IntroductionHypertonic saline (HTS) has been utilized in the treatment of several critical conditions including severe hyponatremia and elevated intracranial pressure. Current practice requires that HTS be administered through a central venous catheter (CVC). Midline catheters (MC) are a type of peripheral venous catheter (PIVC) placed in a large peripheral vein distal to the axillary vein. There are a few comprehensive studies investigating the efficacy of utilizing MCs for the administration of long-term HTS. MethodsA retrospective single center study performed at a tertiary care academic hospital, of patients admitted to the ICU for the administration of HTS through a MC. Data collected from 2019-2023 through a chart review of electronic medical records and recorded in REDCap.ResultsA total of 138 patients who received HTS via a MC were included in the analysis. Subjects were predominantly male (69.57%) and black (59.42%). The median age of the patient was 57 years ± 14.4 years old. The admission diagnoses included intracranial hemorrhage accounting for 67.39%, followed by altered mental status at 18.12%, trauma at 12.32% and sepsis at 7.25%.The concentrations of the HTS infusions were 2% NaCl in 54 patients, 3% NaCl in 82 patients, and 23% NaCl in 2 patients. The average duration of a continuous HTS infusion was 14 h and 34 min ± 15 h and 17 min. The average dosage rate was 86.03 ± 74.43 mL/h. Only one patient experienced thrombophlebitis. Thrombosis developed within the midline catheters for 5 patients. No complications related to drug extravasation or deep vein thrombosis were observed.ConclusionResults showed minor adverse events suggesting that MC may be a safe alternative for the administration of long-term HTS infusions. Midline catheters should be considered when weighing risk and benefits of HTS administration in the management of elevated intracranial pressure and severe hyponatremia.

Introduction: Endotracheal tube (ETT) malpositioning can result in a myriad of complications. Daily chest radiographs (CXR) is the gold standard in monitoring these complications. Point-of-care transtracheal ultrasound (TTUS) is an emerging imaging modality for ETT positioning. We compared ETT malpositioning related adverse events and diagnostic accuracy of ETT malpositioning of a combined TTUS and CXR surveillance protocol to CXR alone. Methods: We performed a randomized control trial of mechanically ventilated patients in an academic multidisciplinary ICU. In the intervention group, the clinical team was provided the results of the TTUS with CXR results to aid in clinical decision making. In the control group only CXR results were used. Adverse events included bronchial migration, vocal cord herniation, balloon rupture, unplanned extubation, and the development of aspiration pneumonia. Data was analyzed via Fisher's Exact Test. Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios were calculated.

Purpose: Midline catheters (ML) are long peripheral intravenous catheters placed in an upper extremity above the antecubital fossa via the basilic, cephalic, or brachial veins. These provide safe and comfortable long-term vascular access for critically ill patients. Central venous pressures (CVP) are obtained from central venous catheters (CVC) and are often used as resuscitation parameters. Given the proximity of ML to the axillary vein, we investigated if midline venous pressure (MVP) is comparable to CVP. Methods: This is an observational study conducted in adult critical care patients at a tertiary academic center. Inclusion criteria were patients with a CVC in the subclavian or internal jugular veins and a ML in place as part of standard ICU care. Pressure measurements were recorded from both catheters every 15 min over a 60-min period. Demographic, clinical, and physiological data points were collected. Continuous variables were analyzed using the t-test. Pearson correlation was used to evaluate the relationship between the paired variables. Results: We enrolled 50 patients with 5 pressure measurements taken per patient (n = 250). The mean MVP and CVP were 10.6 ± 6.4 mm Hg and 9.1 ± 6.3 mm Hg, respectively (P < .001). In Bland Altman analysis, the mean bias was -1.48 ± 3.99 mm Hg with limits of agreement of -9.3 mm Hg to 6.3 mm Hg. The Pearson correlation coefficient was 0.8 (P < .001). Conclusions: Our study investigated MVP as a correlate of CVP. Our results show a mean bias of -1.48 ± 3.99 mm Hg and a strong positive Pearson correlation coefficient of 0.8 between the MVP and the CVP. The large limits of agreement indicate MVP and CVP are not interchangeable. Despite this, clinically significant pressure values from CVCs and MLs trend similarly.

