Arterial Blood Gas Determinations Research Articles

A rare case series of bilateral pneumothorax among adult COVID-19 patients reported at a tertiary care hospital in Mizoram, India

Apart from routine symptoms such as fever, cough, sore throat, myalgia, and dyspnea in severe form of Coronavirus Disease-2019 (COVID-19) infection, very rarely patients can develop worsening of dyspnea due to bilateral pneumothorax. The present case series is about five adult patients, of age ranging from 39 to 57 years, who developed bilateral pneumothorax during their stay in the hospital. All the cases were reported between May 2021 and October 2021 and were tested positive for COVID-19 by reverse transcriptase polymerase chain reaction. Out of five adults, three patients were males and were two females. All the patients were assessed with quick sequential organ failure assessment (q SOFA) score on admission and then monitored by SOFA Score. On admission, baseline contrast enhanced computer tomography chest was done for three patients, and chest radiography for one patient all showing features of moderate to severe COVID-19 pneumoniae. One patient with q SOFA Score of 3 on admission required immediate invasive mechanical ventilatory support with ultrasonogram chest immediately performed showing bilateral pneumothorax. Patients were started on remdesivir, dexamethasone, low molecular weight heparin or unfractionated heparin, tocilizumab, and antibiotics. Subsequently, during the course of stay in the hospital, rest of the four patients developed symptoms of pneumothorax and emergency bedside chest ultrasonography showed the typical barcode or stratosphere sign confirming bilateral pneumothorax. All the patients were managed with bilateral chest intercostal water seal drainage intercostal drain tube and invasive mechanical ventilation. Fraction of Inspired Oxygen (FIO2), and other ventilatory settings were adjusted depending on daily arterial blood gas findings. Attempts to wean off from ventilatory support and extubation were successful for two patients, whereas three patients did not survive. In this case series, we will be presenting about those five cases of bilateral pneumothorax in COVID-19 patients reported at a tertiary care hospital in Mizoram, India.

The Predictive Values of Respiratory Rate Oxygenation Index and Chest Computed Tomography Severity Score for High-Flow Nasal Oxygen Failure in Critically Ill Patients with Coronavirus Disease-2019.

Background:The prediction of high-flow nasal oxygen (HFNO) failure in patients with coronavirus disease-2019 (COVID-19) having acute respiratory failure (ARF) may prevent delayed intubation and decrease mortality.Aims:To define the related risk factors to HFNO failure and hospital mortality.Study Design:Retrospective cohort study.Methods:To this study, 85 critically ill patients (≥18 years) with COVID-19 related acute kidney injury who were treated with HFNO were enrolled. Treatment success was defined as the de-escalation of the oxygenation support to the conventional oxygen therapies. HFNO therapy failure was determined as the need for invasive mechanical ventilation or death. The patients were divided into HFNO-failure (HFNO-F) and HFNO-success (HFNO-S) groups. Electronic medical records and laboratory data were screened for all patients. Respiratory rate oxygenation (ROX) index on the first hour and chest computed tomography (CT) severity score were calculated. Factors related to HFNO therapy failure and mortality were defined.Results:This study assessed 85 patients (median age 67 years, 69.4% male) who were divided into two groups as HFNO success (n = 33) and HFNO failure (n = 52). The respiratory rate oxygenation (ROX) was measured at 1 hour and the computed tomography (CT) score indicated HFNO failure and intubation, with an area under the receiver operating characteristic of 0.695 for the ROX index and 0.628 for the CT score. A ROX index of <3.81 and a CT score of >15 in the first hour of therapy were the predictors of HFNO failure and intubation. Age, Acute Physiology and Chronic Health Evaluation II score, arterial blood gas findings “(i.e., partial pressure of oxygen [PaO2], PaO2 [fraction of inspired oxygen]/SO2 [oxygen saturation] ratio)”, and D-dimer levels were also associated with HFNO failure; however, based on logistic regression analysis, a calculated ROX on the first hour of therapy of <3.81 (odds ratio [OR] = 4.78, 95% confidence interval [CI] = 1.75–13.02, P = 0.001) and a chest CT score of >15 (OR = 2.83, 95% CI = 1.01–7.88, P = <0.001) were the only independent risk factors. In logistic regression analysis, a ROX calculated on the first hour of therapy of <3.81 (OR = 4.78, [95% CI = 1.75–13.02], P = 0.001) and a chest CT score of >15 (OR 2.83, 95% CI = 1.01–7.88, P = <0.001) were the independent risk factors for the HFNO failure. The intensive care unit and hospital mortality rates were 80.2% and 82.7%, respectively, in the HFNO failure group.Conclusion:The early prediction of HFNO therapy failure is essential considering the high mortality rate in patients with HFNO therapy failure. Using the ROX index and the chest CT severity score combined with the other clinical parameters may reduce mortality. Additionally, multi-centre observational studies are needed to define the predictive value of ROX and chest CT score not only for COVID-19 but also other causes of ARF.

