Circulatory Shock Research Articles

The Evolution of Central Venous-to-arterial Carbon Dioxide Difference (PCO2 Gap) during Resuscitation Affects ICU Outcomes: A Prospective Observational Study.

The usual methods of perfusion assessment in patients with shock, such as capillary refill time, skin mottling, and serial serum lactate measurements have many limitations. Veno-arterial difference in the partial pressure of carbon dioxide (PCO2 gap) is advocated being more reliable. We evaluated serial change in PCO2 gap during resuscitation in circulatory shock and its effect on ICU outcomes. This prospective observational study included 110 adults with circulatory shock. Patients were resuscitated as per current standards of care. We recorded invasive arterial pressure, urine output, cardiac index (CI), PCO2 gap at ICU admission at 6, 12, and 24 hours, and various patient outcomes. Significant decrease in PCO2 gap was observed at 6 h and was accompanied by improvement in serum lactate, mean arterial pressure, CI and urine output in (n = 61). We compared these patients with those in whom this decrease did not occur (n = 49). Mortality and ICU LOS was significantly lower in patients with low PCO2 gap, while more patients with high PCO2 gap required RRT. We found that a persistently high PCO2 gap at 6 and 12 h following resuscitation in patients with shock of various etiologies, was associated with increased mortality, need for RRT and increased ICU LOS. High PCO2 gap had a moderate discriminative ability to predict mortality. Zirpe KG, Tiwari AM, Kulkarni AP, Vaidya HS, Gurav SK, Deshmukh AM, et al. The Evolution of Central Venous-to-arterial Carbon Dioxide Difference (PCO2 Gap) during Resuscitation Affects ICU Outcomes: A Prospective Observational Study. Indian J Crit Care Med 2024;28(4):349-354.

The role of echocardiography in pulmonary embolism for the prediction of in-hospital mortality: a retrospective study

PurposePulmonary Embolism (PE) is the third leading cause of cardiovascular death, following myocardial infarction and stroke. The latest European Society of Cardiology (ESC) guidelines on PE recommend short-term prognostic stratification based on right ventricular (RV) overload detected by transthoracic echocardiography (TTE) or contrast-enhanced chest CT. The aim of the study is to find out which of the signs of right ventricular dysfunction best predicts in-hospital mortality (IHM).MethodsThis is a monocentric, retrospective study including adult patients admitted from the emergency department with a c-e cCT confirmed diagnosis of PE between January 2018 and December 2022 who underwent a TTE within 48 h.Results509 patients (median age 76 years [IQR 67–84]) were included, with 7.1% IHM. At univariate analysis, RV/LV ratio > 1 (OR 2.23, 95% CI 1.1–4.5), TAPSE < 17 mm (OR 4.73, 95% CI 2.3–9.8), the D-shape (OR 3.73, 95% CI 1.71–8.14), and LVEF < 35% (OR 5.78, 95% CI 1.72–19.47) resulted significantly correlated with IHM. However, at multivariate analysis including also haemodynamic instability, PESI class > II, and abnormal hs-cTnI levels, only LVEF < 35% (OR 5.46, 95% CI 1.32–22.61) resulted an independent predictor of IHM.ConclusionDespite the recognised role of TTE in the early management of patients with circulatory shock and suspected PE, signs of RV dysfunction have been shown to be poor predictors of IHM, whereas severely reduced LVEF is an independent risk factor for in-hospital death.

Pre-exercise hot water immersion increased circulatory heat shock proteins but did not alter muscle damage markers or endurance capacity after eccentric exercise

ABSTRACT Pre-exercise passive heating attenuates muscle damage caused by eccentric exercise in rats where the induction of heat shock proteins (HSPs) confers a myoprotective effect. We investigated whether pre-exercise hot water immersion (HWI) confers similar benefits in humans. Eleven recreational male athletes were immersed in 41°C water up to 60 min or until rectal temperatures reached 39.5°C. After a 6 h rest, the participants performed an eccentric downhill run for 1 h at −4% gradient to induce muscle damage. An endurance capacity test at 75% VO2max was conducted 18 h later. The control trial was similar except that participants were immersed at 34°C. Blood samples were collected to assess HSPs levels, creatine kinase, and lactate dehydrogenase activities. Plasma eHSP70 was higher post-immersion in HWI trials (1.3 ± 0.4 vs 1.1 ± 0.4; p = 0.005). Plasma eHSP27 was higher before (p = 0.049) and after (p = 0.015) endurance test in HWI. Leukocytic p-HSP27 was increased 18 h after HWI (0.97 ± 0.14 vs 0.67 ± 0.11; p = 0.04). Creatine kinase and lactate dehydrogenase activities were increased by 3-fold and 1.5-fold, respectively, after endurance test in HWI but did not differ across trials (p > 0.05). Mean heart rates were higher during eccentric run and endurance test in HWI as compared to control (p < 0.05). Endurance capacity was similar between trials (57.3 ± 11.5 min vs 55.0 ± 13.5 min; p = 0.564). Pre-exercise heating increased the expression of plasma eHSPs and leukocytic p-HSP27 but did not reduce muscle damage nor enhance endurance capacity.

