Adequate Resuscitation Research Articles

Combat Vascular Access: A Scoping Review.

Medical leadership must decide how to obtain vascular access in a combat environment. Adequate combat trauma resuscitation requires efficient vascular access. A search of the Medline and EMBASE databases was conducted to find articles on combat vascular access. The primary dataset of interest was the type of vascular access obtained. Other data reviewed included who performed the intervention and the success rate of the intervention. The search strategy produced 1,339 results, of which 24 were included in the final analysis. Intravenous (IV), intraosseous (IO), and central venous access have all been used in the prehospital combat environment. This review summarizes the available combat literature to help commanders make an evidence-based decision about their prehospital vascular access strategy.

Factors involved in burn wound healing – short review

Burns represent one of the worldwide leading causes of injury. Burn wounds are associated with increased mortality and morbidity, especially the impaired quality of life due to hypertrophic scarring, scar pain and itching, paresthesia, and contractures. To properly influence the burn wound healing, it is important to establish a correct classification of the acute injury and to understand the main phase of burn wound healing process. There are various local and systemic factors that can be influenced to obtain proper healing. The most important factors include local necrosis and infection, increased local pressure and edema, anemia, hypoxia, hypotension, the presence of important chronic disease and medication, immunosuppression, nutritional status, age, and body constitution. After adequate fluid resuscitation and patient stabilization, the main step is represented by the detachment of the devitalized tissues and rapid coverage of the lesion. There are various methods to be used, like autologous or allogenic skin grafting, the use of skin substitutes, or tissue bioengineering. Knowing all these aspects, allows clinicians to properly define a therapeutic management for patients presenting severe burns.

Advanced Cardiovascular Support in Refractory Shock

“Shock” is a term that is used to signify inadequate tissue perfusion and cellular oxygenation. The basic principle of treating shock is restoring tissue perfusion and adequate cellular oxygenation. Resuscitation from shock is achieved using a combination of fluid therapy, inotropes, and vasopressors. Refractory shock has been defined as requirement of noradrenaline infusion of >0.5 μg/kg/min despite adequate volume resuscitation. Inability to use oxygen damages the cellular machinery and if not restored in time, shock can become irreversible. Mortality in these patients is very high, and the assessment and management of these patients requires a much more aggressive approach for survival. This article will focus on the management of refractory shock.

A case of bowel perforation secondary to burn conversion

Burn conversion is a process by which superficial partial-thickness burns spontaneously progress into deep partialthickness or full-thickness wounds. Factors that influence this process centre around poor perfusion which can be related to either too much or too little fluid resuscitation, infection, free radical damage, and metabolic or nutritional derangements. Therein lies the role of preventative strategies, i.e., adequate fluid resuscitation, prompt identification and management of sepsis, correction of electrolyte derangements and early institution of feeds. Prevention of burn conversion could prevent the need for surgical intervention and improve the morbidity and mortality of burns patients.

Effective Following: A Counterpart to Leadership

Effective Following: A Counterpart to Leadership

Sindroma Kardiorenal

Cardiorenal syndrome (CRS) atau sindroma kardiorenal merupakan suatu kondisi dimana terjadi penyakit ginjal dan penyakit jantung secara bersamaan yang progresifitasnya terjadi dengan cepat. Pada kasus dimana penyakit jantung merupakan penyakit primer, yang terjadi adalah gangguan dinamika kardioavaskular, aktivasi neurohormonal dan faktor inflamasi yang terlibat dalam awal-mulanya perburukan fungsi ginjal dan penyakit ginjal yang progresif.Sepsis adalah “respons sistemik terhadap infeksi yang telah terdokumenetasi atau masih dicurigai dan terjadi disfungsi satu organ”; terdiri dari hipotermia/hipertermia, takikardia, takipnea, infeksi, dan disfungsi organ akhir akibat hipoperfusi. Sepsis yang lebih modern didasari konsep SIRS, sebuah istilah yang mendeskripsikan kompleks imun sebagai respons infeksi dan digunakan untuk menggambarkan ciri klinis yang berkaitan dengan respons tersebut. Penggunaan klinis SIRS menggambarkan kekacauan laju nafas, frekuensi denyut jantung, temperature, dan jumlah leukosit. Jika ada 2 dari 4 kriteria di bawah ini, SIRS bisa ditegakkan: nafas > 20 kali per menit atau PaCo2 <32 mmHg, frekuensi nadi >90 kali per menit, suhu >38o C atau <36o C, dan leukosit >12,000/mm3 atau <4,000/mm3.CRS sepsis adalah disfungsi renal dan kardiak yang terjadi bersamaan dalam sebuah kondisi sistemik primer yang mempengaruhi kedua organ. “Tuntutan iskemik” jantung didasarkan pada alasan meningkatnya kebutuhan oksigen berkaitan dengan respons sepsis (misalnya takikardia, peningkatan curah jantung) yang mengarah kepada cedera iskemik. Disfungsi renal dapat dilihat selama sepsis berat dan merupakan bagian dari gambaran klinis syok septik dan kegagalan multi organ.