Background Central venous oxygen saturation (ScvO2) obtained from a central venous catheter (CVC) is often used to approximate oxygen delivery in critically ill patients. Despite their importance in administering medications and monitoring oxygen delivery, the use of CVCs can be associated with significant complications. Midline catheters are inserted via a peripheral vein above the antecubital fossa and provide a safe alternative to CVCs. This study aimed to determine the equivalence of ScvO2 and midline catheter oxygen saturation (SmO2) in critically ill patients. Methods This was a single-center observational study of critically ill adult patients who had concurrently placed CVCs (internal jugular and subclavian) and midline catheters as part of standard ICU care. Venous oxygen saturation and lactate levels were measured from both catheters using the Abbott point-of-care i-STAT analyzer. Demographic and ICU admission data were collected. Continuous variables were compared using the paired t-test. Pearson's correlation was used to evaluate the linear correlation between ScvO2 and SmO2. The systematic error (bias) was calculated using Bland-Altman analysis. Receiver operating characteristic curves were constructed to evaluate the sensitivities and specificities for different values of SmO2 to predict ScvO2. Results Forty-eight patients (n = 48) were enrolled in the study. The mean ScvO2 and SmO2 were 65.5% +/- 11.2% and 62.7% +/- 17.6% respectively (p = 0.1197). In the Bland-Altman analysis, the mean bias between ScvO2 and SmO2 was 2.8% +/- 12.3% with 95% limits of agreement of −21.3% to 26.9%. More than 60% of the ScvO2 and SmO2 values diverged by ≥ 5%. Conclusions The difference between the mean SmO2 and ScvO2 was not statistically significant and the mean bias between SmO2 and ScvO2 is low. Despite this, the substantially large standard deviation and limits of agreement preclude the use of SmO2 as a direct surrogate of ScvO2.

PURPOSE: Midlines (ML) are long peripheral intravenous catheters inserted above the antecubital space via the basilic, cephalic, or brachial veins terminating within or below the axilla.These catheters provide safe and comfortable mid-term vascular access for critically-ill patients.Central venous oxygen saturations (ScvO 2 ) obtained from central venous catheters (CVCs) are often used to approximate cardiac oxygen delivery.Given the proximity of MLs to the axillary vein, we aimed to compare the equivalence of midline oxygen (MO 2 ) saturation and ScvO 2 .If correlated, MO 2 could provide additional physiologic information, while potentially decreasing the need for invasive CVCs.METHODS: Critically ill adult patients who had simultaneously a internal jugular or subclavian CVC and ML inserted as part of their standard care were included in this prospective study conducted at a single academic tertiary care center.Blood samples were drawn simultaneously from the CVCs and MLs and analyzed for venous oxygen saturation using the Abbott Point of Care i-STAT blood analyzer within a 15 minute period. RESULTS:A total of forty-eight patients (n¼48) were enrolled.The data was analyzed using the Student's t test for parametric data and Wilcoxon analysis for non-parametric data.Bland and Altman analysis was also used to compare midline and nonfemoral oxygen saturation.The mean age was 60.7 +/-13.8years.The mean APACHE II and SOFA scores were 19.8 +/-7.9 and 9.3 +/-4.5 respectively.The mean ScvO 2 and MvO 2 were 65.5% +/-11.2% and 62.7 +/-17.6%respectively [p ¼ 0.1197].In the Bland-Altman analysis, the mean bias is 2.8% +/-12.3%[95% limits of agreement: -21.3% to 26.9%].More than 60% of the ScvO 2 and MvO 2 values diverged by $ 5%.Patients with a right upper extremity midline location had a mean ScvO 2 and MvO 2 of 64.8% +/-11.8% and 63.0% +/-16.8%respectively [p ¼ 0.3744].Patients on vasopressors had a mean ScvO 2 and MvO 2 of 63.6% +/-12.3% and 62.6% +/-18.3%[p ¼ 0.67].Patients with an APACHE II score > 25 had a mean ScvO 2 and MvO 2 of 64.9% +/-10.0%and 65.5% +/-16.0%[p ¼ 0.91].CONCLUSIONS: MO 2 as a potential correlate of ScvO 2 is an intriguing concept and its clinical utility remains to be seen.Our findings showed an approximate aggregate 2.8% difference in mean MO 2 vs ScvO 2 .However, these were found to have a significant divergence of $ 5% in >60% of subjects.In a subgroup analysis, patients with right sided MLs, vasopressor use, and high APACHE II scores were independent variables associated with a closer relationship between the ScvO 2 and MvO 2 .Nevertheless, the large variability presents a challenge for the bedside clinician. CLINICAL IMPLICATIONS:As of now, clinicians should not rely on the MO 2 in lieu of the ScVO 2 to guide resuscitation in critically-ill patients.While these values remain close, the relationship is inconsistent and unclear.Further large scale studies with robust prospective data are required.

