Junad Chowdhury

382: ALL THAT WHEEZES IS NOT ASTHMA

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Severe TBM is characterized by complete or near-complete expiratory collapse of airways. Common causes of TBM in adults include inflammatory conditions & mechanical compression from external structures. We present a case of TBM secondary to radiation therapy (XRT) Methods: 90-year-old female with extensive history including chronic diastolic CHF, COPD and lung cancer (s/p XRT 1 month prior) presented to the ED with intermittent left sided chest pain and worsening dyspnea for 3 days. Within 24hrs patient developed respiratory distress with reduced bilateral air entry and diffuse expiratory wheeze with SpO2 of 70% on 100% NRB. ABG showed respiratory acidosis and wide A-a gradient. She was intubated and given steroids and diuretics. CT chest showed no evidence of PE or consolidation, and the patient was extubated the next day. On Day 3 she developed recurrent acute respiratory failure with similar physical exam findings necessitating re-intubation. Fiber-optic bronchoscopy showed > 90% -near total collapse of trachea and bilateral main stem bronchi during exhalation. TBM was diagnosed and the patient was transferred to a tertiary center for definitive treatment where she was deemed a poor candidate for airway stenting or surgery by interventional pulmonology. She subsequently opted for comfort measures only and died after extubation. Results: TBM is a known cause of dyspnea, cough and recurrent infections. It is frequently misdiagnosed as asthma or COPD due to wheezing/cough. Physicians must be cognizant of this rare and underdiagnosed cause of respiratory failure and difficulty weaning in the ICU. Flexible bronchoscopy remains the gold standard for diagnosis. Prompt referral to a tertiary institute with available expertise of interventional pulmonology and thoracic surgery should be sought to plan for either endoluminal stenting or open tracheobronchoplasty.

1009: A BIG BLEED FROM A SMALL PILL

Critical Care Medicine • Volume 46 • Number 1 (Supplement) www.ccmjournal.org Learning Objectives: Diffuse pulmonary hemorrhage (DAH) results from damage to the small pulmonary vessels which can disrupt gas exchange, the consequences can be fatal if not treated. Dabigatran, a newer oral anticoagulant, works as a direct thrombin inhibitor and is indicated for use in non-valvular atrial fibrillation, deep venous thrombosis and pulmonary embolus. Methods: A 66 year old Caucasian male with a medical history of hypertension, diabetes mellitus type 2, atrial fibrillation on dabigatran, and abdominal aortic aneurysm presented to the ED with complaints of hemoptysis. Patient reported fever, cough, and dyspnea on exertion for 2 weeks which worsened the night prior to presentation. Initial labs showed leukocytosis 13.6, lactate 2.9, APTT 50.1 and hemoglobin 13.4. CT scan of the chest showed bilateral perihilar consolidation and ground glass opacity associated with interlobular septal thickening consistent with DAH. Given continued hemoptysis and labored breathing, the patient was intubated. Idarucizumab was administered to reverse the anticoagulation effects of dabigatran. Less than 48 hours following intubation, repeat CT scan showed clearing of the hemorrhage and he was successfully extubated. Respiratory cultures grew Streptococcus Pneumoniae, Escherichia Coli and Klebsiella Pneumoniae, and he treated with ceftriaxone. Vasculitis work up including ANA, c-ANCA, p-ANCA, C3, C4, total complement and Myeloperoxidase antibody, was negative. Additionally anti-gm antibody, mycoplasma pneumonia IgM and mixing studies were also negative. No other cause of the pulmonary hemorrhage could be identified, and it was attributed to the use of dabigatran. Results: Our research did not identify any reported case of the use of praxbind to reverse DAH secondary to dabigatran in the setting of pneumonia. Another case of DAH secondary to dabigatran was reported in Japan in 2012 before the advent of idarucizumab. DAH is fatal if not treated in a timely manner. This case raises the importance of identifying risk factors such as an underlying pneumonia, which can increase the risk of hemorrhage while on an oral anticoagulant. The use of a reversal agent in a timely manner can drastically alter clinical course.

908: CRITICALLY ILL PATIENTS WITH TOBACCO DEPENDENCE REQUIRE LONGER INFUSION OF DEXMEDETOMIDINE

Learning Objectives: Smoking is one of the most common addictions in the world. It has proven to increase mortality and cause withdrawal when immediately stopped. We have previously shown that patients with alcohol dependence show improved outcomes on dexmedetomidine (DEX) in terms of intensive care unit (ICU) length of stay (LOS) and mortality. We hypothesize that smokers who required DEX, also have better outcomes, when compared to non-smokers in the ICU. Methods: A retrospective observational study was conducted from January 2014 to September 2015 in adult ICUs at two academic community hospitals in a large urban setting. All patients were on a DEX infusion (196) during their hospitalization (15 excluded based on exclusion criteria). Baseline patient demographics, comorbidities, and clinical characteristics were collected. Patients were split into two groups, smokers versus non-smokers. Clinical outcomes were compared using Chi-Squared and unpaired T-test. Results: 181 patients were included in final data analysis; mean age was 58.3, in a primarily male and African American population. Average APACHE II scores were 25.1 for smokers, and 26.4 for non-smokers. In our study, smokers had significant longer hours of infusion on DEX versus non-smokers, 48 hours versus 37 hours (p-value < 0.04, 95% CI 0.40 to 22). Interestingly, smokers on DEX did not have a longer hospital or ICU LOS. Smokers with a nicotine patch were compared with smokers without a patch, and there was no significant reduction in hours of infusion (p-value = 0.66), or ICU LOS (p-value = 0.82). Conclusions: Based on our study, the smoking population required longer duration of infusion when compared to the non-smoking population. We also concluded that smokers with a nicotine patch had no reduction in hours of duration, ICU or hospital LOS when compared with smokers without a patch. We conclude DEX has a role in suppressing nicotine withdrawal, by acting as an alpha-2 agonist to decrease sympathetic activity. Therefore, there is no added benefit of a nicotine patch on patients on a DEX infusion.

1739: WARFARIN-INDUCED SEPTIC SHOCK? A RARE CASE OF DELAYED-ONSET WARFARIN-INDUCED SKIN NECROSIS.

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) in the differential diagnosis of conjugated hyperbilirubinemia in a young infant. This can lead to delay in diagnosis and treatment of a potentially fatal disease. Our case highlights this possibility and reminds clinicians to consider malignancy while evaluating similar patients to facilitate early recognition and prompt referral to the Pediatric Oncologist to initiate appropriate therapy.