Frequency of non-thyroidal illness syndrome in pediatric patients with sepsis and septic shock

BackgroundNon-thyroidal illness syndrome (NTIS) is considered when patients demonstrate altered thyroid hormones and is frequently seen in patients with sepsis and septic shock. Levels keep affected with disease progression and usually get normalized after the sickness is cured. NTIS is not studied well in pediatric population.Aim of the workOur primary outcome was to assess the frequency of hormonal changes of NTIS in sepsis and septic shock patients. The secondary outcome was to follow-up the severity of NTIS and its effect on the prognosis of the primary illness.Patients and methodsThis study (1st phase: cross-sectional, 2nd phase: prospective) included 40 critically ill children categorized into two groups: (i) sepsis group: defined according to standard international criteria using pediatric Sequential Organ Failure Assessment (p SOFA) score and sepsis was considered when p SOFA score > 2; (ii) septic shock group: defined by a vasopressor requirement to maintain a mean arterial pressure ≥ 65 mmHg and having a serum lactate level > 2 mmol/L despite adequate fluid resuscitation, with 20 patients in each group. Patients were admitted to the pediatric intensive care unit (PICU). Thyroid hormone levels were assessed and compared in day 1 and day 5 in all patients and subgroups. All patients were followed up until discharge or death.ResultsNTIS was found in 47.5% of patients. NTIS was higher among septic shock group than sepsis 65.5% versus 30% (p = 0.027). NTIS was associated with each of ventilation, catecholamines infusion and SOFA score (p = 0.044, 0.027, and 0.033) respectively. FT3 (free triiodothyronine) levels were lower and rT3 (reverse T3) levels were higher in day 5 of sickness than day 1 (p = 0.041 and 0.000) respectively. Furthermore, FT3 levels in day 5 were lower, and rT3 levels in day 1 and day 5 were higher in non-survivors than survivors (p = 0.002, 0.015, and 0.003) respectively. ROC curve was done to assess predictors of mortality and revealed that FT3 levels in day 5 was the best in predicting PICU mortality, followed by SOFA score day 5.ConclusionNTIS is common among critically ill children and higher among septic shock group than sepsis. Also, beside the SOFA score, FT3 measured in day 5 of sickness were the best predictors of PICU mortality.

Is venoarterial extracorporeal membrane oxygenation an option for managing septic shock.

To describe sepsis-induced cardiomyopathy. Discuss indications and current evidence of using venoarterial extracorporeal membrane oxygenation (VA-ECMO) in setting of sepsis-induced cardiomyopathy. Recent data suggests a survival benefit with the use of VA-ECMO in patients with septic shock complicated by septic-induced cardiomyopathy with severe left ventricular systolic dysfunction. VA-ECMO was associated with poor outcomes in adults with septic shock without severe systolic dysfunction. The evidence is generated from retrospective and meta-analysis of observational studies. Sepsis-induced cardiomyopathy is an increasingly recognized entity characterized by reversible ventricular dysfunction in the setting of sepsis. When hypotension persists despite standard management of septic shock (e.g. adequate fluid resuscitation, vasopressors, inotropes) and there is evidence of severe cardiac systolic dysfunction and end-organ hypoperfusion, VA-ECMO should be considered as a bridge therapy to recovery. VA-ECMO should not be used for isolated vasodilatory septic shock without significant myocardial dysfunction.