Bacterial load in cerebrospinal fluid predicts unfavourable outcome in pneumococcal meningitis: a prospective nationwide cohort study

ObjectivesThe objective of this study was to determine the role of cerebrospinal fluid (CSF) bacterial load in adults with pneumococcal meningitis. MethodsWe quantified bacterial load in CSF samples from the diagnostic lumbar puncture of adults with community-acquired pneumococcal meningitis. We also measured CSF concentrations of complement component 5a (C5a), and determined associations between bacterial load, clinical characteristics, C5a and unfavourable outcome (Glasgow Outcome Scale score <5). ResultsBacterial load was quantified in 152 CSF samples. Median age of these patients was 61 years (interquartile range [IQR] 51–68), and 69 of 152 (45%) were female. Median CSF bacterial load was 1.6 × 104 DNA copies/mL (IQR 3.4 × 103–1.2 × 105), and did not correlate with CSF white cell count nor with CSF protein concentrations. Median CSF C5a concentration was 35.8 mg/L (IQR 15.9–105.6), and was moderately correlated with CSF bacterial loads (Spearman's rho = 0.42; p < 0001). High bacterial loads were associated with development of complications, such as circulatory shock (OR per logarithmic increase: 2.4, 95% CI: 2.0–2.9; p < 0.001) and cerebrovascular complications [OR: 1.9, 95% CI: 1.6–2.3; p < 0.001]). High bacterial loads were also associated with unfavourable outcome (OR: 2.8, 95% CI: 2.4–3.3; p < 0.001) and death (OR: 3.1, 95% CI: 2.6–3.8; p < 0.001). In a multivariable regression model including age, immunocompromised state, extrameningeal infection focus, admission Glasgow Coma Scale score and CSF C5a concentration, CSF bacterial load remained an independent predictor of unfavourable outcome (adjusted OR: 2.5, 95% CI: 1.6–3.9; p < 0.001). DiscussionHigh CSF bacterial load predicts the development of complications and unfavourable outcome in adults with pneumococcal meningitis.

Early pandemic in-hospital outcomes and mortality risk factors in COVID-19 solid organ transplant patients

Background Solid organ transplant (SOT) recipients with COVID-19 have a higher risk of mortality than those without COVID-19. However, it is unclear how SOT patient outcomes compare to the general population without SOT who contract COVID-19. Methods We used the National Inpatient Sample from January to December 2020 to investigate inpatient outcomes seen in SOT recipients after contracting COVID-19 compared to nontransplant patients. We identified our study sample using ICD-10 CM and excluded those <18 years of age and those with dual organ transplants. Inpatient outcomes were compared in SOT and non-SOT COVID cohorts, and we further evaluated predictors of mortality in the SOT with COVID population. Results Out of the 1,416,445 COVID-19 admissions included in the study, 8315 (0.59%) were single SOT recipients. Our analysis that adjusted for multiple baseline characteristics and comorbidities demonstrated that COVID-19 in SOT patients was associated with higher rates of acute kidney injury (adjusted odds ratio [aOR] 2.34, 95% confidence interval [CI] 1.81–3.02, P < 0.01), lower rates of acute respiratory distress syndrome (aOR 0.68, 95% CI 0.54–0.85, P < 0.01), and similar rates of cardiac arrest, pulmonary embolism, circulatory shock, cerebrovascular events, and in-hospital mortality. Age >65 was associated with mortality in SOT patients. Conclusion In this nationally representative sample, SOT patients presenting with COVID-19 experienced similar rates of mortality compared to those without SOT. SOT patients were more likely to develop acute kidney injury. Further research is needed to understand the complex relationship between transplant patient outcomes and COVID-19.