The effects of inhaled β-adrenergic agonists in transient tachypnea of the newborn

Objective The objective of this study was to evaluate the efficacy of inhaled salbutamol for the treatment of transient tachypnea of the newborn (TTN). Background The most commonly reported cause of neonatal respiratory distress is TTN, with estimated incidence of 0.5–2.8% of all newborn. Patient and methods This is a randomized controlled trial study considering patient with even registration number as cases. Inhaled salbutamol or normal saline solution was administered to 60 infants diagnosed as having TTN. The response was evaluated by determining respiratory rate, heart rate, TTN clinical score, and level of respiratory support, before and at 30 min and 1 and 4 h after drugs therapy. The standard dose of salbutamol was 0.15 mg/kg added to 2 ml normal saline. The second group received dose of 2 ml nebulized (0.9%) normal saline only. Results The studied neonates were between 36 and 39 weeks of gestation. There were 30 (50%) males and 30 (50%) females. Comparing the two groups after 4 h of inhaled therapy, highly significant lower respiratory rate, oxygen, TTN score, respiratory support, and duration of hospitalization were detected in salbutamol group rather than saline group. Regarding arterial blood gas findings after 4 h of inhaled therapy, pH and partial pressure of arterial oxygen were significantly higher in salbutamol group than saline group. No significant difference was detected between the two groups regarding heart rate and serum potassium. Conclusion A single dose of inhaled salbutamol resulted in better clinical aspect and better laboratory outcome measures in cases of TTN.

Pneumocystis pneumonia in HIV-negative immunocompromised patients in Internal Medicine ward

Pneumocystis jirovecii pneumonia (PJP) is an opportunistic infection typically observed in AIDS patients, for whom it represents a leading cause of death. However, its incidence among HIV-negative immunocompromised patients is progressively increasing, with a significantly higher mortality compared to that of AIDS-patients. We performed a retrospective observational study on HIV-negative patients with PJP. We aimed to determine their epidemiological features and their biohumoral and therapeutic variables, searching for a correlation between them and our patients’ outcome. We included all patients admitted to our Internal Medicine ward from January 2010 to June 2015, who were immunocompromised at the time of admission and had microbiologically confirmed PJP (association between compatible clinical-radiological findings and qualitative polymerase chain reaction positivity on bronchoalveolar lavage). Their immune impairment was assessed considering both their medical history and their complete white blood cells (WBC), differential WBC and their CD4 cell count. Transfer to Intensive Care Unit (ICU) or death was considered as an unfavorable clinical outcome, while hospital discharge or transfer to a non-ICU ward was considered as a favorable outcome. We included a total of 18 patients in our statistical analysis. We used Student’s t-test and Fischer’s χ-square test to compare, respectively, normally distributed continuous variables and non-continuous variables. Our patients’ mean age was 65±13.9 years. All of them had cancer, mostly hematological malignancies (13/18), notably non-Hodgkin lymphoma (NHL; 8/13). They were all being or had been recently treated with chemotherapy (10/18) and/or high-dose glucocorticoids, with full dose or during tapering (13/18). Statistical analysis of blood tests results showed a significant difference between mean serum lactate dehydrogenase (LDH) concentration in the group of patients with favorable vs unfavorable outcome. Also, mean serum immunoglobulins G (IgG) concentration and certain arterial blood gas findings (mean arterial paO2/FiO2, mean blood Ph and mean paCO2) at the time of admission were significantly different in the two groups of patients. 12/18 patient’s outcome turned out unfavorable. Trimethoprim + sulfamethoxazole (TMP+SMX) treatment was given to all our patients, with a mean duration of 13.39±9.36 days. Patients with a favorable outcome had received TMP+SMX treatment significantly earlier than those with an unfavorable outcome. Hematological malignancies, according to literature, confer the strongest predisposition to PJP. Both chemotherapy and high-dose Glucocorticoid treatment are well known predisposing factors. A remarkable elevation of serum LDH represents both a typical clinical feature and a well-known negative prognostic factor in PJP. Low IgG levels have never been reported as a negative prognostic factor, but their role in enhancing macrophage killing of pneumocystis may account for the worst observed prognosis in the group of patients with lower mean levels. Therefore, in order to reduce the heavy mortality rate associated with PJP, an early beginning of specific treatment is of utmost importance, and even if this is certainly true for many infectious diseases, the time gap is particularly limited in the setting of this type of pneumonia. Hence, PJP should be ruled out as soon as possible and, in case of a strong clinical- radiological suspicion, therapy should be started immediately, even while waiting for microbiological confirmation (especially in critically-ill patients).