Autonomic and circulatory alterations persist despite adequate resuscitation in a 5-day sepsis swine experiment

Autonomic and vascular failures are common phenotypes of sepsis, typically characterized by tachycardia despite corrected hypotension/hypovolemia, vasopressor resistance, increased arterial stiffness and decreased peripheral vascular resistance. In a 5-day swine experiment of polymicrobial sepsis we aimed at characterizing arterial properties and autonomic mechanisms responsible for cardiovascular homeostasis regulation, with the final goal to verify whether the resuscitation therapy in agreement with standard guidelines was successful in restoring a physiological condition of hemodynamic profile, cardiovascular interactions and autonomic control. Twenty pigs were randomized to polymicrobial sepsis and protocol-based resuscitation or to prolonged mechanical ventilation and sedation without sepsis. The animals were studied at baseline, after sepsis development, and every 24 h during the 3-days resuscitation period. Beat-to-beat carotid blood pressure (BP), carotid blood flow, and central venous pressure were continuously recorded. The two-element Windkessel model was adopted to study carotid arterial compliance, systemic vascular resistance and characteristic time constant τ. Effective arterial elastance was calculated as a simple estimate of total arterial load. Cardiac baroreflex sensitivity (BRS) and low frequency (LF) spectral power of diastolic BP were computed to assess autonomic activity. Sepsis induced significant vascular and autonomic alterations, manifested as increased arterial stiffness, decreased vascular resistance and τ constant, reduced BRS and LF power, higher arterial afterload and elevated heart rate in septic pigs compared to sham animals. This compromised condition was persistent until the end of the experiment, despite achievement of recommended resuscitation goals by administered vasopressors and fluids. Vascular and autonomic alterations persist 3 days after goal-directed resuscitation in a clinically relevant sepsis model. We hypothesize that the addition of these variables to standard clinical markers may better profile patients’ response to treatment and this could drive a more tailored therapy which could have a potential impact on long-term outcomes.

Abstract 10085: Troponin Release is Associated With Mortality and Poor Fluid Resuscitation in Patients With Sepsis

Introduction: Septic patients are predisposed to myocardial injury manifested as cardiac troponin release (TnR). Prognostic significance and management implications of TnR in this setting has not been fully elucidated. We aimed to determine the impact of admission TnR and fluid resuscitation on outcomes of patients with sepsis admitted to intensive care units (ICU). Methods: A total of 24,778 patients with sepsis from eICU-CRD (n=11,992), MIMIC-III (n=6,638) and MIMIC-IV (n=6,148) databases were examined for mortality and 1-year survival by multivariable logistic, Cox regression analysis, or Kaplan-Meier survival analysis with overlap weighting adjustment, as well as generalized additive models for fluid resuscitation. Results: TnR on admission was associated with higher in-hospital mortality [adjusted odds ratios (aOR)=1.33; 95% confidence interval (CI)=1.23-1.43; p< 0.001 in unweighted analysis and aOR=1.39; 95% CI=1.29-1.50; p< 0.001 with overlap weighting]. One-year survival was lower in patients with admission TnR (Kaplan-Meier survival analysis; p=0.002). A trend was noted for association between admission TnR and 1-year mortality [aOR=1.16; 95% CI, 0.99-1.37; p = 0.067 in unweighted analysis] while the association was statistically significant after overlap weighting (aOR=1.25; 95% CI=1.06-1.47; p=0.008). We also found that patients with admission TnR were less likely to benefit from more liberal fluid resuscitation. Adequate fluid resuscitation within a range of 70 to 90 ml/kg in the first 24 hours of ICU stay was associated with lower in-hospital mortality in septic patients without TnR but not in those with admission TnR. Conclusions: Admission TnR was significantly associated with higher in-hospital mortality and worse 1-year survival among septic patients. Adequate fluid resuscitation improved in-hospital mortality in septic patients without but not with admission TnR.

Optimal Sizing of Aortic Stent Graft for Blunt Thoracic Aortic Injury Considering Hypotension-Related Decrease in Aortic Diameter