The shrapnel-crushed wounds in dogs: status evaluation and therapy for wound healing

Determining the clinical and laboratory status of animals with crushed wounds as a result of the traumatic effect of ammunition fragments, as well as the wound healing effect of ecologically safe drugs based on natural beekeeping products is of great importance under the conditions of the animals' stay in the war zone and territories subject to rocket-bomb and artillery fire. The aim of the research is to study the clinical condition of dogs with shrapnel-crushed wounds, observing its dynamics during systemic therapy and evaluating the therapeutic effect of wound healing using the universal biological ointment Unibiol®. During the research, various physical, hematological, biochemical, hemorheological, hemodynamic, and statistical methods were employed. Six animals with shrapnel-crushed wounds on their limbs and groin were analyzed. It was established that due to the traumatic factor, injuries in dogs are characterized by extensive tissue destruction and deconstruction. The overall condition of the animals, based on clinical signs, is described as toxemic-septic. Hematological changes such as anemia, leukocytosis, thrombocytopenia, left shift in the nucleus, monocytosis, and lymphocytosis indicate a systemic inflammatory reaction and a septic state in the dogs' bodies. Biochemical studies revealed hypoalbuminemia leading to hypoproteinemia, creatinine elevation, uremia, elevated levels of indicator transaminases, suggesting multi-organ failure. A significant decrease in circulating blood volume, increased spontaneous platelet aggregation, characterizes a moderate traumatic circulatory shock, while a 5-fold increase in the circulation of D-dimer levels indicates a significant potential for disseminated intravascular coagulation syndrome. Following infusion and antibiotic therapy, wound sanitation over 5 days led to a significant restoration of the clinical-laboratory status of the injured dogs, setting the stage for Unibiol® ointment wound-healing therapy. As a result of the treatment conducted over 21 days, the wound defect healed with the formation of complete granulation tissue and an elastic scar. The clinical trials conducted allow recommending Unibiol® ointment for effective and environmentally safe healing of severe shrapnel-crushed wounds.

The impact of chronic and acute problems on sea turtles: The consequences of the oil spill and ingestion of anthropogenic debris on the tropical semi-arid coast of Ceará, Brazil

Sea turtle mortality is often related to materials that reach the coast from different anthropic activities worldwide. This study aimed to investigate whether sea turtle mortality was related to older marine problems, such as solid waste, or one of the largest oil spill accidents on the Brazilian coast, that occurred in 2019. We posed three questions: 1) Are there solid residues in the digestive tract samples, and which typology is the most abundant? 2) Can meso‑ and macro-waste marine pollutants cause mortality? 3) Is the dark material found really oil? A total of 25 gastrointestinal content (GC) samples were obtained, of which 22 ingested waste of anthropogenic origin and 18 were necropsied. These 22 samples were obtained during or after the 2019 oil spill, of which 17 specimens were affected, making it possible to suggest oil ingestion with the cause of death in the animals that could be necropsied. Macroscopic data showed that the most abundant solid waste was plastic (76.05 %), followed by fabrics (12.18 %) and oil-like materials. However, chemical data confirmed only three specimens with oil levels ranging from remnants to high. It was possible to infer possible causes of death in 16 of the total 18 necropsied cases: Most deaths were due to respiratory arrest (62.5 %), followed by pulmonary edema (12.5 %), cachexia syndrome (12.5 %), circulatory shock (6.25 %), and head trauma (6.25 %), which may have been caused by contact with solid waste, oil, or both. The study showed that not all dark material found in the GCs of turtles killed in oiled areas is truly oil, and in this sense, a chemical analysis step to prove the evidence of oil must be added to international protocols.

MIS-C and Kawasaki disease: Different illnesses or part of the same spectrum?

During COVID-19 pandemic pediatricians have been challenged by the occurrence of the multisystem inflammatory syndrome in children (MIS-C). This condition displays some features similar to those of Kawasaki disease (KD), but was is characterized by clinical signs and symptoms that are infrequent in this illness, such as diarrhea, abdominal pain, neurologic dysfunction and cardiac involvement, especially myocarditis. Many children with MIS-C necessitated ICU admission due to development of multiorgan failure and circulatory shock, usually of myocardial origin. Management is based on the administration of intravenous immunoglobulin, glucocorticoids and, in the most severe forms, anakinra. The clinical similarities between MIS-C and KD have raised an intense debate about whether they represent different illnesses with overlapping clinical features or are part of the same disease spectrum. Most authorities favor the assumption that MIS-C is distinct from KD, based on epidemiological, clinical and immunological differences between the two entities. Others argue that the two disorders may represent a continuum, with some differences in phenotype and severity being related to viral load or strain or magnitude or kinetics of immune response. The present article is aimed to analyze critically the rationale and evidence in favor of the second hypothesis.

Retrospective Study of 25 Cases of Acorn Intoxication Colitis in Horses between 2011 and 2018 and Factors Associated with Non-Survival.