Ivanovic, Sasa; Prasanna, Nivedita; Kallam, Diya; Maddali, Aditya; Jenkins, Colin; Benjenk, Ivy; Hawkins, Katrina; Levine, Andrea; Park, Paul; Smischney, Nathan; Wieruszewski, Patrick; Khanna, Ashish; Kethireddy, Shravan; Meena, Nikhil; Jackson, Amanda; Wiepking, Matthew; Chow, Jonathan; Yamane, David; Williams, Jeffrey Author Information

We present the case of a 39-year-old woman, G1P0, who had conceived twins via in-vitro fertilization, who presented at 27 weeks of gestation with nasal congestion and dry cough for 7 days. On presentation, her physical examination was benign, except for sinus tachycardia, and she was oxygenating adequately on room air. Laboratory studies were unremarkable, except a PCR test positive for SARS-COV2, and a CT scan of her chest showed bilateral multi-focal ground-glass opacities. A fetal non-stress test was reassuring. She was treated with intravenous fluids, ceftriaxone, azithromycin, and hydroxychloroquine. During her hospital stay, she developed progressively worsening respiratory failure, initially requiring non-invasive ventilation, and subsequently progressed to acute respiratory distress syndrome requiring mechanical ventilation. She then suffered from sudden hypoxemia and hemodynamic collapse, on maximal ventilatory support, prompting an emergency cesarean section at bedside. This led to rapid stabilization of hemodynamic parameters, and of her overall respiratory status. Both the twins were born prematurely, and one of them tested positive for SARS-COV2.

Ivanovic, Sasa; Thiyagalingam, Shano; Rezai, Fariborz; Ovnanian, Vagram; Fless, Kristin; Yodice, Paul; Mistry, Nirav Author Information

SESSION TITLE: Tuesday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM PURPOSE: Cerebral edema in the neurosurgical population can cause intracranial hypertension leading to neurological deterioration. Hypertonic saline (HTS) has become a mainstay for the treatment of cerebral edema given its ability to reduce the rate of neuronal injury by increasing intravascular tonicity. The resulting hyperosmolar state shifts water from the intracellular compartment to the intravascular space. However, treatment with HTS has been shown to be associated with a higher incidence of acute kidney injury (AKI), contributing to higher mortality and morbidity. Despite being widely used, studies investigating the incidence and predictors of nephrotoxicity are lacking and there is no recent data regarding the risk of AKI. The aim of this study is to determine if hypernatremia is associated with an increased incidence of AKI in the general neurosurgical population treated with hypertonic saline. METHODS: We conducted a retrospective review of patients admitted to the neuro-intensive care unit at a tertiary medical center between January 1, 2015 and September 31, 2017 who had a primary diagnosis of subarachnoid hemorrhage, intraparenchymal hemorrhage, or stroke and also received HTS (3% or 2%). AKI was defined according to the Acute Kidney Injury Network criteria with hypernatremia defined as a sodium level > 149 mmol/L during the hypertonic saline infusion. Logistic regression was used to evaluate the impact of hypernatremia on the development of AKI and in-hospital mortality, with the Wilcoxon Rank-Sum test used to evaluate the impact of hypernatremia on length of stay. RESULTS: A total of sixty-six patients were included in the analysis of which thirty-six had hypernatremia. In-hospital mortality was higher in patients who developed hypernatremia [38.9% vs. 10%, OR 5.7 (95% CI 1.6, 27.2), p=0.012] as well as AKI [77.8% vs. 36.7%, OR 6.0 (95% CI 2.1, 18.7), p=0.001]. There was no difference in length of stay [15.6 vs. 17.7 days respectively, p=0.74]. CONCLUSIONS: In our retrospective study, the development of hypernatremia during hypertonic saline infusion was associated with greater rates of in-hospital mortality and acute kidney injury. Whether hypertonic saline directly or indirectly leads to acute kidney injury is unclear. Despite this, physicians should be aware of the potential risks associated with hypertonic saline therapy and closely monitor sodium levels. CLINICAL IMPLICATIONS: Prospective studies should be conducted to evaluate the causality of hypertonic saline and acute kidney injury. DISCLOSURES: No relevant relationships by Kristin Fless, source=Web Response No relevant relationships by Patrick Hilden, source=Web Response No relevant relationships by John Hoffman, source=Web Response No relevant relationships by Sasa Ivanovic, source=Web Response No relevant relationships by Aimen Liaqat, source=Web Response No relevant relationships by Nirav Mistry, source=Web Response No relevant relationships by Vagram Ovnanian, source=Web Response No relevant relationships by Fariborz Rezai, source=Web Response No relevant relationships by Paul Yodice, source=Web Response