Purpose: To evaluate the optimal sizing of an aortic stent graft in patients with blunt thoracic aortic injury (BTAI), considering the decrease in diameter in hypovolemic status. Materials and Methods: From 2014 to 2020, 25 patients who underwent thoracic endovascular aortic repair (TEVAR) for BTAI were included. Hemodynamic parameters in the emergency room (ER) and just before the main procedure (MP) were collected. The aortic sizes were measured during initial computed tomography (CT) on arrival in the ER, aortography (AG) during TEVAR, and final CT in the outpatient clinic. The appropriateness of the inserted stent graft size was investigated. Results: The mean values of the final CT/initial CT and final CT/initial AG (proximal descending thoracic aorta [pDTA]) were 113% and 105%, respectively. The final CT/initial CT (pDTA; 122.2% vs 108.8%, p=0.01) and final CT/initial AG (pDTA; 113.4% vs 102.1%, p<0.01) were significantly higher in patients with systolic blood pressure (SBP; MP) ≤90 mm Hg. The final CT/initial CT (pDTA; 120.4% vs 109.0%, p=0.03) and final CT/initial AG (pDTA; 111.4% vs 102.6%, p=0.01) were significantly higher in patients with mean blood pressure (MBP; MP) ≤70 mm Hg. On an average, the inserted stent grafts were oversized by 130% on initial AG. Based on the final CT scan, the inserted stent graft was as large as 122%. Conclusion: In the case of hemodynamic instability with SBP (MP) ≤90 mm Hg or MBP (MP) ≤70 mm Hg, despite adequate resuscitation, an oversized TEVAR stent graft of 130% can reduce the occurrence of endoleak and is sufficiently safe. Clinical Impact Despite sufficient resuscitation, the aorta size measured during TEVAR in patients with hemodynamic instability with systolic BP <90 mmHg and mean BP <70 mmHg may be reduced by more than 15% compared to that in the normal state. In this study, the mean size of the stent grafts were oversized by 130% on initial aortography, but were oversized by 122% based on final CT. When the stent graft was oversized by 130% in TEVAR for hemodynamic unstable patient with BTAI, the patient reached the proper oversizing subsequent to hemodynamic recovery.

Type 1 diabetes in DKA with hypogonadotropic hypogonadism and pituitary apoplexy – A diagnostic dilemma

A 17-year-old underweight boy came with a classical emergency of diabetic ketoacidosis associated with two additional clinical features; persistently low blood pressure despite adequate fluid resuscitation and hypogonadal features with Tanner stage 3 pubic hair, absent facial, and axillary hair along with a high-pitched voice. These findings triggered an endocrine workup which revealed hypogonadotropic hypogonadism. Suspecting primary pituitary pathology, an magnetic resonance imaging brain, was done which showed a well-defined hyperintense lesion in the pituitary suggestive of pituitary apoplexy. In the absence of headache, diplopia, and visual field defects, this incidental finding posed a dilemma regarding the diagnosis and management of diabetic ketoacidosis in the presence of apoplexy.

S2542 A Rare Case of Renal Cell Carcinoma Diagnosed on EGD

Introduction: Neoplasms of the duodenum account for a fraction of overall gastrointestinal tumors. Even when a lesion is found in the duodenum, it is more likely to be of secondary neoplastic origin than primary. Here we present a unique case of primary renal cell carcinoma (RCC) diagnosed on EGD. Case Description/Methods: A 55-year-old male with a history of alcohol use disorder presented to the emergency department for lightheadedness, fatigue, and 100-pound unintentional weight loss over 3 months. On exam, the patient was found to be hypotensive, tachycardic, and jaundiced. Laboratory values were pertinent for a Hemoglobin of 4.4 g/dl. After adequate resuscitation, esophagogastroduodenoscopy (EGD) was performed that showed a large partially obstructive, infiltrative, and ulcerated mass with no bleeding in the second part of the duodenum. Histology from the duodenal mass biopsy revealed clear cell carcinoma of renal origin with mucosal ulceration. An abdominal computerized tomography (CT) scan showed a heterogeneous, centrally necrotic right renal mass causing mass effect on the second and third portions of the duodenum, right hemicolon, and hepatic flexure. The scan was also suggestive of duodenal invasion by the mass. Solid pulmonary nodule biopsy was unequivocal for metastasis. The patient was discussed in tumor board and deemed to be a candidate for cytoreductive surgery with partial duodenal resection and systemic immunotherapy if metastasis was confirmed on future biopsies (Figure). Discussion: Duodenal metastasis from RCC is very rare and poses a diagnostic challenge. The most common presentation is with upper gastrointestinal hemorrhage or obstruction, though sometimes it can present with perforation, intussusception, or obstructive jaundice. Duodenal involvement is often from direct infiltration or metastatic spread. Delay in care and large tumor size are the likely reasons for the rare presentation seen in this patient. This case highlights the importance of considering all neoplasms of extraintestinal origin when duodenal lesions are identified endoscopically.Figure 1.: Left: 2nd portion of duodenum. Right: CT Abdomen/Pelvis.