The aim of this study is to describe clinical data associated with acorn intoxication and to find variables associated with survival. Data from horses presented at CISCO-ONIRIS from 2011 to 2018 with a diagnosis of acorn intoxication were included. Diagnosis was based on the following: season, the presence of acorns in the environment, clinical and hemato-biochemical parameters suggestive of a digestive/renal disease, the co-morbidity of companion animals, and post-mortem findings. Statistical analysis was completed using Student's t-test for mean comparisons and a Chi-square test for group comparisons (p < 0.05). A total of 25 horses were included, and seasonality suggests that the intoxication may vary from year to year. Clinical signs associated with acorn intoxication were signs of circulatory shock (lethargy, tachycardia, abnormal mucous membrane, tachypnea), digestive signs (diarrhea, ileus, colic), and abnormal temperature. Clinical pathological findings included increased hematocrit, WBC, creatinine, BUN, GGT, AST, CK and decreased albumin. Overall, 44% (11/25) of horses survived. The majority (13/14) of non-survivors died, or were euthanized, during the first 48 h. Findings significantly associated with non-survival were age, heart rate, hemorrhagic diarrhea, ileus, hematocrit, creatinine, blood lactate, and thickness of the colon wall at ultrasonography. This study provides equine practitioners with valuable prognostic information in cases of acorn intoxication.

Dynamic arterial elastance as a predictor of arterial pressure response to norepinephrine weaning in mechanically ventilated patients with vasoplegic syndrome-a systematic review and meta-analysis.

During the de-escalation phase of circulatory shock, norepinephrine weaning may induce diverse arterial pressure responses in patients with different vasomotor tones. Dynamic arterial elastance (Eadyn) has been extensively studied to predict the arterial pressure response to interventions. We conducted this meta-analysis to systematically assess the predictive performance of Eadyn for the mean arterial pressure (MAP) response to norepinephrine weaning in mechanically ventilated patients with vasoplegic syndrome. A systematic literature search was conducted on May 29, 2023 (updated on January 21, 2024), to identify relevant studies from electronic databases. The area under the hierarchical summary receiver operating characteristic curve (AUHSROC) was estimated as the primary measure of diagnostic accuracy because of the varied thresholds reported. Additionally, we observed the distribution of the cutoff values of Eadyn, while computing the optimal value and its corresponding 95% confidential interval (CI). A total of 5 prospective studies met eligibility, comprising 183 participants, of whom 67 (37%) were MAP responders. Eadyn possessed an excellent ability to predict the MAP response to norepinephrine weaning in patients with vasoplegic syndrome, with an AUHSROC of 0.93 (95% CI: 0.91-0.95), a pooled sensitivity of 0.94 (95% CI: 0.85-0.98), a pooled specificity of 0.73 (95% CI: 0.65-0.81), and a pooled diagnostic odds ratio of 32.4 (95% CI: 11.7-89.9). The cutoff values of Eadyn presented a nearly conically symmetrical distribution; the mean and median cutoff values were 0.89 (95% CI: 0.80-0.98) and 0.90 (95% CI: not estimable), respectively. This meta-analysis with limited evidences demonstrates that Eadyn may be a reliable predictor of the MAP response to norepinephrine weaning in mechanically ventilated patients with vasoplegic syndrome. PROSPERO CRD42023430362.

Improving the precision of shock resuscitation by predicting fluid responsiveness with machine learning and arterial blood pressure waveform data

Fluid bolus therapy (FBT) is fundamental to the management of circulatory shock in critical care but balancing the benefits and toxicities of FBT has proven challenging in individual patients. Improved predictors of the hemodynamic response to a fluid bolus, commonly referred to as a fluid challenge, are needed to limit non-beneficial fluid administration and to enable automated clinical decision support and patient-specific precision critical care management. In this study we retrospectively analyzed data from 394 fluid boluses from 58 pigs subjected to either hemorrhagic or distributive shock. All animals had continuous blood pressure and cardiac output monitored throughout the study. Using this data, we developed a machine learning (ML) model to predict the hemodynamic response to a fluid challenge using only arterial blood pressure waveform data as the input. A Random Forest binary classifier referred to as the ML fluid responsiveness algorithm (MLFRA) was trained to detect fluid responsiveness (FR), defined as a ≥ 15% change in cardiac stroke volume after a fluid challenge. We then compared its performance to pulse pressure variation, a commonly used metric of FR. Model performance was assessed using the area under the receiver operating characteristic curve (AUROC), confusion matrix metrics, and calibration curves plotting predicted probabilities against observed outcomes. Across multiple train/test splits and feature selection methods designed to assess performance in the setting of small sample size conditions typical of large animal experiments, the MLFRA achieved an average AUROC, recall (sensitivity), specificity, and precision of 0.82, 0.86, 0.62. and 0.76, respectively. In the same datasets, pulse pressure variation had an AUROC, recall, specificity, and precision of 0.73, 0.91, 0.49, and 0.71, respectively. The MLFRA was generally well-calibrated across its range of predicted probabilities and appeared to perform equally well across physiologic conditions. These results suggest that ML, using only inputs from arterial blood pressure monitoring, may substantially improve the accuracy of predicting FR compared to the use of pulse pressure variation. If generalizable, these methods may enable more effective, automated precision management of critically ill patients with circulatory shock.