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: A complication of any medication given via a peripheral intravenous catheter (IV) is the administration of the medication into the surround perivascular tissue. This can be associated with adverse events such as tissue necrosis, increased risk of infection, and acute compartment syndrome. Propofol is a sedative-hypnotic IV anesthetic that has a rapid onset of action, rapid recovery, neutral pH, and is isotonic. Due to these properties, adverse events related to the use of propofol are relatively rare. We report a case of propofol extravasation resulting in prolonged sedation requiring mechanical ventilation and soft tissue injury. CASE PRESENTATION: A 51-year-old female with past medical history of cervical stenosis underwent an elective anterior cervical discectomy and fusion. During the procedure, she was noted to require increasing amounts of sedation and received approximately 700 mL of propofol (10mg/ml concentration). After surgery, extravasation of the propofol was noted in the left forearm with significant edema, erythema, and warmth from the elbow to the wrist. Scattered superficial skin wounds with superficial partial thickness depth were present on the elbow, forearm, and wrist. There was no evidence of necrosis with a palpable distal radial pulse. Post-operatively, the patient remained unresponsive and required prolonged mechanical ventilation for an additional 12 hours. She was initially managed with broad spectrum antibiotics and 1% silver sulfadiazine; however, antibiotics were quickly discontinued as her condition improved and there was no suspicion of underlying infection. She was discharged in stable condition on hospital day 4. DISCUSSION: Despite the favorable chemical properties of propofol, there have been recent case reports of tissue necrosis related to propofol extravasation. Patient co-morbidities such as malnutrition, peripheral vascular disease, and diabetes may predispose to tissue necrosis secondary to poor vascular supply and delayed healing. Moreover, propofol is an excellent culture medium for bacterial growth secondary to its high lipid content. Extrinsic contamination's of propofol preparations have been reported in literature resulting in post-operative septic shock and wound infections. Increased pressure within a closed fascial compartment can lead to compartment syndrome. Management involves immediate termination of the propofol infusion. A surgical consult should be obtained for the management of tissue necrosis and chemical burn injury. Some authors advocate for aspiration of propofol before withdrawing the infusion needle and washing the area with isotonic fluids. CONCLUSIONS: Even though propofol is a fairly benign anesthetic, physicians need to be aware of the complications associated with its use. There needs to be a high index of suspicion for IV infiltration in patients requiring increasing doses of sedation for any procedure. Reference #1: Leblanc JM, Lalonde D, Cameron K, Mowatt JA. Tissue necrosis after propofol extravasation. Intensive Care Medicine. 2013;40(1):129-130. https://doi.org/10.1007/s00134-013-3137-z. Reference #2: Kalraiya AJ, Madanipour S, Colaco H, Cobiella C. Propofol extravasation: a rare cause of compartment syndrome. BMJ Case Rep. 2015;2015:bcr2015209360. Published 2015 May 7. https://doi.org/10.1136/bcr-2015-209360. Reference #3: Sharma R, Yoshikawa H, Abisaab J. Chemical burn secondary to propofol extravasation. West J Emerg Med. 2012;13(1):121-2. DISCLOSURES: No relevant relationships by Abdullah Al Twal, source=Web Response No relevant relationships by Jason Cohen, source=Web Response No relevant relationships by Kristin Fless, source=Web Response No relevant relationships by Sasa Ivanovic, source=Web Response No relevant relationships by Nirav Mistry, source=Web Response No relevant relationships by Vagram Ovnanian, source=Web Response No relevant relationships by Fariborz Rezai, source=Web Response No relevant relationships by Paul Yodice, source=Web Response