S3551 Gastric Metastasis of Merkel Cell Carcinoma: A Rare Cancer

Introduction: Merkel Cell Carcinoma (MCC) is a rare aggressive cutaneous neuroendocrine carcinoma. MCC is localized in 65% of cases, 26% cases spread to lymph nodes and metastasis is seen in 8% of cases. Stomach metastasis is rare site of metastasis, seen in 0.2 to 0.7% of cases on autopsy. CK 20 is a sensitive and specific marker of MCC. We present a case of a 63-year-old man who presented with chronic anemia and was found to have gastric metastasis of his cutaneous Merkel Cell Carcinoma. Case Description/Methods: A 63-year Caucasian man with pertinent history for hypertension, chronic anemia on iron therapy and stage IV neuroendocrine cutaneous tumor of left thigh with distant metastasis on treatment presented with melena, worsening fatigue, and shortness of breath for 2 weeks. Two months prior to this hospitalization, the patient was admitted for symptomatic anemia where patient had undergone Upper Gastrointestinal (UGI) Endoscopy. It had revealed non-bleeding gastric ulcers with pigmented material and biopsy was negative for malignancy (Figure a). On presentation his labs were significant for hemoglobin/hematocrit of 5.2/14.7% (g/dL/%). Computed Tomography Angiogram of abdomen and pelvis revealed a GI bleeding source within the proximal stomach. UGI endoscopy was performed after adequate resuscitation which revealed a large, fungating, infiltrative and ulcerated masses in the body of the stomach (Figure b). Biopsies showed malignant cells with immunohistochemical staining positive for chromogranin, synaptophysin, CK7, and CK20. It was reported that the immunomorphological features of initial biopsy of left posterior thigh were like this gastric biopsy. It was concluded that the patient's gastric mass was metastatic MCC. Discussion: MCC is a rare extremely aggressive carcinoma. Its spread to stomach is rare but should be considered in patients with cutaneous neuroendocrine tumor who present with iron deficiency anemia/GI bleeding. In addition, gastric metastasis is exponentially aggressive. Our patient’s gastric ulcer with negative biopsy grew into a fungating mass with proven MCC in two months. Thus, we would also like to highlight the importance of re-biopsy when the index of suspicion is high. Our patient’s initial biopsies were negative for malignancy while subsequent biopsies showed MCC. A combination surgical excision and loco-regional radiotherapy is used for treatment of aggressive primary MCC without distant metastasis. Radiotherapy, or combination with chemotherapy can be used for unresectable MCC.Figure 1.: (a) Initial UGI endoscopy done 2 months before the presentation. Shown above is gastric ulcer with pigmentation in Gastric body and Fundus (b) A large, fungating, infiltrative and ulcerated mass with no bleeding at gastric body. Biopsy of this mass showed MCC.

Gastric volvulus in the mediastinum through a hiatal hernia

Hiatal hernia (HH) is gastric herniation through the oesophageal hiatus into posterior mediastinum. We present an uncommon case of congenital sliding HH in healthy child, with organo-axial gastric-volvulus and normal mid-gut rotation. A 3-month-old female, presented with worsening coffee-ground vomiting for the last 6 weeks. Medical history was unremarkable. She was severely dehydrated with a soft abdomen and no obvious abdominal masses. Initial blood tests revealed elevated White Cell Count (WCC) mainly neutrophils, C-Reactive Protein (CRP) and lactate levels with normal electrolytes. CXR reported discontinuity of left hemi-diaphragm with the stomach shadow occupying the left lower hemi-thorax. The upper GI contrast study and chest CT-scan revealed stomach, pylorus and liver lobe wholly located in the chest, occupying the posterior mediastinum. Both sides of the hemi-thorax were clear, with no evidence of mid-gut malrotation. Radiological images confirmed presence of a large defect in posterior diaphragm around the midline, with stomach and liver herniating into the chest. Following resuscitation, nasogastric tube insertion and consent, a laparotomy revealed organo-axial volvulus of stomach and incarceration, along with the presence of a complete sliding HH through a large defect. Complete reduction of herniated contents, fundoplication and primary closure of defect undertaken. Uneventful post-operative recovery and discharged from hospital after 10 days. We present an infant with complete sliding HH complicated with organo-axial gastric volvulus. Such cases although rare, require high suspicion and prompt management in view of gastric volvulus, as mortality is considerable. With prompt evaluation and adequate resuscitation, we were able to provide immediate optimal surgical treatment and avoid unnecessary complications.