The use of whole body computed tomography does not lead to increased 24-h mortality in severely injured patients in circulatory shock

The Advanced Trauma Life Support (ATLS) approach is generally accepted as the standard of care for the initial management of severely injured patients. While whole body computed tomography (WBCT) is still considered a contraindication in haemodynamically unstable trauma patients, there is a growing amount of data indicating the absence of harm from cross sectional imaging in this patient group. Our study aimed to compare the early mortality of unstable trauma patients undergoing a WBCT during the initial workup with those who did not. Single-center retrospective observational study based on the local trauma registry including 3525 patients with an ISS > 15 from January 2008 to June 2020. We compared the 24-h mortality of injured patients in circulatory shock undergoing WBCT with a control group undergoing standard workup only. Inclusion criteria were the simultaneous presence of a systolic blood pressure < 100 mmHg, lactate > 2.2 mmol/l and base excess < − 2 mmol/l as surrogate markers for circulatory shock. To control for confounding, a propensity score matched analysis with conditional logistic regression for adjustment of residual confounders and a sensitivity analysis using inverse probability weighting (IPW) with and without adjustment were performed. Of the 3525 patients, 161 (4.6%) fulfilled all inclusion criteria. Of these, 132 (82%) underwent WBCT and 29 (18%) standard work-up only. In crude and matched analyses, no difference in early (24 h) mortality was observed (WBCT, 23 (17.4%) and no-WBCT, 8 (27.6%); p = 0.21). After matching and adjustment for main confounders, the odds ratio for the event of death at 24 h in the WBCT group was 0.36 (95% CI 0.07–1.73); p = 0.20. In the present study, WBCT did not increase the risk of death at 24 h among injured patients in shock. This adds to the growing data indicating that WBCT may be offered to trauma patients in circulatory shock without jeopardizing early survival.

The association between prolonged capillary refill time and microcirculation changes in children with sepsis

BackgroundsIn children with sepsis, circulatory shock and multi-organ failure remain major contributors to mortality. Prolonged capillary refill time (PCRT) is a clinical tool associated with disease severity and tissue hypoperfusion. Microcirculation assessment with videomicroscopy represents a promising candidate for assessing and improving hemodynamic management strategies in children with sepsis. Particularly when there is loss of coherence between the macro and microcirculation (hemodynamic incoherence). We sought to evaluate the association between PCRT and microcirculation changes in sepsis.MethodsThis was a prospective cohort study in children hospitalized with sepsis. Microcirculation was measured using sublingual video microscopy (capillary density and flow and perfused boundary region [PBR]—a parameter inversely proportional to vascular endothelial glycocalyx thickness), phalangeal tissue perfusion, and endothelial activation and glycocalyx injury biomarkers. The primary outcome was the association between PCRT and microcirculation changes.ResultsA total of 132 children with sepsis were included, with a median age of two years (IQR 0.6–12.2). PCRT was associated with increased glycocalyx degradation (PBR 2.21 vs. 2.08 microns; aOR 2.65, 95% CI 1.09–6.34; p = 0.02) and fewer 4–6 micron capillaries recruited (p = 0.03), with no changes in the percentage of capillary blood volume (p = 0.13). Patients with hemodynamic incoherence had more PBR abnormalities (78.4% vs. 60.8%; aOR 2.58, 95% CI 1.06–6.29; p = 0.03) and the persistence of these abnormalities after six hours was associated with higher mortality (16.5% vs. 6.1%; p < 0.01). Children with an elevated arterio-venous CO2 difference (DCO2) had an abnormal PBR (aOR 1.13, 95% CI 1.01–1.26; p = 0.03) and a lower density of small capillaries (p < 0.05). Prolonged capillary refill time predicted an abnormal PBR (AUROC 0.81, 95% CI 0.64–0.98; p = 0.03) and relative percentage of blood in the capillaries (AUROC 0.82, 95% CI 0.58–1.00; p = 0.03) on admission. A normal CRT at 24 h predicted a shorter hospital stay (aOR 0.96, 95% CI 0.94–0.99; p < 0.05).ConclusionsWe found an association between PCRT and microcirculation changes in children with sepsis. These patients had fewer small capillaries recruited and more endothelial glycocalyx degradation. This leads to nonperfused capillaries, affecting oxygen delivery to the tissues. These disorders were associated with hemodynamic incoherence and worse clinical outcomes when the CRT continued to be abnormal 24 h after admission.