Learning Objectives: Antibiotic dosing was developed in healthy volunteers and may not account for pharmacokinetic and pharmacodynamic changes in critically ill patients with septic shock, which may result in significant under-dosing of antibiotic therapy. This study evaluated the empiric antibiotic dosing in septic shock patients. We hypothesize that the current culture of antibiotic dosing in this population is conservative. Methods: This retrospective cohort study enrolled patients admitted to the MICU from January 1, 2016 to January 1, 2017 who required vasopressors and antibiotics for suspected septic shock. Antibiotics given during the resuscitation phase (0 to 48 hours of shock onset) and the maintenance phase (48 hours to 7 days) were characterized as aggressive dosing strategy (ADS) or conservative dosing strategy (CDS), based on predefined dosing regimens according to the patient’s renal function. We evaluated beta-lactam, glycopeptide, aminoglycoside, and polymixin antibiotics. We also examined the correlation of ADS and CDS with hospital length of stay (LOS), ICU LOS, and hospital mortality. Fischer’s exact test and 2-tailed Student’s t-test were used where appropriate. Results: Fifty patients were evaluated with a mean age of 59.2 ± 11.3 years, 62.0% male, APACHE II score of 24.0 ± 8.5, and overall hospital mortality rate of 46.0%. A total of 208 antibiotic orders were placed. 81.8% of the orders during the resuscitation phase (n=143) were CDS. 72.3% of the orders during the maintenance phase (n=65) were CDS. Of those discharged alive (n=27), there was no difference in hospital LOS between ADS and CDS (25.1 ± 21.4 vs 18.6 ± 8.3 days, p=0.11), but ICU LOS was longer with ADS (9.6 ± 7.2 vs 6.8 ± 6.0 days, p=0.04). Overall mortality was higher for CDS (52.4% vs 29.5%, p=0.01). In a subanalysis of each time period, CDS was associated with an increased mortality during the resuscitation phase (57.8% vs 20.0%, p=0.0008), but no difference in mortality during the maintenance phase (38.3% vs 38.9%, p=1.00). Conclusions: Empiric antibiotic dosing is conservative for a majority of the patients in septic shock. Conservative antibiotic dosing during the resuscitation phase may be associated with a higher mortality. Future prospective studies should further explore the benefits of ADS of empiric antibiotics in septic shock.