Plasmatic Concentrations of ADMA and Homocystein in Llama (Lama glama) and Regulation of Arginase Type II: An Animal Resistent to the Development of Pulmonary Hypertension Induced by Hypoxia.

There are animal species that have adapted to life at high altitude and hypobaric hypoxia conditions in the Andean highlands. One such species is the llama (Lama glama), which seem to have developed efficient protective mechanisms to avoid maladaptation resulting from chronic hypoxia, such as a resistance to the development of hypoxia -induced pulmonary hypertension. On the other hand, it is widely known that different models of hypertension can arise as a result of changes in endothelial function. The respect, one of the common causes of deregulation in endothelial vasodilator function have been associated with down-regulation of the NO synthesis and an increase in plasma levels of asymmetric dimethylarginine (ADMA) and homocysteine. Additionally, it is also known that NO production can be regulated by plasma levels of L-arginine as a result of the competition between nitric oxide synthase (NOS) and arginase. The objective of this study, was to determine the baseline concentrations of ADMA and homocysteine in llama, and to evaluate their effect on the arginase pathway and their involvement in the resistance to the development of altitude-induced pulmonary hypertension. METHOD: Lowland and highland newborn sheep and llama were investigated near sea level and at high altitude. Blood determinations of arterial blood gases, ADMA and homocysteíne are made and the effect of these on the arginase activity was evaluated. RESULTS: The basal concentrations of ADMA and homocysteine were determined in llama, and they were found to be significantly lower than those found in other species and in addition, the exposure to hypoxia is unable to increase its concentration. On the other hand, it was observed that the llama exhibited 10 times less arginase II activity as compared to sheep, and the expression was not induced by hypoxia. Finally, ADMA y Hcy, has no effect on the type II arginase pathway. CONCLUSION: Based on our results, we propose that low concentrations of ADMA and homocysteine found in llamas, the low expression of arginase type II, DDAH-2 and CBS, as well as its insensitivity to activation by homocysteine could constitute an adaptation mechanism of these animals to the hypoxia.

Spontaneous and Reflex Movements of the Brain Death in South-East Province of South Korea

