tab This study adds importantly to the growing literature describing pulmonary complications of COVID-19. In our cohort, the overall rate of spontaneous PTX and/or PTM was 1.4% with the majority of patients being male (76%) and having no prior history of lung disease. These findings are remarkably consistent with those of Ekanum et al., who documented a spontaneous PTX rate of 1.4% with a strong male predominance.3.Ekanem E. Podder S. Donthi N. Khandhar S. Mahajan A. Desai M. Spontaneous pneumothorax: an emerging complication of COVID-19 pneumonia.Heart Lung: J Acute Crit Care. January 29, 2021; https://doi.org/10.1016/j.hrtlng.2021.01.020Abstract Full Text Full Text PDF Scopus (19) Google Scholar In addition, we found that PTX/PTM reoccurred in around one-third of patients. The overall mortality in this cohort was 52%, while mortality was 36% in Ekanum. However, their study concluded with 4 patients remaining on mechanical ventilation or extracorporeal membrane oxygenation. The work of Ekanum et al. and our findings indicate that COVID-19 patients are at potential risk for the development of PTX/PTM through a variety of mechanisms. Histological findings from lung tissue in patients with COVID-19 include alveolar damage with septa disruption, desquamation, edema, and exudates with fibrotic/thickened interstitial tissue.5.Aiolfi A. Bruni B. Biraghi T. et al.Late histological findings in symptomatic COVID-19 patients: a case report.Medicine (Baltimore). 2020; 99: e21046https://doi.org/10.1097/MD.0000000000021046Crossref PubMed Scopus (13) Google Scholar This tissue damage along with other inflammatory sequelae of COVID-19 likely permits air entry into the pleural and/or mediastinal spaces causing PTX/PTM and also sets the stage for potential recurrence. In addition, COVID-19 patients frequently require mechanical ventilation and/or invasive procedures/interventions under challenging circumstances. In Ekanum, 41% of patients were on mechanical ventilation when PTX developed and in our cohort mechanical ventilation preceded PTX/PTM in nearly three-fourths of patients. Care of critically patients with COVID-19 is uniquely challenging due to reduced direct patient/provider contact and difficulties in transporting patients for procedures/tests. These factors may contribute to higher than usual risks of procedural complications or delays in diagnosis. Furthermore, a sudden deterioration in respiratory status of the mechanically ventilated COVID-19 patient could be attributed to progression of viral disease, pulmonary embolism, aspiration event, new or worsening ARDS or secondary bacterial infection in addition to PTX/PTM. As such, diagnosis of PTX and PTM in these patients requires a high index of clinical suspicion. Future studies designed to identify more effective ways to prevent PTX and PTM in hospitalized patients with COVID-19 are warranted.

As obesity becomes more common worldwide, the prevalence of obstructive sleep apnoea (OSA) continues to rise. Obstructive sleep apnoea is a wellknown disorder that causes chronic intermittent hypoxia (CIH), which is considered a risk factor for atherosclerosis directly and indirectly. Ischaemic heart disease remains the leading cause of death. Most risk factors for atherosclerosis are well understood. However, other factors such as CIH are less well understood. Several studies have investigated the pathophysiology of CIH, attempting to uncover its link to atherosclerosis and to determine whether OSA treatment can be a therapeutic modality to modify the risk for atherosclerosis. In this article, we will review the pathophysiology of OSA as an independent risk factor for cardiovascular disease and discuss the most common markers that have been studied. We will also examine the potential impact of OSA management as a risk factor modifier on the reversibility of atherosclerosis.

BACKGROUND:Characteristics of intensive care unit (ICU) downgrades who experience a complicated post-ICU ward course (ICU return or floor death) and the incidence of this phenomenon have not been examined in ICU survivors of coronavirus disease 2019 (COVID-19) pneumonia. The aim of the present study was to establish the rate of a complicated post-ICU ward course among survivors of COVID-19 pneumonia and describe the associated patient, ICU management, and serum biomarker characteristics. An additional aim was to compare these parameters between those who experienced a complicated post-ICU course and those who did not.METHODS:This was a retrospective study of patients who were admitted to the ICU with COVID-19 pneumonia and were downgraded to a hospital floor at the end of their initial ICU stay. Patients were divided based on a complicated or uncomplicated post-ICU course. Groups were compared with respect to relevant clinical variables. Serum biomarker levels were compared on day of ICU exit and were trended in the days preceding the downgrade. Ward stay of patients who had a complicated course was examined for notable floor events surrounding their decompensation.RESULTS:Eighteen out of 99 downgraded patients (18%) experienced a complicated post-ICU course, among them there were 14 returns (14%) and four deaths (4%). They had higher Charlson Comorbidity Index, higher Acute Physiology and Chronic Health Evaluation (APACHE) IV score, as well as higher D-dimer and C-reactive protein (CRP) at ICU departure. They were less likely to have received therapeutic anticoagulation and convalescent plasma during their ICU stay. On multivariable analysis, these parameters except D-dimer remained independently associated with a complicated course. Review of biomarker trends preceding ICU exit demonstrated an upward trajectory of D-dimer, CRP, and lactate dehydrogenase (LDH) in the complicated course group not mirrored by the uncomplicated course group. Examination of notable floor events leading up to decompensation revealed that in 50% the ward course was characterized by new cardiac disturbances.CONCLUSIONS:Our rate of ward death among ICU downgrades was similar to pre-COVID data, but the rate of ICU return was higher. Complicated post-ICU course patients were exhibiting upward biomarker trends at ICU exit, and their ward stay was punctuated by acute cardiac abnormalities.

