Acute Hemodynamic Instability Research Articles

Case Report of Spontaneous Rupture of Hepatocellular Carcinoma: Clinical Presentation, Management, and Outcome

Spontaneous rupture of hepatocellular carcinoma (HCC) is a rare but life-threatening complication, presenting with acute abdominal pain and hemodynamic instability. This case report describes the clinical manifestations, diagnostic challenges, and management strategies employed in a patient with spontaneous rupture of HCC. The patient, with underlying cirrhosis, presented with signs of hemorrhagic shock. Immediate resuscitation, imaging, and subsequent embolization were performed to stabilize the patient, followed by definitive treatment. The rarity of this complication, combined with the precarious nature of the underlying liver disease, creates significant therapeutic challenges. This case underscores the need for rapid diagnosis and a multidisciplinary approach to optimize patient outcomes.

Utilizing Fetal Echocardiography to Risk Stratify and Predict Neonatal Outcomes in Fetuses Diagnosed with Congenital Heart Disease.

Risk stratification of fetuses diagnosed with congenital heart disease (CHD) helps provide a delivery plan and prepare families and medical teams on expected course in the delivery room. Our aim was to assess the accuracy of echocardiographically determined risk-stratification assignments in predicting postnatal cardiac outcomes beyond the delivery room. This was a retrospective study at a single center evaluating all fetuses with CHD who were risk-stratified by echocardiographically determined level of care (LOC) assignment, ranging from 1a (lowest risk) to 4 (highest risk). All data were collected from January 1, 2017, to November 1, 2021. Outcomes included any unexpected cardiac interventions and neonatal clinical outcomes including in-hospital mortality, the need for prostaglandins or inotropes, and defined critical illness. These outcomes were assessed for each LOC assignment by Fisher's exact test. Out of 817 patients assigned a LOC, a total of 747 fetuses were included in our final cohort with a separate subanalysis of 70 fetuses diagnosed with coarctation of the aorta. The sensitivity and specificity were high for all LOC levels in predicting delivery room needs (93-100%). Higher LOC levels (3-4) had a lower positive predictive value (66-67%) indicating a high false-positive rate. Subjects with higher LOC assignments had a greater frequency of critical illness, hospital mortality, need for inotropes, need for neonatal surgical or catheterization interventions, and need for prostaglandins (p < 0.001 for all outcomes). A post-hoc analysis reviewing LOC assignments revealed a greater tendency to over-assign LOC at higher assignments (19% for LOC 3 and 4) compared to lower assignments (4% for LOC 1 and 2). Risk stratification based on fetal echocardiography can predict neonatal clinical outcomes and acuity of postnatal management needs. However, there is greater variability in expected clinical events and an expected degree of false positives for those with higher LOC assignments. · Risk stratification utilizing fetal echocardiography can be used to predict neonatal needs.. · Complex heart disease has lower positive predictive value in predicting postnatal clinical needs.. · There is a tendency to over-assign risk of acute hemodynamic instability for complex heart disease.. · False positives are expected when planning high-risk deliveries to avoid compromising situations..

Outcome of Veno-Pulmonary Extracorporeal Life Support in Lung Transplantation Using ProtekDuo Cannula: A Systematic Review and Description of Configurations.

Background: Refractory end-stage pulmonary failure may benefit from extracorporeal life support (ECLS) as a bridge to lung transplantation. Veno-venous (VV) extracorporeal membrane oxygenation (ECMO) has been recommended for patients who have failed conventional medical therapy and mechanical ventilation. Veno-arterial (VA) ECMO may be used in patients with acute right ventricular (RV) failure, haemodynamic instability, or refractory respiratory failure. Peripheral percutaneous approaches, either dual-site single-lumen cannulation for veno-pulmonary (VP) ECMO or single-site dual-lumen (dl)VP ECMO, using the ProtekDuo right ventricular assist device (RVAD) cannula, has made this configuration a desirable option as a bridge to transplantation. These configurations support the right ventricle, prevent recirculation by placing the tricuspid and pulmonary valve between the drainage and return cannulas, provide the direct introduction of oxygenated blood into the pulmonary artery, and have been shown to decrease the incidence of acute kidney injury (AKI), requiring continuous renal replacement therapy (CRRT) in certain disease states. This promotes haemodynamic stability, potential sedation-weaning trials, extubation, mobilisation, and pre-transplant rehabilitation. Methods: A web-based literature search in PubMed and EMBASE was undertaken based on a combination of keywords. The PICOS and PRISMA approaches were used. Results: Four case series were identified out of 323 articles, with a total of 34 patients placed on VP ECMO as a bridge to lung transplantation. All relevant data are reviewed and integrated into the Discussion. Conclusions: Despite the limited available evidence, the use of ProtekDuo has become very promising for the management of end-stage lung disease as a bridge to lung transplantation.