Introduction During the diagnosis of the brain death, remained spontaneous or reflex movements of the patient may cause confusion of status of brain death and many medical staffs are reluctant to diagnose the brain death. In order to analyze multiple movements of brain death patients and provide the helpful basis for diagnosis of brain death, we reviewed our video record checked during patient management. Methods We conducted a regional cohort study of adult patients (≥aged 19 years old) with brain death admitted to the hospital care systems in south-east province of South Korea from January 2013 to December 2016. We divide the patients into two groups: ‘Brain death with spontaneous and reflex movements’ and ‘Brain death without spontaneous and reflex movements’. We described the patterns of spontaneous and reflex movements through video analysis. Demographic and clinical characteristics including the causes of brain death, timing of spontaneous and reflex movement detection, hemodynamic parameters, and arterial blood gas findings were compared between the two groups. Results During the study period, 436 patients met criteria for brain death. Among them, 74 (17.0%, age 49.7±12.6 years, 64.9% males) subjects had spontaneous or reflex movements, which were analyzed in the way of video record. The most common movements were the extensor plantar response and tonic neck reflex. The logistic regression analysis revealed that hypoxic brain injury (OR=2.93, p=0.001), higher mean systolic blood pressure (OR=1.05, p=0.000), and longer the time from diagnosis of brain death (OR=1.04, p=0.016) were significantly correlated with presence of spontaneous or reflex movement in brain death subjects. There were no statistically significant differences in age, sex, height, heart rate, body temperature, blood PH, bicarbonate and partial pressure of oxygen and carbon dioxide levels. Conclusions While diagnosing a brain death especially caused by hypoxic brain injury, higher mean systolic pressure, and longer time from diagnosis of brain death, special attention is necessary not to exclude brain death in such patients with spontaneous and reflex movements. The common movements that appeared on video review were extensor plantar response and tonic neck reflex. As we know through the above results, medical staffs who perform the diagnosis of the brain death need opportunities for sharing diverse experiences and information.

Dexmedetomidine-treated hyperventilation syndrome triggered by the distress related with a urinary catheter after general anesthesia: a case report

BackgroundHyperventilation syndrome (HVS) sometimes occurs in patients under stressful conditions and may provoke severe complications such as myocardial infarction and death. The authors report a case of HVS following general anesthesia, where a continuous intravenous infusion of dexmedetomidine was effective for HVS.Case presentationA 23-year-old male patient with recurrent tongue cancer was scheduled to undergo partial glossectomy and neck dissection. Emergence from general anesthesia was prompt. Twenty-two minutes after extubation, the patient complained of unbearable distress caused by the urinary catheter. He began to cry, with an increased respiratory rate of over 40 breaths per minute. Intravenous infusion of flurbiprofen, droperidol, and morphine was not effective. Electrocardiography and laryngofiberscopy indicated the absence of acute coronary syndrome and airway obstruction, respectively. An arterial blood gas determination showed pH 7.63, PaCO2 18.2 mmHg, PaO2 143 mmHg on O2 mask 4 L/min, Ca2+ 4.29 mmol/L, and lactate 3.4 mmol/L. The patient was diagnosed with HVS. Dexmedetomidine infusion 2.0 μg/kg/h for 10 min followed by 0.7 μg/kg/h reduced respiratory rate, suppressed arousal, and disappeared the complaint of bladder distension. One hour after extubation, an arterial blood gas determination showed pH 7.33, PaCO2 51.3 mmHg, PaO2 196 mmHg on O2 mask 4 L/min, Ca2+ 4.70 mmol/L, and lactate 1.5 mmol/L. After admission to the intensive care unit, dexmedetomidine infusion was maintained at the rate of 0.2 to 0.7 μg/kg/h until the following morning, and he did not complain of distress caused by the urinary catheter.ConclusionsHVS can occur after emergence from general anesthesia, and dexmedetomidine infusion was effective for HVS.

An Educational Intervention Optimizes the Use of Arterial Blood Gas Determinations Across ICUs From Different Specialties: A Quality-Improvement Study