S2284 Black Esophagus as Cause of UGIB After a Complicated Urologic Procedure

Introduction: We report a case of upper endoscopy performed for a patient with coffee-ground emesis after a complicated urologic procedure. It showed diffuse black discoloration in mid-distal esophagus consistent with acute esophageal necrosis (AEN). Case Description/Methods: This is a 68-year-old male with diabetes mellitus (DM), chronic kidney disease, hypertension (HTN) and bladder cancer. He was admitted to intensive care after transurethral resection of bladder tumor (TURBT) was complicated by bladder perforation that required open laparotomy and bladder repair. Patient remained intubated for 48 hours. During the postoperative period, he developed ileus with nausea, vomiting and abdominal distention. He subsequently developed coffee-ground emesis and chest pain. He was not on acid suppressing medication. Upper endoscopy was performed to investigate etiology of upper gastrointestinal bleeding (UGIB), which showed diffuse areas of black discoloration in mid-distal esophagus suggestive for esophageal necrosis (Figure). Pathology showed tissue necrosis consistent with AEN. Patient was promptly treated with a proton-pump inhibitor and sucralfate. Symptoms rapidly improved without recurrence of bleeding or complication. Discussion: AEN, also known as “black esophagus” or necrotizing esophagitis, is a rare syndrome characterized by circumferential black mucosa at the distal esophagus and stops at the gastroesophageal junction. The prevalence is about 0.2% and 4 times more likely in men than women. Risk factors include DM, malignancy, HTN, alcohol abuse and coronary artery disease. The etiology is likely esophageal ischemia from a low-flow state followed by a backflow injury from chemical contents of gastric secretions. Majority of patients present with UGIB, followed by dysphagia and epigastric/chest pain. Symptoms can develop rapidly following an inciting event. With adequate resuscitation and medical therapy (proton pump inhibitors and sucralfate), patients can recover rapidly. Complications may include stricture, perforation, mediastinitis, and death. Prognosis is poor due to underlying critical illness, but mortality specific to AEN is much lower. Endoscopic appearance is suggestive, but biopsy is recommended to establish the diagnosis and exclude other diagnoses (e.g. melanoma and acanthosis nigricans). Repeat endoscopic evaluation is important to assess mucosal healing and determine duration of antacid therapy. Endoscopic balloon dilation may be necessary for stricture from AEN.Figure 1.: Diffuse circumferential black discoloration in lower esophagus.

VASOPRESSOR-RESISTANT HYPOTENSION, COMBINATION VASOPRESSOR THERAPY, AND SHOCK PHENOTYPES IN CRITICALLY ILL ADULTS WITH VASODILATORY SHOCK.

ABSTRACTObjective: To examine the risk factors, resource utilization, and 1-year mortality associated with vasopressor-resistant hypotension (VRH) compared with vasopressor-sensitive hypotension (VSH) among critically ill adults with vasodilatory shock. We also examined whether combination vasopressor therapy and patient phenotype were associated with mortality. Design: Retrospective cohort study. Setting: Eight medical-surgical intensive care units at the University of Pittsburgh Medical Center, Pittsburgh, PA. Patients: Critically ill patients with vasodilatory shock admitted between July 2000 and October 2008. Interventions: None. Measurements and Main Results: Vasopressor-resistant hypotension was defined as those requiring greater than 0.2 μg/kg per minute of norepinephrine equivalent dose of vasopressor consecutively for more than 6 h, and VSH was defined as patients requiring ≤0.2 μg/kg per minute to maintain MAP between 55 and 70 mm Hg after adequate fluid resuscitation. Of 5,313 patients with vasodilatory shock, 1,291 patients (24.3%) developed VRH. Compared with VSH, VRH was associated with increased risk of acute kidney injury (72.7% vs. 65.0%; P < 0.001), use of kidney replacement therapy (26.0% vs. 11.0%; P < 0.001), longer median (interquartile range [IQR]) intensive care unit length of stay (10 [IQR, 4.0–20.0] vs. 6 [IQR, 3.0–13.0] days; P < 0.001), and increased 1-year mortality (64.7% vs. 34.8%; P < 0.001). Vasopressor-resistant hypotension was associated with increased odds of risk-adjusted mortality (adjusted odds ratio [aOR], 2.93; 95% confidence interval [CI], 2.52–3.40; P < 0.001). When compared with monotherapy, combination vasopressor therapy with two (aOR, 0.91; 95% CI, 0.78–1.06) and three or more vasopressors was not associated with lower mortality (aOR, 0.93; 95% CI, 0.68–1.27). Using a finite mixture model, we identified four unique phenotypes of patient clusters that differed with respect to demographics, severity of illness, processes of care, vasopressor use, and outcomes. Conclusions: Among critically ill patients with vasodilatory shock, VRH compared with VSH is associated with increased resource utilization and long-term risk of death. However, combination vasopressor therapy was not associated with lower risk of death. We identified four unique phenotypes of patient clusters that require further validation.