Percutaneous Venopulmonary Extracorporeal Membrane Oxygenation as Bridge to Lung Transplantation.

Mechanical circulatory support (MCS) as a bridge to lung transplant is an infrequent but accepted pathway in patients who have refractory end-stage pulmonary failure. The American Association of Thoracic Surgeons Expert Consensus Guidelines, published in 2023, recommends venovenous (VV) extracorporeal membrane oxygenation (ECMO) as the initial configuration for those patients who have failed conventional medical therapy, including mechanical ventilation, while waiting for lung transplantation and needing MCS. Alternatively, venoarterial (VA) ECMO can be used in patients with acute right ventricular failure, hemodynamic instability, or refractory respiratory failure. With the advancement in percutaneous venopulmonary (VP) ECMO cannulation techniques, this option is becoming an attractive configuration as bridge to lung transplantation. This configuration enhances stability of the right ventricle, prevents recirculation with direct introduction of pulmonary artery oxygenation, and promotes hemodynamic stability during mobility, rehabilitation, and sedation-weaning trials before lung transplantation. Here, we present a case series of eight percutaneous VP ECMO as bridge to lung transplant with all patients mobilized, awake, and successfully transplanted with survival to hospital discharge.

Comparison of the Effects of Nitroglycerin, Labetalol and Lidocaine in Hypertensive Patients in Attenuation of the Endotracheal Intubation Reflex

Background: Laryngoscopy and tracheal intubation integral parts of general anesthesia which may cause acute haemodynamic instability. Hypertensive patients are more prone of developing cardiovascular complications such as pulmonary oedema, cardiac failure and cerebrovascular haemorrhage. To attenuate such intubation reflex, some drugs are used, e.g., opioids. lidocaine sodium nitroprusside, nitroglycerin, beta blockers, calcium channel blockers etc. Objective: The purpose of the study is to see the effectiveness of nitroglycerin, labetalol and lidocaine in attenuation of intubation reflex and their anesthetic outcome in hypertensive patients. Methods: This randomized controlled study was carried out in the Department of Anesthesia, Pain, Palliative and Intensive care Medicine, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh, between March and September of 2021. A total of 90 patients were included: 30 in each group as per inclusion and exclusion criteria. Group A patients received inj. nitroglycerin 2 minutes before intubation, while group B patients received inj. labetalol 0.25mg/kg 5 minutes before intubation, and group C was given 2% lidocaine 1.5mg/kg 2 minutes before intubation. Haemodynamic status of all patients was checked before and after intubation. Results: Mean age of the patients was 44.4±10.9 years in group A, 47.6±9.4 years in group B and 46.4±10.6 years in group C. Heart rate after intubation was low and statistically significant in groups-B after 1.2 and 5 minutes. Regarding mean arterial pressure (MAP), group A patients had significantly low blood pressure. Rate pressure product (RRP) of the patients was significantly low in group B at 1 minute, 2 minutes and 5 minutes. Regarding ECG changes sinus tachycardia was observed in 26.6%, 86.6% and 20% in group A, group B and group C immediately after intubation. Groups B patients showed lower incidence of sinus tachycardia than that of two other groups and showed no premature ventricular contractions, whereas group A (6.7%) and group C (3.3%) showed premature ventricular contractions. Conclusion: Labetalol showed better rhythm control, mean arterial pressure and less incidence of tachycardia. To summarize, labetalol is safer and more effective than nitroglycerin and lidocaine to attenuate the endotracheal intubation reflex in hypertensive patients. Mugda Med Coll J. 2023; 6(2): 64-70

Abstract 16265: Precipitants of Acute Hemodynamic Instability in Patients With Hypertrophic Cardiomyopathy Admitted to the Cardiac Intensive Care Unit