Overuse of arterial blood gas (ABG) determinations leads to increased costs, inefficient use of staff work hours, and patient discomfort and blood loss. We developed guidelines to optimize ABG use in the ICU. ABG use guidelines were implemented in all adult ICUs in our institution: three medical, two trauma-surgery, one cardiovascular, and one neurosurgical ICU. Although relying on pulse oximetry, we encouraged the use of ABG determination after an acute respiratory event or for a rational clinical concern and discouraged obtaining ABG measurements for routine surveillance, after planned changes of positive end-expiratory pressure or Fio2 on the mechanical ventilator, for spontaneous breathing trials, or when a disorder was not suspected. ABG measurements and global ICU metrics were collected before (year 2014) and after (year 2015) the intervention. We saw a reduction of 821.5 ± 257.4 ABG determinations per month (41.5%), or approximately one ABG determination per patient per mechanical ventilation (MV) day for each month (43.1%), after introducing the guidelines (P< .001). This represented 49L of saved blood, a reduction of $39,432 in the costs of ICU care, and 1,643 staff work hours freed for other tasks. Appropriately indicated tests rose to 83.4%from a baseline 67.5%(P= .002). Less than 5%of inappropriately indicated ABG determinations changed patient management in the postintervention period. There were no significant differences in MV days, severity of illness, or ICU mortality between the two periods. The large scale implementation of guidelines for ABG use reduced thenumber of inappropriately ordered ABG determinations over seven different multidisciplinary ICUs, without negatively impacting patient care.

Comparison of Outcomes Between Patients Treated by Therapeutic Hypothermia for Cardiac Arrest Due to Cardiac or Respiratory Causes

Outcome for patients experiencing out-hospital cardiac arrest (OHCA) due to respiratory causes is poor, even with treatment by therapeutic hypothermia (TH). The purpose of this study is to clarify difference in outcome and respiratory state during resuscitation between cases due to respiratory causes versus those due to cardiac causes, to establish alternative strategies for the patient. This study was conducted as a retrospective analysis of patients with post CA syndrome who underwent TH. Patients were divided into two groups according to cause of CA: cardiac (C group) or respiratory (R group). Utstein Style data, outcome, and arterial blood gas (ABG) findings after emergency room admission of the two groups were compared. Of 74 patients treated with TH during the 2-year study period, 49 were placed in the C group and 19 in the R group. The rates of ventricular fibrillation/pulseless ventricular tachycardia at initial rhythm were significantly higher in the C group than in the R group. The rate of favorable neurological outcome was significantly higher in the C group (15/49: 30.6%) than in the R group (1/19: 5.3%) 30 days after resuscitation. In the ABG findings, PaCO2 was significantly higher in the R group than in the C group. For patients experiencing OHCA from respiratory causes, TH was less effective and PaCO2 accumulated immediately after admission. From this, interpretation of the significance of PaCO2 in these patients at the early stage after return of spontaneous circulation should be seriously considered.

Approach of pulmonologists in Turkey to noninvasive mechanical ventilation use at home for chronic respiratory failure.

To define approach of pulmonologists in Turkey to noninvasive mechanical ventilation (NIV) use for chronic respiratory failure (CRF), the most currently applied technique for home mechanical ventilation. A 38-question survey, developed and tested by the authors, was distributed throughout Turkey to 2205 pulmonologists by e-mail. Twenty-seven percent of the pulmonologists responded (n=596). Domiciliary NIV was reported to be prescribed by 340 physicians [57.1% of all responders and 81% of pulmonologists practicing NIV at clinical practice (n= 420)]. NIV prescription was associated with physician's title, type of hospital, duration of medical license, total number of patients treated with NIV during residency and current number of patients treated with NIV per week (p< 0.05). Main estimated indications were listed as chronic obstructive pulmonary disease (median, 25-75 percentile of the prescriptions: 75%, 60-85), obesity hypoventilation syndrome (10%, 2-15), overlap syndrome (10%, 0-20) and restrictive lung disease (5%, 2-10). For utilization of NIV at home, Bilevel positive airway pressure-spontaneous mode (40%, 0-80) and oronasal mask (90%, 60-100) were stated as the most frequently recommended mode and interface, respectively. Pressure settings were most often titrated based on arterial blood gas findings (79.2%). Humidifier was stated not to be prescribed by approximately half of the physicians recommending domicilliary NIV, and the main reason for this (59.2%) was being un-refundable by social security foundation. There is a wide variation in Turkey for prescription of NIV, which is supposed to improve clinical course of patients with CRF. Further studies are required to determine the possible causes of these differences, frequency of use and patient outcomes in this setting.