Analysis of the unicentric registry of the Infarction Code program: retrospective cohort

Acute coronary syndrome (ACS) is the most serious manifestation of coronary heart disease. The Infarction Code (according to its initialism in Spanish, CI: Código Infarto) program aims to improve the care of these patients. To describe the clinical presentation and outcomes of CI program in a coronary care unit (CCU). A database of a CCU with 5 years of consecutive records was analyzed. Patients diagnosed with ACS were included. The groups with acute myocardial infarction with and without ST-segment elevation were compared using Student's t, Mann-Whitney U and chi-squared tests. We calculated the relative risk (RR) and 95% confidence intervals (95% CI) of cardiovascular risk factors for mortality. A total of 4678 subjects were analyzed, 78.7% men, mean age 63 years (± 10.7). 80.76% presented acute myocardial infarction with positive ST-segment elevation and fibrinolytic was granted in 60.8% of cases. Percutaneous coronary intervention was performed in 81.4% of patients, which was successful in 82.5% of events. Patients classified as CI presented mortality of 6.8% vs. 11.7%, p = 0.001. Invasive mechanical ventilation had an RR of 26.58 (95% CI: 20.61-34.3) and circulatory shock an RR of 20.86 (95% CI: 16.16-26.93). The CI program decreased mortality by 4.9%. Early fibrinolysis and successful coronary angiography are protective factors for mortality within CCU.

Neurological disorders with general overheating of the body (scientific and literary review)

Based on the understanding of the pathophysiology of heat stroke, it has been suggested that heat stroke can be considered as a form of hyperthermia that is associated with a systemic inflammatory response leading to a syndrome of multiple organ dysfunction in which encephalopathy predominates. Mechanisms of neuronal injury in heat stroke include: cellular effects (damage to membranes, mitochondria, and DNA, stimulation of excitotoxic mechanisms, protein denaturation), local effects (ischemia, inflammatory changes, edema, cytokine release, vascular damage), systemic effects (changes in cerebral blood flow, endotoxemia, translocation of bacteria through a dysfunctional gastrointestinal tract). Neurological manifestations of heat stroke develop in 3 stages according to the time of occurrence: acute, convalescent and late. In the acute stage, cerebral dysfunction prevails. Overheating of the body directly caused polyetiological cerebral dysfunction with deep suppression of consciousness in the acute stage; circulatory shock, hypoxia and cerebral ischemia, excessive accumulation of cytotoxic free radicals and oxidant brain damage developed. During the convalescence stage, cerebral dysfunction gradually decreases. This stage is characterized by transient cerebellar dysfunction. For the late stage, long-term neurological and cardiovascular complications with a constant risk of death are typical. When late stage with permanent neurologic deficits develop, cerebellar dysfunction is the most common symptom. The delayed onset of degeneration and deafferentation suggests that the syndrome is not caused by the primary lesion itself but may be a consequence of postsynaptic hypersensitivity or secondary reorganization of the involved pathways.

Severe neurological complications in a child with multisystem inflammatory syndrome in children after asymptomatic COVID-19

Introduction. Coronavirus disease-2019 (COVID-19) usually leads to a mild infectious disease course in children, but serious neurological complications have been described in association with both acute infection and the multisystem inflammatory syndrome in children (MIS-C). Cerebrovascular disorders (CVD) in children are rare complication of MIS-C, and various potential mechanisms of CVD in MIS-C have been hypothesized. Case outline. In an eight-year old girl, diagnosis of MIS-C was made according to clinical features of prolonged fever, circulatory shock, heart and renal insufficiency, skin abnormalities, conjunctival hyperemia, and stomach pain associated with laboratory findings (increased CRP, D-dimers, pro BNP, troponins, IL-6), supported by positive contact with SARS-CoV2 one month before the disease onset and increased IgG and IgM anti-SARS-CoV2 antibodies. From the second day of hospitalization, left-side hemiplegia was observed, and using brain CT and MR, CVD was diagnosed. Together with cardiovascular support, corticosteroids and intravenous immunoglobulin were administered. On the fourth day of hospitalization, diagnosis of cerebral salt wasting syndrome (CSWS) was made according to severe dehydration, polyuria, hyponatremia, increased natriuria, and increased urine: serum osmolality ratio. CSWS had very severe course lasting more than one month. The girl was discharged with stable vital signs, normal diuresis and hemiparesis. Conclusion. This is the first case in the literature presenting association of severe CSWS and CVD in a child with MIS-C after COVID-19.