Background: Hypertrophic cardiomyopathy (HCM) is the most common genetic heart disease in the United States which can infrequently present with acute hemodynamic instability. Our study aimed to identify the precipitants of acute cardiovascular decompensation resulting in Cardiac Intensive Care Unit (CICU) admission in patients with HCM. Methods: All patients admitted to Cleveland Clinic Cardiac Intensive Care Unit (CICU) between Jan 1 st , 2010, to Dec 31 st , 2021, with a diagnosis of CS and co-existing HCM were identified through electronic medical charts. Only those with previously uncorrected HCM in the form of no prior myectomy/alcohol septal ablation and not on mavacamten were included in our study. Chart review was performed by physician investigators to identify the etiology precipitating hemodynamic instability in these patients. Results: Overall, 2754 patients were admitted to our CICU with CS during the study period, of which 21 patients (1%) had coexisting uncorrected HCM. The median age of patients with HCM admitted to our CICU was 61 years, 52% (n=11) were females, and 86% (n=18) were White Americans. The in-hospital mortality of patients with HCM-CS was around 24% (n=5). Retrospective chart review to identify the precipitating agent revealed atrial fibrillation with rapid ventricular response (Afib-RVR) to be the most common precipitant (33%, n=7), followed by severe MR in the setting of dynamic outflow obstruction (19%, n=4) and non-obstructive heart failure (19%, n=4). Conclusion: Identification of the precipitating mechanisms is critical to manage HCM patients presenting with hemodynamic instability. Rapid atrial fibrillation appears to be the most common precipitant leading to hemodynamic instability in this population.

Syphilitic ostial coronary artery occlusion treated with percutaneous coronary intervention: Case series and literature review

IntroductionNon-atherosclerotic causes of acute coronary syndrome (ACS) are important contributors to a substantial number of acute ischemic coronary events. Syphilitic aortitis is a rare complication of tertiary cardiovascular syphilis that may result in ostial coronary artery stenosis, aortic insufficiency, and ascending aortic aneurysm. MethodsIn this manuscript, we present two Case Reports of patients with bilateral syphilitic coronary artery ostial occlusion, and we review the associated literature. The immunofluorescent test was positive for syphilis in both patients. ResultsDiagnostic coronary angiography revealed bilateral occlusions of the left main coronary artery (LMCA) and right coronary artery (RCA), which were successfully treated with percutaneous coronary intervention (PCI) with bare metal stents (BMS). After deployment of the stents, arterial blood flow was re-established with TIMI flow grade 3. DiscussionThe angiographic finding of bilateral coronary ostial lesions in young patients should raise the suspicion of cardiovascular syphilis. Options for revascularization should be discussed amongst the patient and the Heart Team. PCI may be an option for treatment of isolated syphilitic coronary stenosis in the setting of acute hemodynamic instability or chronic inflammation.

Diagnostic imaging of ovarian endometrioma rupture with hemoperitoneum

An endometrioid ovarian cyst (known as endometrioma) is the most common variant of external endometriosis. Clinical symptoms range from asymptomatic to negatively affecting on quality of life and daily activities of a reproductive age woman. Rupture of an endometrioid cyst with hemorrhage into the abdominal cavity occurs in 3% of women with this pathology, which is a rare complication.&#x0D; Ruptured endometrioid cysts may present a diagnostic and surgical challenge: patients may have acute abdominal symptoms and hemodynamic instability, also imaging of a ruptured endometrioid cyst may mimic ovarian malignancy. Therefore, the emergency radiologist needs to know the semiotics of an endometrioid cyst with rupture and hemorrhage into the abdominal cavity.&#x0D; We represent the clinical case of a prime diagnosed large endometrioid cyst in a 32-year-old patient, complicated by hemorrhage in the abdominal cavity. In the emergency department, the patient underwent native computed tomography and ultrasound investigation.&#x0D; Based on the study of Russian and foreign literature, the review was made about main aspects of radiation semiotics of endometrioid cysts with rupture and hemorrhage in the abdominal cavity and about of differential diagnosis of rupture of endometrioid cysts with ruptures of functional cysts and malignant cystic ovarian formations.