Repair of a thrombosed pseudoaneurysm that developed after puncture for an arterial blood gas using a vein graf

Pseudoaneurysms involving the leakage of blood between the arterial wall and the peripheral parenchyma can occur as a result of an artery’s perforation. In this case report, we present a repair, using a vein graft, of a thrombosed pseudoa- neurysm that developed in a radial artery after a single puncture to obtain a sample for the determination of arterial blood gases. A 56-year-old female patient was admitted with a mass in her left wrist on the radial side. Upon examination, a sen- sitive and mobile mass was detected by palpation. The patient had no fever or any other symptoms of inflammation. Her detailed anamnesis revealed that the mass had developed after a puncture to obtain a blood sample for an arterial blood gas measurement. By using magnetic resonance imaging the mass was determined to be a thrombosed pseudoaneurysm. The mass was excised and the gap that had developed in the radial artery was repaired with a vein graft obtained from the forearm. Magnetic resonance angiography imaging after 1 month confirmed the vein graft’s patency. Cannulations for blood monitoring, blood gas analysis and interventional radiological procedures are indispensable processes used in medicine; however, they are not risk-free. Following these procedures, thromboses and pseudoaneurysms can develop. A number of treatment options exist, including bandaging, percutaneous thrombin injections, and surgical treatment for complicated cases. For pseudoaneurysms that create a mass effect, as in our case, surgery is needed. Such complications after interventional procedures involving the radial artery should be kept in mind.

Factors Related to NIMV Failure in Hospitalized COPD Patients With Exacerbation

SESSION TITLE: COPD Posters VI SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM PURPOSE: Non-invasive mechanical ventilation (NIMV) is routinely used in exacerbations of COPD patients admitted with hypercapnia. In this study treatment results and factors affecting successful NIMV application in COPD patients in chest clinics were investigated. METHODS: All COPD patients admitted to emergency clinics with acute hypercapnic respiratory failure between May 2010 and May 2012 were included in this study. After first application of NIMV in emergency clinics, patients were hospitalized and NIMV was continued in patient wards. Demographic properties, comorbidities, arterial blood gas findings on admission and follow-up, hematologic and biochemical findings were noted. Factors influencing success and failure (transfer to ICU or death) of NIMV application were investigated. RESULTS: NIMV was successful in 377 patients (83.6%) and unsuccessful in 67 patients (16.4%). Factors affecting the failure were found as low albumin, high CRP, unresolved pH and PaCO2 levels 1 hour after application of NIMV, higher number of comorbidities, presence of any malignancy and low IPAP. CONCLUSIONS: Our success rate is high in hospitalized patients having NIMV due to COPD exacerbation. In this study, we found multiple factors leading to failure of NIMV in COPD exacerbations. We think that clinicians should be careful about applying NIMV in COPD patients carrying these negative factors during exacerbation and should consider early admission to the ICU. CLINICAL IMPLICATIONS: Clinicians can predict NIMV failure by using multipl parametres . DISCLOSURE: The following authors have nothing to disclose: Meltem Agca, Fatma Tokgoz, Dildar Yetis, Fatma Merve Tepetam, Aysun Misirlioglu, Hakan Gunen, Tulay Yarkin

Nosocomial pneumonia in non-invasive ventilation patients: incidence, characteristics, and outcomes

Nosocomial pneumonia occasionally occurs in non-invasive ventilation (NIV) patients. To report the incidence, characteristics, and outcomes of nosocomial pneumonia in NIV patients. A prospective observational study was performed in a respiratory intensive care unit (ICU). After admission, patients who received NIV for more than 48 h were enrolled. Pneumonia was considered nosocomial when it occurred after at least 48 h of NIV. Between January 2012 and August 2014, we enrolled 520 NIV patients. Nosocomial pneumonia occurred in 16 patients (3.1%). The nosocomial pneumonia rate was 4.5 cases per 1000 NIV-days. The most common pathogen was Acinetobacter baumannii (81%). At the initiation of NIV, there were no differences in age, gender, diagnosis, disease severity, or arterial blood gas findings between patients with and without nosocomial pneumonia. Compared to patients without nosocomial pneumonia, nosocomial pneumonia patients had a longer duration of NIV (8.4 vs 5.0 days, P < 0.01), a longer ICU stay (10.8 vs 7.9 days, P = 0.01), a longer hospital stay (25.9 vs 15.3 days, P = 0.04), a higher intubation rate (63% vs 21%, P < 0.01), and higher hospital mortality (75% vs 25%, P < 0.01). Nosocomial pneumonia was an independent risk factor for intubation (OR: 6.74; 95% CI: 2.24-20.28) and death (7.65; 1.34-43.72). The incidence of nosocomial pneumonia in NIV patients in this population was 3.1%. Nosocomial pneumonia increased the time that NIV was required, length of ICU stay, length of hospital stay, intubation rate, and hospital mortality.