INVASIVE HEMODYNAMIC MONITORING WITH PULMONARY ARTERY CATHETER IN SEPSIS-ASSOCIATED CARDIOGENIC SHOCK.

Background: Both sepsis-induced cardiomyopathy and worsening of preexisting cardiac disease can contribute to circulatory shock in septic patients. The early use of pulmonary artery catheter (PAC) could play a pivotal role in the management of sepsis-associated cardiogenic shock. In this study, we aimed to evaluate the impact of early invasive hemodynamic monitoring with PAC in patients with sepsis-associated cardiogenic shock. Method: We performed a retrospective study using the National Inpatient Sample data from January 2017 to December 2019. The early use of PAC was defined as the use of PAC within 2 days from the admission. We performed the multivariable logistic regression analysis to investigate the association between the early use of PAC and in-hospital mortality in patients with sepsis-associated cardiogenic shock and sepsis without cardiogenic shock, respectively. Results: There was no difference in in-hospital mortality between PAC and no PAC groups in sepsis without cardiogenic shock (adjusted odds ratio [aOR] = 1.05, 95% confidence interval [CI] = 0.82-1.35, P = 691). On the other hand, the early use of PAC was independently associated with lower in-hospital mortality in patients with sepsis-associated cardiogenic shock (aOR = 0.58, 95% confidence interval [CI] = 0.46-0.72, P < 0.001). The use of PAC was also associated with increased use of mechanical circulatory support in those with sepsis-associated cardiogenic shock (aOR = 12.26, 95% CI = 9.37-16.03, P < 0.001). For patients with sepsis-associated cardiogenic shock, the use of PAC after 2 days of admission was associated with significantly higher in-hospital mortality and decreased use of mechanical circulatory support. Conclusion: The use of pulmonary artery catheters in sepsis-associated cardiogenic shock was associated with significantly lower in-hospital mortality and increased use of mechanical circulatory supports in patients with sepsis-associated cardiogenic shock.

Characteristics and prognostic factors of bacterial meningitis in the intensive care unit: a prospective nationwide cohort study

BackgroundPatients with bacterial meningitis can be severely ill necessitating intensive care unit (ICU) treatment. Here, we describe clinical features and prognostic factors of adults with bacterial meningitis admitted to the ICU in a nationwide prospective cohort study.MethodsWe prospectively assessed clinical features and outcome of adults (age > 16 years) with community-acquired bacterial meningitis included in the MeninGene study between March 1, 2006 and July 1, 2022, that were initially admitted to the ICU. We identified independent predictors for initial ICU admission and for unfavourable outcome (Glasgow Outcome Scale score between 1–4) by multivariable logistic regression.ResultsA total of 2709 episodes of bacterial meningitis were included, of which 1369 (51%) were initially admitted to the ICU. We observed a decrease in proportion of patients being admitted to the ICU during the Covid-19 pandemic in 2020 (decreased to 39%, p = 0.004). Median age of the 1369 patients initially admitted to the ICU was 61 years (IQR 49–69), and the rates of unfavourable outcome (47%) and mortality (22%) were high. During the Covid-19 pandemic, we observed a trend towards an increase in unfavourable outcome. Prognostic factors predictive for initial ICU admission were younger age, immunocompromised state, male sex, factors associated with pneumococcal meningitis, and those indicative of systemic compromise. Independent predictors for unfavourable outcome in the initial ICU cohort were advanced age, admittance to an academic hospital, cranial nerve palsies or seizures on admission, low leukocyte count in blood, high C-reactive protein in blood, low CSF: blood glucose ratio, listerial meningitis, need for mechanical ventilation, circulatory shock and persistent fever. 204 of 1340 episodes (15%) that were initially not admitted to the ICU were secondarily transferred to the ICU. The rates of unfavourable outcome (66%) and mortality (30%) in this group were high.ConclusionsThe majority of patients with community-acquired bacterial meningitis are admitted to the ICU, and the unfavourable outcome and mortality rates of these patients remain high. Patients that are initially admitted to non-ICU wards but secondarily transferred to the ICU also had very high rates of unfavourable outcome.