Successful surgical management of massive hemoretroperitoneum caused by spontaneous rupture of retroperitoneal lymph node metastases in a patient with advanced mixed germ cell tumor: a COVID-19 pandemic-related surgical challenge

BackgroundSpontaneous rapture of a germ cell tumor (GCT) metastases causing massive hemoretroperitoneum in a patient without choriocarcinoma component who has not received previous systemic chemotherapy is an exceedingly rare event. In such a devastating case scenario, a high index of clinical suspicion for early diagnosis and appropriate management is crucial.Case presentationWe report on a 25-year-old male patient with a 4-month history of orchiectomy for testicular GCT (tGCT), who presented in the emergency department with acute abdomen and hemodynamic instability. Urgent computed tomography scan depicted a retroperitoneal mass measuring approximately 13 × 11.4 × 15 cm and massive intraperitoneal hemorrhage. Hemoperitoneum caused by spontaneous rapture of the metastatic retroperitoneal mass was suspected. COVID-19 pandemic-related deviation from the oncologic surveillance standards combined with COVID-19-related patient’s emotional distress and self-neglect had led to loss of opportunity for appropriate adjuvant chemotherapy, obviously leading to the development of this devastating complication. An emergency, surgical exploration was decided. The bleeding mass was adequately exposed following a Cattell–Braasch maneuver and active bleeding was controlled by a challenging resection of approximately 80% of the lymph node mass volume. Pathological evaluation of the specimen revealed teratoma with low volume of yolk sac tumor component and extensive necrosis, findings compatible with the patient’s history. Postoperative recovery was uneventful, followed by early start of adjuvant chemotherapy. Two years after the operation the patient is doing well with no evidence of recurrent disease.ConclusionsMassive hemoperitoneum is a devastating event that exceedingly rarely can complicate the clinical course of patients with advanced tGCT. Emergency surgical intervention is usually necessary however, sound judgement and careful surgical techniques are required for a positive and uneventful outcome. During COVID-19 pandemic, first-line medical personnel push their limits further not only to ensure health care services standards but also, to manage unpredictable, life-threatening cancer-related complications, associated with COVID-19-related deviation from appropriate oncologic surveillance and care.

Judging Urgency in 343 Ectopic Pregnancies Prior to Surgery - The Importance of Transvaginal Sonographic Diagnosis of Intraabdominal Free Blood.

Assessing urgency in ectopic pregnancies (ECP) remains controversial since the disorder covers a large clinical spectrum. Severe conditions such as acute abdomen or hemodynamic instability are mostly related to intra-abdominal blood loss diagnosed as free fluid (FF) on transvaginal sonography (TVS). The aims of the current study were to investigate the value of FF and to assess other potentially predictive parameters for judging urgency. Retrospective cohort analysis on prospectively collected cases of proven ECP (n = 343). Demographics, clinical and laboratory parameters, and findings on TVS and laparoscopy (LSC) were extracted from the digital patient file. FF on TVS and free blood (FB) in LSC were evaluated. Low urgency was defined as FB (LSC) < 100 ml and high urgency as FB (LSC) ≥ 300 ml. The best subset of variables for the prediction of FB was selected and predictors of urgency were evaluated using receiver operator characteristic (ROC) curves. Clinical symptoms, age, β-HCG, hemoglobin (HB) preoperative, and FF were examined in multivariate analysis for the cutoff values of 100 ml and 300 ml. FF was the only independent predictor for low and high urgency; HB preoperative was only significant for high urgency offering marginal improvement. ROC analysis revealed FF as an excellent discriminatory parameter for defining low (AUC 0.837, 95% CI 0.794-0.879) and high urgency (AUC 0.902, 95 % CI 0.860-0.945). Single assessment of FF on TVS is most valuable for judging urgency. However, the exact cutoff values for a low- and high-risk situation must still be defined.

Aortic dissection presenting as a stroke: a case report

Aortic dissection is an uncommon yet frequently fatal illness. Patients generally present with tearing chest pain with possible acute hemodynamic instability. Hence, early diagnosis and intervention is critical for survival. This is a case of a 62-year-old male who was transferred to our emergency department for severe chest pain, left side hemiplegia, left hemianopsia, left facial weakness, suggesting a right-sided stroke. A chest computed tomography angiogram showed an extensive circumferential aortic dissection of the intimal layer involving the great vessels. Antiplatelet medications were withheld, nicardipine was started, and the cardiothoracic surgeon was consulted. There was no indication for surgery, and patient was admitted to the intensive care unit. We highlight here the importance of considering an aortic dissection in patients who present with neurological symptoms and an acute history of tearing chest pain.