PURPOSE: Secondary infections are well-described complications in patients with viral pneumonia and are associated with increased mortality and morbidity (1).A recent meta-analysis reported that secondary infections in critically ill Coronavirus Disease 19 (COVID-19) patients in intensive care unit (ICU) are around 14% (2).Most of the studies are limited by false-positive cultures in non-sterile body fluids (2).Our study aims to assess the burden of secondary infections by focusing on the positive rate of sterile body fluid cultures in ICU patients, to examine associated risk factors and to assess their impact on outcome. METHODS:Retrospective analysis of all adult patients with COVID-related acute respiratory distress syndrome (ARDS) admitted to the ICUs of a quaternary care hospital between 03/01/2020 and 05/31/2020.Patients who had positive sterile body fluid (blood, peritoneal, pleural or cerebrospinal fluid) cultures for bacteria or fungi, were compared with those without positive cultures. RESULTS:Of the 210 patients admitted to our ICU with COVID-19 related ARDS, 55 patients (26%) had positive sterile body fluid cultures, of which 37 grew bacteria, 7 fungi and 11 both.Patients with positive cultures were similar in terms of baseline demographics, comorbidities and severity of illness at ICU admission to those patients without positive cultures.Peak inflammatory markers were significantly higher in the positive culture group.In the positive culture group, the rates of receipt of steroids (78% vs. 61%, p¼0.02) and convalescent plasma (64% vs. 45%, p¼0.03) were significantly higher.The prevalence of acute kidney injury (AKI) requiring dialysis was significantly greater in the positive culture group (55% vs. 28%, p<0.001).There was no difference in terms of mortality between the two groups.However, mechanical ventilation (MV) free days at day 28 were significantly lower in the positive culture group (Mean AE S.D: 2.7 AE 5.7 vs. 6 AE 9.9, p¼0.004). CONCLUSIONS:Our study shows that the incidence of superinfections in COVID-19 patients admitted to ICUs is higher than previously reported.The higher incidence is comparable to the rate of superinfections in the H1N1 influenza pandemic of 2009 (2).However, the high rates of steroid and plasma administration in our positive culture group may also have contributed to the high incidence of secondary infections.Our results have also shown that these infections may prolong ventilatory support as well as increase the likelihood of developing AKI requiring dialysis.Therefore, intensivists need to be vigilant about not missing superinfections in patients with COVID-19 which can negatively impact patient outcomes.CLINICAL IMPLICATIONS: This study will help to identify the risk factors associated with higher incidence of secondary infections in patients with COVID-19, and will assist physicians to identify and treat them early in the course of disease.1. I.

Corticosteroid dosing in the range of 0.5-2 mg/kg/day of methylprednisolone equivalents has become a standard part of the management of intensive care unit (ICU) patients with COVID-19 pneumonia based on positive results of randomized trials and a meta-analysis. Alongside such conventional dosing, administration of 1 gm of methylprednisolone daily (pulse dosing) has also been reported in the literature with claims of favorable outcomes. Comparisons between such disparate approaches to corticosteroids for Coronavirus disease 2019 (COVID-19) pneumonia are lacking. In this retrospective study of patients admitted to the ICU with COVID-19 pneumonia, we compared patients treated with 0.5-2 mg/kg/day in methylprednisolone equivalents (high-dose corticosteroids) and patients treated with 1 gm of methylprednisolone (pulse-dose corticosteroids) to those who did not receive any corticosteroids. The endpoints of interest were hospital mortality, ICU-free days at Day 28, and complications potentially attributable to corticosteroids. Pulse-dose corticosteroid therapy was associated with a significant increase in ICU-free days at Day 28 compared to no receipt: adjusted relative risk (aRR): 1.45 (95% confidence interval [CI]: 1.05-2.02; p = 0.03) and compared with high-dose corticosteroid administration (p = 0.003). Nonetheless, receipt of high-dose corticosteroids-but not of pulse-dose corticosteroids-significantly reduced the odds of hospital mortality compared to no receipt: adjusted Odds ratio (aOR) 0.31 (95% CI: 0.12-0.77; p = 0.01). High-dose corticosteroids reduced mortality compared to pulse-dose corticosteroids (p = 0.04). Pulse-dose corticosteroids-but not high-dose corticosteroids-significantly increased the odds of acute kidney injury requiring renal replacement therapy compared to no receipt: aOR 3.53 (95% CI: 1.27-9.82; p = 0.02). The odds of this complication were also significantly higher in the pulse-dose group when compared to the high-dose group (p = 0.05 for the comparison). In this single-center study, pulse-dose corticosteroid therapy for COVID-19 pneumonia in the ICU was associated with an increase in ICU-free days but failed to impact hospital mortality, perhaps because of its association with development of severe renal failure. In line with existing trial data, the effect of high-dose corticosteroids on mortality was favorable.