Effects of Moderate Glycemic Control in Type II Diabetes With Insulin on Arterial Blood Gas Parameters Following Coronary Artery Bypass Graft Surgery.

Background:Coronary artery bypass grafting (CABG) is one of the common surgeries in patients with coronary artery disease (CAD). It is more probable for patients with diabetes to undergo surgeries due to CAD and they have a higher mortality rate compared to the othersObjectives:The aim of the present study was to assess the effects of insulin infusion therapy on blood gas parameters in two groups of patients, eligible for CABG, defined as A: well controlled diabetes (HbA1C < 7%) and B: non-diabetic patients.Patients and Methods:We followed two groups of patients, defined as patients with and without diabetes who were candidates for CABG, between March 2010 and March 2012. Patients with diabetes underwent moderate or semi-tight glycemic control, using continuous intravenous insulin infusion.Results:There were 13 male and 18 female subjects in the on-diabetic group and 11 male and 7 female patients in the controlled diabetic group. There was no significant difference between the studied participants regarding age, cardiac ejection fraction, blood pH and PO2 and PCO2 levels.Conclusions:CABG surgery adversely affects arterial blood gas (ABG) determinations. On the other hand, findings showed there is no significant difference in the ABG parameters between patients with well controlled diabetes and the ones without.

Arterial blood gas analysers: accuracy in determining haemoglobin, glucose and electrolyte concentrations in critically ill adult patients

Arterial blood gas (ABG) machines are vital tools in the assessment of critically ill patients. Current ABG point-of-care (POC) analysers provide information on concentrations of haemoglobin, glucose and electrolytes in addition to acid-base balance. Awaiting results from venous analysers may present a significant delay in diagnosis and management, thus reliance on arterial blood gas determination of these parameters is increasing. However, published data on the concordance between the two modalities are limited. This study aims to assess the concordance of ABG machines in analysing haemoglobin, glucose and electrolyte concentrations compared to standard venous analysers as the gold standard. Results from 100 patients undergoing ABG analysis and simultaneous venous sampling without therapeutic intervention between sampling were compared. Differences in haemoglobin, glucose, sodium and potassium concentrations were determined and analysed using statistical software (Statview). There was a significant difference (P<0.02, paired signed test) in the mean haemoglobin concentration between the two modalities of 0.91 g/dL (range: 0–4.3 g/dL). Mean discrepancy in glucose concentrations was 1.16 mmol/L (range: 0-10.5 mmol/L; P<0.012, paired-signed test). Sodium and potassium showed no significant difference within the physiological range. At higher concentrations of potassium (>5 mmol/L), ABG readings varied significantly (P<0.0013, paired sign test) from standard venous estimates (mean difference: 0.44 mmol/L). Arterial blood gas analysers are invaluable for rapid assessment of critically ill patients; however, estimations of haemoglobin, glucose and potassium concentrations (>5 mmol/L) obtained from such machines should be interpreted with caution and confirmed using standard venous samples.