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Loperamide is an intestinal mu-opioid receptor agonist that is sold as an anti-diarrhea medication. At high doses, it has been reported to alleviate symptoms of opioid withdrawal and achieve euphoria. In 2017, The American Association of Poison Control Centers reported 374 cases of intentional loperamide overdose, of which 56 had major adverse outcomes with 4 deaths. Despite the widespread use, few physicians are aware of the toxicity associated with loperamide overdose. CASE PRESENTATION: A 32-year-old male with a past medical history of Percocet abuse presented to the emergency department (ED) after he reportedly took 250 tablets of 2 mg loperamide to alleviate the symptoms of opioid withdrawal. In the ED, the patient was lethargic but maintaining his airway. Physical examination revealed a temperature of 101.4 °F, blood pressure of 88/68 mmHg, heart rate of 100 beats/minute, respiratory rate of 14 breaths/minute, and oxygen saturation of 97% on a non-rebreather. Pertinent positive findings included left lower lung rales with a depressed respiratory effort, hypoactive bowel sounds, and a tense distal right lower extremity with weakness and sensory loss. Laboratory work showed leukocytosis of 14.3 x 1000/uL, bicarbonate 20 mmol/L, creatinine 2.36 mg/dL, lactic acid 6.2 mmol/L, and arterial blood gas with pH 7.2/pCO2 41 mmHg/pO2 60 mmHg on a non-rebreather. An elevated creatine kinase, acute kidney injury, and a positive urinalysis for blood were consistent with rhabdomyolysis. EKG showed a normal sinus rhythm with a prolonged QTc of 525 ms, wide QRS complex of 0.12 seconds, left posterior hemiblock, and a rightward axis. The patient was initially given naloxone with improvement in his mental and respiratory status. He was also managed with broad-spectrum antibiotics, intravenous fluids, and vasopressors. Right lower extremity compartment syndrome required emergent fasciotomy. Despite aggressive management, his respiratory and renal function continued to deteriorate necessitating mechanical ventilation and acute hemodialysis. With supportive management, he was weaned off mechanical ventilation but required permanent hemodialysis. Serial EKG monitoring showed a decrease in his QTc length and QRS complex width. DISCUSSION: The low potential for loperamide abuse was originally thought to be due to its extensive first-pass metabolism, low oral bioavailability, and poor penetration of the blood-brain barrier. At supra-therapeutic doses, the central nervous system concentration of loperamide increases. Adverse effects include nausea, constipation, drowsiness, respiratory failure, and QTc prolongation leading to fatal arrhythmias. CONCLUSIONS: Loperamide overdose can be catastrophic in the correct clinical scenario leading to multi-organ failure and death. Physicians need to be aware of the potential for loperamide and other non-prescription medication abuse. Reference #1: Upadhyay A, Bodar V, Malekzadegan M, et al. Loperamide induced life threatening ventricular arrhythmia. Case Rep Cardiol. 2016;2016:5040176. Reference #2: Salama A, Levin Y, Jha P, Alweis R. Ventricular fibrillation due to overdose of loperamide, the "poor man's methadone". J Community Hosp Intern Med Perspect. 2017;7(4):222-226. Published 2017 Sep 19. DISCLOSURES: No relevant relationships by Abdullah Al Twal, source=Web Response No relevant relationships by Kristin Fless, source=Web Response No relevant relationships by Sasa Ivanovic, source=Web Response No relevant relationships by Nirav Mistry, source=Web Response No relevant relationships by Vagram Ovnanian, source=Web Response No relevant relationships by Fariborz Rezai, source=Web Response No relevant relationships by Aditi Saha, source=Web Response No relevant relationships by Paul Yodice, source=Web Response