PURPOSE:Based on survival benefit with the use of extracorporeal membrane oxygenation (ECMO) in the management of severe acute respiratory distress syndrome (ARDS) in patients with viral pneumonia, international organizations including the World Health Organization and Extracorporeal Life Support Organization have suggested a role for ECMO during the current pandemic (1).Mortality rates of Coronavirus Disease-19 (COVID-19) patients with the use of ECMO has ranged between 40-94% (2).Some reports suggest early initiation of ECMO leads to better outcomes before refractory hypoxemia leads to multi-organ failure (1).However, ECMO has been associated with potentially life-threatening bleeding and thromboembolic complications (3).This study details our experience with the use of ECMO in COVID-19 patients admitted to our Intensive Care Unit (ICU).METHODS: Retrospective analysis of adult patients with COVID-related ARDS admitted to the ICUs of a quaternary care hospital between 03/01/2020 and 05/31/2020.Patients who received ECMO within 10 days of ICU admission were compared and analyzed with those patients who were managed with conventional ventilatory support. RESULTS:Of the 210 patients admitted to our ICU with COVID-19, 179 patients were mechanically ventilated.Ten patients received ECMO, all within 10 days of ICU admission.Patients in the ECMO group were significantly younger (Mean age AE SD: 50 AE 4.5 vs. 64 AE 15 years, p¼0.002) and had a lower Charlson Comorbidity Index compared to the conventional ventilation group (1.2 AE 0.8 vs. 3.6 AE 2.6, p¼0.002).Severity of illness at ICU admission, measured by the APACHE-IV score, was similar in both groups.There was no statistical difference in bleeding (based on hemoglobin < 7 mg/dl) and thromboembolic (stroke) complications between the two groups.None of the patients on ECMO developed limb ischemia.There was no significant difference in mortality between the two groups.However, the patients in the ECMO group had significantly higher ICU (Mean days AE SD: 43.3 AE 22.5 vs. 27.7 AE 22, p¼0.03) and hospital (42.8 AE 24.9 vs. 21 AE 18.6, p <0.001) length of stay.CONCLUSIONS: Our study did not show increased incidence of bleeding or thromboembolic complications in COVID-19 patients on ECMO compared to patients managed with conventional ventilatory support.Our study also seems to imply that there is no major survival benefit in patients with COVID-19-related ARDS with the use of ECMO despite early initiation.This may be explained by sicker patients in the ECMO group, although this was not statistically significant.Our study is also limited by small sample size and therefore larger studies are needed to confirm our findings.CLINICAL IMPLICATIONS: This study provides a generalisable estimate of bleeding and thromboembolic complications of ECMO in patients with COVID-19 and can be used to evaluate the role of ECMO in the current pandemic.

PURPOSE:The electronic intensive care unit (eICU) is a form of telemedicine that allows remotely located intensivists and critical care nurses to partner with bedside teams to manage patients in an intensive care unit (ICU).Its goal is to improve the quality and safety of patient through an additional layer of monitoring and support.Timely liberation from mechanical ventilation (MV) is one of the main goals of any medical ICU (MICU).One of the tasks of an eICU can be to facilitate and support timely extubations.Whether the bedside intensivist has taken care of the ICU during the preceding workweek (continuous coverage) or is picking up the service that weekend (discontinuous coverage) may influence the weekend extubation rates.METHODS: eICU support was implemented in January 2016.We performed a retrospective observational analysis of all WE extubations between March 2016 and December 2019 in our quaternary care hospital MICU.Each WE during this period was defined as bedside intensivist "continuity" or "non-continuity".RESULTS: 190 weekends were analyzed of which 53 (28%) were continuity WEs while 137 (72%) were non-continuity WEs.Over the course of the 4 years, there was no significant impact on the overall number of extubations per WE in our MICU with averages of 1.7 in 2016, 1.7 in 2017, 1.5 in 2018 and 1.9 in 2019.However, there was a noticeable impact of eICU implementation on the non-continuity WEs with the number of extubations increasing from averages of 1.5 in 2016 to 1.7 in 2017 to 1.7 in 2018 to 2.3 in 2019. CONCLUSIONS:As the consequences of prolonged MV include delirium, pneumonia and myopathy among others, efforts are being made to install protocols for more efficient liberation.This can translate into lower length of stay and possibly mortality and morbidity.One such intervention has been the involvement of the eICU in tracking ventilator days, helping in the assessment of readiness for weaning and ultimately facilitating and supporting extubations.This task may become particularly useful during weekends when other factors may be at play such as changes in coverage.CLINICAL IMPLICATIONS: Our study demonstrated a greater impact of the eICU on weekends where the bedside attending was less familiar with the patients in the ICU.