Gender Disparities in Outcomes of Autoimmune Hemolytic Anemia Admissions: An Analysis of the National Inpatient Sample

Introduction Autoimmune hemolytic anemia (AIHA) is a condition characterized by the immune destruction of red blood cells, which can necessitate hospitalization in severe cases. The purpose of this study is to compare outcomes of AIHA hospitalizations between genders. Methods We utilized the International Classification of Diseases (ICD) codes to identify all hospitalizations with the primary diagnosis of AIHA in the National Inpatient Sample (NIS) from 2002 to 2019. We excluded all pediatric (age &amp;lt; 18 years) and elective hospitalizations. We described the baseline characteristics of both groups including demographics and comorbidities. We fitted multivariable logistic regression models to compare outcomes between males and females while adjusting for age, race, and comorbidities. Results A total of 60,529 met the inclusion and exclusion criteria. The majority of these were females (59.1% vs 40.1%, p &amp;lt; 0.001). Males were older (median age 67 vs. 66 years, p &amp;lt; 0.001) and had more white race (73.4% vs. 67.9%, p &amp;lt; 0.001). The distribution of associated comorbidities also differed different between both groups ( (Table 1). On adjusted analysis, males had higher in-hospital mortality rates. They also had higher rates of most secondary outcomes; including rates of circulatory shock, need for mechanical ventilation, bacterial pneumonia, acute myocardial infarction, deep vein thrombosis, hemorrhagic stroke, acute kidney injury, and requiring new hemodialysis. Females had higher rates of urinary tract infections. No significant differences were found in the rates of requiring blood transfusions, sepsis, acute heart failure, pulmonary embolism, ischemic stroke, encephalopathy, and gastrointestinal bleeding (Figure 1). Furthermore, male hospitalizations were associated with higher costs (median [IQR] of $11,400 [6,700-20,500] vs. $10,000 [6,000- 17,200]) despite similar length of stay (median [IQR] of 4 days [3-7] vs. 4 days [3-7]). Conclusion Male patients hospitalized with AIHA experience poorer in-hospital compared to females. More research is essential to understand the underlying causes for these disparities and to tailor management to improve outcomes for both male and female AIHA patients.

The ‘Weekend Effect’ on Immune Cytopenia: Insights from the National Inpatient Sample Database

Introduction: Outcomes for weekend versus weekday admissions for immune cytopenias including immune thrombocytopenic purpura (ITP), thrombotic thrombocytopenic purpura (TTP), and autoimmune hemolytic anemia (AIHA)/Evan's Syndrome are explored in this abstract. Methods: A query of the 2012-2019 National Inpatient Sample was performed for primary hospitalizations with immune thrombocytopenic purpura (ITP), thrombotic thrombocytopenic purpura (TTP), and autoimmune hemolytic anemia (AIHA)/Evan's Syndrome using ICD-9/10 codes. Demographics, comorbidities, and outcomes were identified. Univariate analysis with t-tests or chi-square performed as appropriate. A 1:1 nearest neighbor propensity score matched cohorts was generated for each of the ITP, TTP and AIHA/Evan's hospitalization dataset. Variables with standardized mean differences &amp;gt;0.1 used in multivariate regression to generate adjusted odds ratios (AOR)/β-coefficients for weekend admission status on outcomes. Significance was set at an alpha level of &amp;lt;0.05. All analysis performed in SPSS versions 26. Results: 24,325, 2992,and 7,609 hospitalizations were included with 4592, 656, and 1468 weekend admissions in ITP, TTP, and AIHA/Evan's respectively. Propensity matched cohorts were generated adjusting for age, sex, race, median household income and co-morbidities including DM, CHF, CKD/ESRD, and liver disease. The results showed significantly higher, almost two-fold, in-hospital mortality in AIHA for weekend admissions (Odds ratio (OR): 1.85, CI 1.20-2.85, p-value=0.005). In addition, there was significantly higher risk of circulatory shock and mechanical ventilation requirement for weekend admissions in AIHA along with significantly increased length of hospital stay and total hospital charges. TTP patients also showed similar trend towards higher mortality with significantly higher incidence of AKI and increased length of stay for weekend admissions. There was no significant difference seen in ITP. The results are summarized in table 1. These results are partly in agreement with findings of Manadan et al study, which showed lower rate of procedures and higher adjusted mortality for general inpatient admissions in weekends. Conclusion: Weekend admissions showed poorer outcomes especially in AIHA and TTP. Although the exact reasons are unknown, decreased staffing and procedural availability may be responsible for such findings. Further studies are needed to clarify the steps needed to decrease adverse outcomes for weekend admissions.