COVID-19 presentation as acute pancreatitis

Rationale: The gastrointestinal manifestations of COVID-19 include anorexia, nausea, vomiting, abdominal pain, and diarrhea. However, pancreatitis as the presentation of COVID-19 is rarely reported. Patient’s Concern: A 63-year-old COVID-19 patient presented with complaints of abdominal pain and difficulty breathing for 5 d. Diagnosis: Contrast-enhanced computed tomography of the abdomen suggested acute interstitial pancreatitis without any biliary tract obstruction. Interventions: The patient was resuscitated with intravenous fluids based on dynamic parameters of fluid responsiveness. The patient was started on enteral feeding, analgesics, antibiotics, dexamethasone, low molecular weight heparin, and supportive therapy. Outcomes: The patient developed severe acute respiratory distress syndrome and died 6 days after admission. Lessons: Management of COVID-19 in the presence of pancreatitis is challenging. Adequate early fluid resuscitation is an important aspect of medical management for COVID-19 patients with pancreatitis and restrictive strategies must be followed. Increased liver enzymes and renal dysfunction in acute pancreatitis can also limit the use of specific therapies like remdesivir. Dexamethasone, even though it has shown a beneficial effect in treating COVID-19, can have an additive effect in causing hyperglycemia in these cases. Clinicians should be aware of this atypical presentation of COVID-19 with pancreatitis and adjust their management strategies, keeping in mind the considerations for both diseases.

Fifteen-minute consultation: Intubation of the critically ill child presenting to the emergency department

Intubation of critically ill children presenting to the emergency department is a high-risk procedure. Our article aims to offer a step-by-step guide as to how to plan and execute a...

875 Atraumatic Splenic Rupture Secondary to Ruptured Pancreatic Pseudo Cyst- a Rare Phenomenon

Abstract Introduction Chronic pancreatitis can be complicated by the development of a pancreatic pseudocyst in 20 – 40% of cases. Splenic rupture is usually associated with blunt trauma but can be associated with non-traumatic causes like pancreatic pseudocysts associated with chronic pancreatitis. Atraumatic splenic rupture (ASR) is rare, and a life-threatening process with a mortality of about 12%. Possible mechanisms of action of pancreatic pseudocysts causing ASR to have been described in literature, with some of them involving the action of proteolytic enzymes on the splenic vessels, parenchyma and hilum. Management of these cases involves resuscitation, and emergency splenectomy because they usually present with haemodynamic instability. Case report A 50-year-old woman with a background of pancreatic pseudocyst secondary to alcoholic chronic pancreatitis presented with severe left sided abdominal pain. A Computed Tomography (CT)scan confirmed the presence of splenic rupture with moderate haemoperitoneum. Emergency laparotomy revealed a ruptured and necrotic spleen adjacent to a ruptured pancreatic pseudocyst. A splenectomy was performed with abdominal packs left insitu with the view to a relook surgery 24 /48 hours later. She recovered uneventfully after HDU care. Conclusions ASR secondary to pancreatic pseudocyst as a complication of chronic pancreatitis is a rare phenomenon which requires a high index of suspicion for diagnosis. CT is the gold standard imaging modality for investigation in a haemodynamically stable patient. Management is surgical with adequate resuscitation and perioperative critical care.