SESSION TITLE: Tuesday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM PURPOSE: The incidence of Atrial Fibrillation (AF) during the early postoperative period after coronary artery bypass grafting (CABG) or valve surgery ranges between 15%-40%. Despite postoperative AF being regarded as a benign problem, it is in fact associated with an increased risk of adverse events. Several studies have investigated the use of amiodarone as a prophylactic agent. However, optimal drug dosage and duration remains elusive. The aim of this study is to determine if there is a reduction in the incidence of postoperative AF after implementing a protocol that uses amiodarone as a prophylactic agent during cardiac surgery. METHODS: We conducted a retrospective review of patients undergoing CABG or valve surgery admitted to the cardiothoracic intensive care unit in a tertiary medical care center between January 1, 2016 and December 31, 2016.The protocol consisted of a perioperative intravenous amiodarone bolus followed by a 24 hour amiodarone drip and a PO maintenance dose that was continued during hospitalization and discharge. Data was collected on 93 patients pre-protocol implementation (January 1, 2016 to June 30, 2016) and 63 patients post-protocol implementation (July 1, 2016 to December 31, 2016). Exclusion criteria included a history of chronic AF, left ventricular ejection fraction of less than 30%, open sternum, complete heart block, sinus bradycardia, severe pulmonary fibrosis, and elevated liver function tests. Data was collected on patient demographics, comorbidities, beta-blocker use, electrolytes, type of surgery, cross clamp time, bypass time, number of transfusions, and duration of mechanical ventilation. The primary outcome was in-hospital incidence of new onset AF in the post-operative period, and the secondary outcome was length of stay. Logistic regression was used to evaluate the impact of prophylactic amiodarone on incidence of new onset atrial fibrillation between the two groups. RESULTS: The incidence of AF was lower in patients who received amiodarone in the post operative period [12.7% vs. 29.3%, OR 0.35 (95% CI 0.15 - 0.83), p=0.018]. There was no difference in length of stay [7.0 days vs. 7.2 days respectively, p=0.53]. There was no difference between the two groups with regards to the patient’s age, sex, co-morbidity, beta-blocker use, type of surgery. Specifically, there was no difference between the cross clamp times, bypass times, duration of mechanical ventilation, and the need for transfusions between the two groups. CONCLUSIONS: In our study, the use of prophylactic amiodarone in the perioperative period after CABG or valve surgery is associated with a decreased incidence of post-operative AF. CLINICAL IMPLICATIONS: Amiodarone use in the post-operative period after cardiac surgery may be associated with a reduced incidence of atrial fibrillation. DISCLOSURES: No relevant relationships by Sasa Ivanovic, source=Web Response No relevant relationships by Randy Ramcharitar, source=Web Response No relevant relationships by Gary Rogal, source=Web Response

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Obstructive sleep apnea (OSA) is associated with fragmented sleep caused by intermittent narrowing or occlusion of the upper airways leading to hypoxia. Uvulopalatopharyngoplasty (UPPP) is a common surgical treatment for adult patients with OSA. Complications are infrequent post-UPPP and include respiratory failure, hemorrhage, and hypertension. We report a serious complication of negative pressure pulmonary edema (NPPE) leading to respiratory failure after a UPPP procedure. CASE PRESENTATION: A 33 year-old-male with a past medical history of morbid obesity and OSA underwent UPPP without intraoperative complications. Immediately following extubation, he developed hypoxia refractory to increasing oxygen supplementation requiring intubation. The post intubation chest X-ray (CXR) showed diffuse pulmonary edema with a deep sulcus sign on the right. Extensive pink frothy secretions were suctioned repeatedly and required an endotracheal tube exchange. The repeat CXR showed worsening pulmonary edema and a right-sided pneumothorax which failed to improve despite right-sided chest tube placement. He subsequently required a second right-sided chest tube which expanded the right lung, decreased the peak pressures, and improved oxygenation. Echocardiogram was consistent with longstanding OSA and revealed a moderate to severely dilated right ventricle with reduced function. Patient’s condition improved rapidly with diuretics and aggressive mechanical ventilation; he was weaned off the ventilator and the chest tubes were quickly removed. After a short hospital course, he was discharged home in stable condition. DISCUSSION: The temporal cause of events following the relief of upper airway obstruction after UPPP suggests that NPPE was the cause of the respiratory failure. Clinicians need to be aware of this serious complication as rapid recognition can improve outcomes. NPPE can be classified as either Type I or Type II. Type I develops in patients who generate a negative intrathoracic pressure against acute airway obstruction. This can occur in patients with upper airway infections and laryngospasms leading to increased venous return and pulmonary edema. Type II develops after relief of chronic upper airway obstruction with loss of positive end-expiratory pressure (PEEP). The rapid removal of PEEP leads to interstitial fluid transudation and pulmonary edema. Regardless of type, patients usually present with hypoxia, pulmonary edema, and pink frothy sputum. Manifestations of acute airway obstruction may be present and include stridor with use of accessory muscles. Management is supportive with or without the use of diuretics. The use of positive airway pressure ventilation has been suggested for both acute management and prevention of pulmonary edema. CONCLUSIONS: Although a benign surgical procedure, UPPP has complications that need to be rapidly identified in the immediate post-operative period. Reference #1: Bhaskar B, Fraser JF. Negative pressure pulmonary edema revisited: Pathophysiology and review of management. Saudi J Anaesth. 2011;5(3):308-13. Reference #2: Miro AM, Shivaram U, Finch PJ. Noncardiogenic pulmonary edema following laser therapy of a tracheal neoplasm. Chest. 1989;96:1430–1. Reference #3: Guffin TN, Harel G, Sanders A, Lucente FE, Nash M. Acute postobstructive pulmonary edema. Otolaryngol Head Neck Surg. 1995;112:235–7. DISCLOSURES: No relevant relationships by Abdullah Al Twal, source=Web Response No relevant relationships by Kristin Fless, source=Web Response No relevant relationships by Sasa Ivanovic, source=Web Response No relevant relationships by Nirav Mistry, source=Web Response No relevant relationships by Vagram Ovnanian, source=Web Response No relevant relationships by Anish Patel, source=Web Response No relevant relationships by Fariborz Rezai, source=Web Response No relevant relationships by Paul Yodice, source=Web Response