The effectiveness of self- instructional module on knowledge regarding multisystem inflammatory syndrome in children (MIS-C) among nurses working in paediatric departments

Introduction: A severe multisystem inflammatory syndrome associated with Kawasaki disease manifestations (MIS-C) has been reported in children with signs of recent infection with SARS-CoV-2. We here reported the case of a young adult woman who presented the complete manifestations of Kawasaki disease associated with a severe myocarditis, acute respiratory distress syndrome and hemodynamic instability a few weeks after a transient anosmia. Methodology: A quantitative approach with one group pre-test design was used for the study. The samples consisted of 60 staff nurses selected by Non probability purposive sampling technique. Research design was pre-experimental one group pre-test and post-test design. Main study was conducted from 01/05/2022 to 15/06/2022 Data was collected by administering a structured knowledge questionnaire by the investigator before and after self-instructional module. Post-test was conducted after 7 days of pre-test and intervention. Data was analyzed using descriptive & inferential statistics (Paired ‘t’ test, Chi- square test, Karl- Person’s correlation coefficient.Result: The pretest knowledge score was 9.05±2.45, while the posttest knowledge score was 19.98±2.57. The difference was found to be statistically significant (‘t’ value = -24.62, df=59, p value=0.05, Significant), showing a higher posttest knowledge score. Conclusion: The finding in the study proved that the structured teaching programme is effective in improving knowledge of staff nurses. The entire subject had improved in knowledge compared to their pre- test score.

This Month in Anesthesiology

This Month in Anesthesiology

A study of posterior reversible encephalopathy syndrome as a cause of sudden transient vision loss during pregnancy

To emphasize the importance of Posterior Reversible Encephalopathy syndrome (PRES) as the cause of sudden vision loss during pregnancy in patients with acute haemodynamic instability like preeclampsia, eclampsia, severe PIH.: In this prospective observational study pregnant women within age group of 25-40 years presenting with acute onset of visual, neurological symptoms to the emergency department were examined. Blood pressure recorded. Patients vision was recorded using snellens chart at the time of presentation and after the recovery. Slit lamp examination, fundus examination, pupillary reactions were noted to rule out other causes of vision impairment. MRI was done to detect PRES. Patients were stabilised and their blood pressure was monitored and treated with intravenous anti hypertensives.: 8 out of 10(80%) of the pregnant women presented with sudden vision impairment were preeclamptic and 2 out of 10(20%) were with features of eclampsia. Majority were in third trimester. All the patients were diagnosed early with PRES on MRI and regained vision within 2 days with immediate treatment with intravenous antihypertensives.Posterior Reversible Encephalopathy syndrome has to be kept in mind as one of the differential diagnosis while examining the pregnant women with eclampsia, preeclampsia, PIH coming with sudden visual impairment.

A Rare Case Report of Ruptured Sinus of Valsalva Aneurysm

&lt;p&gt;主動脈竇動脈瘤是一種罕見的心臟結構病變，因具非特異性表徵及困難診斷，容易導致高死亡風險。本案例是一位53歲男性患者，因急性胸痛入院治療，藉由實驗室檢查發現心肌酵素升高、D-二聚體升高，心電圖檢查為aVR導程ST段上升、於第I、II、V4~6導程出現ST-T波段變化，初步診斷為左冠狀動脈主幹心肌梗塞，立即行冠狀動脈攝影檢查發現無異常。個案出現胸痛合併心因性休克之症狀，從中排除主動脈剝離、肺栓塞、心包填塞等診斷，深入檢視病史紀錄及影像報告，發現心臟超音波、胸部電腦斷層及冠狀動脈血管攝影檢查有由左流向右心室的瘻管分流，最終確診為主動脈竇動脈瘤破裂。患者緊急接受右冠狀竇動脈瘤修補及主動脈瓣置換手術治療後，胸痛、休克狀況改善且左心室功能恢復，術後預後良好。在面對急性胸痛合併血液動力學不穩定的患者時，除了須考慮症狀相關的疾病診斷外，當聽診發現S1及S2連續性心雜音時，建議將主動脈竇動脈瘤破裂列入考慮，以掌握治療處置之重要時機。&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;&lt;p&gt;Aneurysm of the sinus of Valsalva is a rare cardiac anomaly due to the nonspecific symptoms and dif-ficult confirmation of diagnosis leading to high mortality. This report describes the case of a 53-year-old man who had suffered from acute chest pain. The electrocardiogram showed the ST segment ele-vation in lead aVR and ST-T wave changes in leads I, II and V4-6. Elevated D-dimer levels and cardi-ac enzymes were also observed. Acute myocardial infarction caused by the left main coronary artery obstruction was initial diagnosed. Coronary angiogram was performed immediately and the result indicated non-obstructive coronary artery. However, cardiogenic shock with persistent chest pain was discovered. Aortic dissection, pulmonary thromboembolism and cardiac tamponade were gradually excluded. Through detailed review and analysis of medical history, physical assessment and image ex-aminations with echocardiography, chest computed tomography and coronary angiogram, a ruptured sinus of Valsalva aneurysm was eventually diagnosed based on image examinations which revealed left-to-right shunt communicating with the right-sided heart chambers. The patient received emergen-cy right coronary sinus aneurysm repairment and aortic valve replacement surgery. Symptoms with chest pain and shock gradually disappeared and left ventricular function was restored postoperatively. The patient demonstrated excellent recovery. In facing relevance diagnostics for patients with acute chest pain and hemodynamic instability, a ruptured sinus of Valsalva aneurysm must be considered to endure best treatment timing if heart auscultation reveals S1 and S2 continuous murmurs.&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;