Persistent hiccups followed by cardiorespiratory arrest

In January, 2011, a 78-year-old man was referred to us with syncope and persistent hiccups. He had had nausea and continuous hiccups 9 days earlier, and had fainted while visiting a local clinic. At our hospital, he had an immediate reduction in systolic blood pressure of 40 mm Hg and loss of consciousness after standing up after lying in a supine position for 5 min. Neurological evaluation showed a right hypoglossal nerve palsy, but MRI of the brain and spinal cord and cerebrospinal fl uid were normal. Chest radiography, gastroendoscopy, ECG, and echocardiography showed no abnormalities. Metoclopramide was prescribed for hiccups and amezinium metilsulphate for orthostatic hypotension. He was discharged because his symptoms improved. 2 weeks later he developed muscle weakness, and after 3 days could not walk. On readmission, he had dysarthria and dysphagia. Ophthalmoscopy showed no abnormalities. He had severe muscle weakness in his upper and lower limbs. CSF white blood cell count was 78 μL (99% lymphocytes) and protein concentration 1·03 g/L. MRI of the brain showed lesions in the medulla oblongata. We suspected acute disseminated encephalomyelitis, herpes simplex virus encephalitis, or neuromyelitis optica (NMO) spectrum disorder, and he was given methylprednisolone pulse therapy (1 g per day) and acyclovir 1500 mg per day. Despite treatment, his muscle weakness worsened. 1 week after completion of methylprednisolone pulse therapy, he had dyspnoea. Arterial blood gas fi ndings were unremarkable while on 2 L oxygen, so we planned MRI of the spinal cord the same day. His blood saturation level started decreasing, while he was in the

Apparent Life-Threatening Events: An Update

Based on strong research evidence, the most common causes of apparent life-threatening events (ALTEs) are gastroesophageal reflux, lower respiratory tract infection, and seizure. • The minimum initial diagnostic panel for ALTE should include complete blood cell (CBC) count with differential; blood levels of C-reactive protein,glucose, sodium, potassium, urea, calcium,magnesium, ammonia, lactate, and pyruvate; arterial blood gas determination, urinalysis, and toxicology screen; electrocardiography; and assessments for Bordetella pertussis and respiratory syncytial virus in season. • Other testing should be done based on the infant’s clinical presentation and clinician’s degree of suspicion.• Most infants should be hospitalized for cardiorespiratory monitoring for 23 hours after an ALTE. • There is strong evidence that newborns are at higher risk of ALTE and sudden infant death syndrome (SIDS)within the first 24 hours after birth and therefore should be frequently monitored as much as possible while room sharing with their mothers. • Evidence suggests that maternal smoking may place an infant for higher risk of SIDS after an ALTE.

Apparent Life-Threatening Events

Apparent Life-Threatening Events

Thrombocytosis at time of hospitalization is a reliable indicator for severity of CAP patients in ICU

BackgroundClinicians have always evaluated the degree of leukocytosis in patients with pneumonia as an indication of systemic inflammatory response and severity of disease. But platelets have been increasingly recognized as inflammatory cells with an important role in host defenses. ObjectiveTo evaluate if abnormal platelet count in hospitalized patients with CAP was associated with severity of CAP comparing it with abnormal leucocytes’ count. MethodsThe study enrolled 66 patients with community acquired pneumonia admitted to respiratory ICU of Ain Shams University and Ain Shams University specialized hospitals. Data were collected from each patient including demographic data, clinical findings, comorbidities, laboratory data, arterial blood gas results, chest radiographic findings; pneumonia severity index (PSI) and CURB-65 were calculated. Simple correlations between variables were examined by calculating Pearson’s product correlation coefficient. Four models of multiple linear regression analysis was performed to study the simultaneous effects of the different data variables on PSI, CURB-65 score, need for mechanical ventilation and length of stay in ICU as dependent variables respectively indicating pneumonia severity. ResultsThere were significant correlations between the following: personal data, clinical findings, arterial blood gas findings, laboratory results, radiological findings and data of severity which are (PSI, PSI class, CURB-65 score, length of stay in ICU, mechanical ventilation) (p<0.001). Thrombocytosis was strongly associated with CAP severity parameters and was more significant than abnormal leucocytic count in predicting the severity of CAP as studied on their effect on PSI, CURB-65 score and need for mechanical ventilation; while leucocytosis was more significant in predicting the length of stay in ICU than thrombocytosis. ConclusionThrombocytosis can be used as a marker of severity in patients with community-acquired pneumonia better than leucocytes’ count.

Methanol Ingestion

Methanol Ingestion