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Acupuncture has emerged as an increasingly popular choice for complementary and alternate approaches to conventional medical treatment. More than 10 million acupuncture treatments are administered in the United States alone. The procedure is generally considered safe but a variety of complications have been reported from time to time. We report a case of serious bilateral pneumothorax following acupuncture. CASE PRESENTATION: A 53-year-old Caucasian male presented to the ER with progressively worsening shortness of breath following an acupuncture treatment earlier in the day. Shortly after the procedure, he developed a dull tightness in his upper back and difficulty in breathing while speaking. He had received regular acupuncture treatments from the same practitioner over the past seven years. Physical examination was remarkable for bilaterally reduced breath sounds. Chest radiography showed moderate right sided pneumothorax and a small left apical pneumothorax. CT scan showed bilateral moderate to large pneumothorax and a slight shift of the mediastinal contents from the right to left. Bilateral thoracostomy tubes were placed with Seldinger technique using the Thal-Quick Set and repeat radiography demonstrated almost complete re-expansion of both lungs. He improved over the next few days, chest tubes were removed after complete re-expansion was confirmed, and the patient was discharged home. Two weeks later, the chest radiograph showed no residual pneumothorax. DISCUSSION: Acupuncture, an ancient technique that originated in China, is based on the theory that disease is treated by allowing for the normal flow of energy throughout the body using as many as 2000 acupuncture points. It is believed that these points are connected by different pathways that conduct energy between the body surface and internal organs. So far, there is evidence for possible efficacy in post-operative nausea and vomiting, postoperative dental pain, and chronic pain conditions. The possible mechanism of action has been attributed to a release of endogenous opioids augmented by the release of ACTH and cortisol as well as down-regulation of signaling through pain fibers. Typically, the depth of insertion of acupuncture needles varies from a few millimeters to a few centimeters with the tip in the muscle but it can also overlie structures like pleura and nerves and cause a wide variety of adverse events including needling site pain, infections, broken needle fragments left behind, tension pneumothorax, hemothorax, cardiac tamponade, spinal cord trauma, organ perforation, and even death. Of note, this was the first time our patient received acupuncture at a site on the front of his chest. CONCLUSIONS: There is wide variability in the skill level among acupuncture practitioners. There is a need for more education and increased awareness of the complications that can arise from this seemingly safe procedure. Reference #1: J. K. Juss, C. A. Speed, J. Warrington, and R. Mahadeva, “Acupuncture induced pneumothorax—a case report,” Acupuncture in Medicine, vol. 26, no. 3, pp. 193–196, 2008. Reference #2: J. W. Su, C. H. Lim, and Y. L. Chua, “Bilateral pneumothoraces as a complication of acupuncture,” Singapore Medical Journal, vol. 48, no. 1, pp. e32–e33, 2007. DISCLOSURES: No relevant relationships by Sasa Ivanovic, source=Web Response No relevant relationships by Mehak Laharwal, source=Web Response No relevant relationships by Gabriel Mekel, source=Web Response No relevant relationships by Sunil Sapru, source=Web Response

Ivanovic, Sasa; Shiels, Lisa; Zywot, Alexander; Mistry, Nirav; Fless, Kristin; Ovnanian, Vagram; Yodice, Paul; Rezai, Fariborz Author Information