Adrenal gland haemorrhages following motor vehicle accident with resultant adrenal insufficiency.

SummaryAdrenal gland haemorrhage is an uncommon, yet likely under-diagnosed complication of high-impact trauma, such as motor vehicle accidents (MVA). It usually occurs with multi-trauma and is associated with additional injuries to the ribs, liver, kidney, spleen and vertebrae. Trauma cases with resultant adrenal gland injury have higher mortality rates. Primary adrenal insufficiency as a result of bilateral adrenal haemorrhage is potentially fatal. We report three cases of life-threatening adrenal insufficiency following adrenal injuries sustained in MVA’s. Case 1 was a 60-year-old-male who presented with acute haemodynamic instability on admission. Case 2 was an 88-year-old female on anticoagulation for atrial fibrillation, who developed haemodynamic instability 10 days into her admission. Case 3 was a 46-year-old male who developed hyponatraemia 2 weeks post-MVA. All were commenced on stress dose hydrocortisone replacement with improvement in clinical status. Only case 1 has had complete adrenal axis recovery, whereas the other patients remain on maintenance hydrocortisone replacement. Our cases demonstrate acute and subacute presentations of adrenal insufficiency following traumatic bilateral adrenal haemorrhages and highlight the importance of assessing adrenal morphology and function in any trauma patient with haemodynamic instability or hyponatraemia.Learning pointsAdrenal gland haemorrhage is an under-diagnosed consequence of high-impact trauma.Trauma patients with adrenal haemorrhage have a significantly increased mortality risk.Bilateral adrenal gland haemorrhage can result in life-threatening adrenal insufficiency requiring urgent glucocorticoid replacement.Biochemical assessment of the adrenocortical axis should be considered in all patients presenting with high-impact trauma following motor vehicle accidents.Given the potential for delayed presentation, any patients with new haemodynamic instability should have repeat biochemistry and/or imaging performed, even if initial adrenal imaging and investigations were normal.

Transfusion-related acute lung injury (TRALI) in post-partum bleeding patient

Abstract Transfusion-related acute lung injury (TRALI) is a rare but fatal complication of blood transfusion. However, it is frequently under-reported and not diagnosed. We reported a 32-year-old pregnant woman at 30/31 gestational weeks who developed acute respiratory distress and hemodynamic instability during transfusion in the post-operative period. Diagnosis of TRALI was made after excluding other possible causes of acute lung injury. We treated the patient with conservative treatment in the obstetrics emergency room based on the initial examination results and scheduled for an elective cesarean section (C-section). Transfusions of packed red blood cells were planned to increase the Hb level. The patient suddenly experienced shortness of breath during the transfusion with a relative risk of 30–36×/min. The patient was given 10 lpm oxygen via a non-rebreathing mask, and oxygen saturation was 86%. The patient's blood pressure was 88/40 mmHg, and heart rate was 126×/min. The transfusion was immediately stopped. Fluid resuscitation with a crystalloid solution for hemodynamic improvement was given when the patient was intubated. After several treatments, the patient's condition was getting better. On day 4, hemoglobin level increased to 9.1 mg/dL, hematocrit 27.6%, leukocytes 9.660/µL, and platelets 72,000/µL. Ventilator weaning was done gradually, and the patient was finally extubated on the 5th day of treatment.

Pulmonary Embolism and Pregnancy-Challenges in Diagnostic and Therapeutic Decisions in High-Risk Patients.

Diagnosis of acute PE in pregnant women with haemodynamic instability is following the general integrated risk-adapted diagnostic algorithm and starts with bedside echocardiography to assess RV function. If RV dysfunction is identified, a prompt and immediate reperfusion without further imaging should be initiated. Although pregnancy is listed as a relative contraindication of systemic thrombolysis, in pregnant women with acute PE and haemodynamic instability thrombolysis must be considered. In those cases, other treatment strategies as surgical embolectomy or catheter-directed low-dose thromboylysis or percutaneous thrombectomy should be taken into consideration as well. A multidisciplinary team with experience of PE management in pregnancy should be consulted to reach consensus on the best treatment approach.

Indications for and Findings on Transthoracic Echocardiography in COVID-19 patients admitted to a Tertiary Care Government Medical Hospital

PurposeWe aimed to document the performance of transthoracic echocardiography (TTE) and the spectrum of echocardiographic findings as complications associated with coronavirus disease 2019 (COVID-19).Methods & MaterialsA retrospective analysis was performed among adult patients admitted to a tertiary care government hospital in Maharashtra between January 01, 2021 and May 31, 2021. Patients were included if they underwent TTE during the hospitalization after a known positive diagnosis for COVID-19. Demographic and clinical data were obtained using chart abstraction from the medical record system.ResultsOf 1539 patients, 187 (12.15%) underwent TTE following positive results on severe acute respiratory syndrome coronavirus-2 polymerase chain reaction testing. The most common clinical indications for TTE were concern for a major acute cardiovascular event (52.95%) and hemodynamic instability (32.29%). Although most patients had preserved biventricular function, 41.30% were found to have left ventricular ejection fractions ≤ 50%, and 13.9% had at least moderately reduced right ventricular function. Eleven patients had wall motion abnormalities suggestive of stress-induced cardiomyopathy. Using Spearman rank correlation, there was an inverse relationship between high-sensitivity troponin T and left ventricular ejection fraction (ρ = -0.41, P < 0.01). Amongst 37 patients with prior echocardiograms, only seven (18.91%) had new reductions in LVEF of >10%. Clinical management was changed in seventeen individuals (26.98%) in whom TTE was ordered for concern for acute major cardiovascular events and seven (14.58%) in whom TTE was ordered for hemodynamic evaluation.ConclusionOur study describes the clinical indications for use and diagnostic performance of TTE, as well as findings seen on TTE, in hospitalized patients with COVID-19. In appropriately selected patients, TTE can be an invaluable tool for guiding COVID-19 clinical management.

CME/Answers: Metformin - Dos and Don'ts

CME/Answers: Metformin - Dos and Don'ts Abstract. CME/Answers: Metformin - Dos and Don'ts In the absence of contraindications metformin is still considered the initial medication in patients with diabetes mellitus type 2, although diabetes therapy is rapidly changing. Metformin is used both as monotherapy and in combination with any other diabetic medication. As a biguanide metformin improves glycemic control by inhibiting gluconeogenesis and increasing insulin-mediated glucose utilization in peripheral tissues. Metformin promotes modest weight reduction and provides several other advantages: no risk of hypoglycemia, excellent general tolerability, well-known long-term safety profile and low-cost. The most common gastrointestinal side effects are usually mild and transient, but vitamin B12 deficiency may develop. Metformin-associated lactic acidosis (MALA) is a rare, but relevant and life-threatening complication. The risk increases with renal impairment; therefore the metformin dose must be adjusted to the eGFR. The use of metformin is contraindicated with an eGFR <30 ml/min/1.73 m2. There are other contraindications: concurrent active or progressive severe liver disease, active alcohol abuse, unstable or acute heart failure, hypoperfusion and hemodynamic instability, as well as a past history of lactic acidosis. Since metformin remains a modern therapy, it is important to be aware of its indications and contraindications.