Intensive Care Med Research Articles

Clinical outcomes of patients with in-hospital witnessed cardiac arrest: effect of co-morbidities

IntroductionCardiopulmonary resuscitation (CPR) is frequently performed in hospitalized patients after in-hospital cardiac arrest (IHCA), especially in the intensive care unit (ICU) (J Crit Care 24:408-414, 2009). Despite the fact that nearly half of the in-hospital cardiac arrests (IHCA) actually happen in intensive care units (ICUs) (N Engl J Med 367:1912-1920, 2012), intensive care unit cardiac arrest (ICU-CA) compared to IHCA or out-of-hospital cardiac arrests (OHCA) has received little attention, and data on ICU-CA remains scanty (Intensive Care Med 40:1853-1916, 2014).AimWe aimed to evaluate the clinical status and factors associated with the survival of patients subjected to cardiopulmonary resuscitation (CPR) after a witnessed cardiac arrest (CA) inside the medical intensive care unit (MICU).PatientsThe study included 110 patients, mean age of 60 ± 18 years, 69 (63%) males, and 41 (37%) females. Co-morbidities included diabetes mellitus was present in 46 (42%), hypertension 57 (52%), central nervous system (CNS) disease 31 (29%), cardiovascular (CVS) 76 (69%), respiratory 63 (57%), hepatic 16 (15%), shock 35 (32%), and renal 44 (40%). Mechanical ventilation was present in 97 (88%) of patients. SOFA score < 9 was present in 38%, MPM III score < 10 in 37%, and GCS > 7 in 66% of patients. Non-shockable rhythm occurred in 95 (86%) while shockable rhythm in 15 (14%) of patients.MethodsData were collected prospectively at the medical ICU of Cairo University from Jan. 2013 to Feb 2013. A resuscitation protocol was done according to the latest recommendation of the European Society of Cardiology at the time of patient inclusion. Clinical data were recorded and surviving patients were clinically followed daily until hospital discharge.ResultsOut of 110 witnessed cardiac arrests, CPR was initially successfully manifested by return of spontaneous circulation (ROSC) in 60 patients (55%), of whom 22 (20%) survived hospital discharge and only 9 patients (8%) were functionally independent. Compared to non-survivors, 60 patients (55%) with ROSC had a MPM III < 10 (p 0.015), EF ≥ 50% (p 0.001), and non-shocked patients (p 0.008). Other factors such as DC shocks < 3 (p 0.02), CPR cycles < 2 (p < 0.001), resuscitation duration < 10 min (p 0.03), time to start CPR < 1 min (p 0.001), maintained HCO3 (p 0.03), and PaCO2 (p 0.002) were found to improve ROSC. Mortality before discharge decreased with asystole (p < 0.01). Mortality before discharge increased with CNS (p < 0.02) and respiratory comorbidities (p 0.02), shock (p < 0.001) and mechanical ventilation (p < 0.0001), SOFA > 9 (p 0.001), MPM III > 10 (0.018), and time to start CPR > 1 min (p 0.001).ConclusionNot all ROSC reached long-term survival and hospital discharge. Several co-morbidities affect ROSC and short-term and long-term patient survival after witnessed MICU cardiac arrest.

SAT505 Pericardial Effusion as The Primary Manifestation of Hypothyroidism

Abstract Disclosure: W. Lai: None. A. Karca: None. J. Zheng: None. Q. Shi: None. V.G. Kankani: None. A 50-year-old woman with no known past medical history, medications, or allergies. She presented with right arm pain, headache, neck swelling on the right side for 3 days. She concomitantly had loss of appetite, weight gain, drowsiness, and daytime somnolence. Denied any chest pain, nausea, or abdominal pain. Her vitals included a temperature of 96oF, blood pressure of 107/82mmHg, and respiratory rate of 8. She had hypoxia requiring 2L oxygen. On exam, heart sounds were distant. Significant tests included a TSH 69uIU/mL and FT4 &amp;lt;0.1ng/FL. Metabolic panel had a normal sodium 139mmol/L and glucose 116mg/dL. 3 a.m. cortisol level was 6.3ug/dL.EKG showed low-voltage QRS complexes. CTA chest revealed marked pericardial effusion. Echocardiogram showing septal motion abnormalities with large pericardial effusion (&amp;gt;20mm) suggestive of tamponade. Pericardiocentesis was performed and 800mL of serous fluid was drained. Fluid analysis showed total nucleated cell of 223/uL, lymphocyte 169.48 /uL, monocyte 51.29 /uL, RBC &amp;lt; 2000 /uL, protein 3.9g/dL, and glucose 81mg/dL. Pericardial effusion was negative for malignancy or infections. Patient was administered intravenous (IV) hydrocortisone, levothyroxine, and liothyronine. Her mentation and breathing gradually improved and she was discharged on oral medications. Large pericardial effusion due to hypothyroidism is rare ranging from 1-5%.[1,2] It is caused by increased permeability of pericardial capillaries with effusion of protein and glycosaminoglycan rich fluid.[3] Cardiac tamponade is an exceedingly rare presentation for hypothyroidism. Pericardial effusion secondary to hypothyroidism is treated with intravenous thyroxine. This case was complicated by concerns for myxedema crisis so glucocorticoid were given to treat possible adrenal insufficiency as the random cortisol was &amp;lt;18ug/dL. IV liothyronine was added to the therapy of this patient’s myxedema to provide biologic active thyroid hormone for faster onset though there is no consensus on optimal hormone treatment. [4] Pericardiocentesis is performed if tamponade is present such as this case.This case highlights variability in hypothyroidism presentation. Massive pericardial effusion complicated by cardiac tamponade in hypothyroidism is rare but exceedingly rare as primary symptom of presentation. 1. Sagrista-Sauleda J, Merce J, Permanyer-Maralda G, et al. Clinical clues to the causes of large pericardial effusions. Am J Med 2000; 109:95.2. Levy PY, Corey R, Berger P, et al. Etiologic diagnosis of 204 pericardial effusion. Medicine (Baltimore) 2003; 82:385.3. Badiu C MD, PhD. WILLIAMS TEXTBOOK OF ENDOCRINOLOGY. Acta Endocrinol (Buchar). 2019 Jul-Sep;15(3):416. doi: 10.4183/aeb.2019.416. PMCID: PMC6992389.4. Kwaku MP, Burman KD. Myxedema coma. J Intensive Care Med. 2007 Jul-Aug;22(4):224-31. doi: 10.1177/0885066607301361. PMID: 17712058. Presentation Date: Saturday, June 17, 2023

On culture and blood cultures

Dogma is defined as “a belief or set of beliefs that is accepted by the members of a group without being questioned or doubted” (https://www.britannica.com/dictionary/dogma; accessed May 2, 2023). Everyone who has worked in different healthcare institutions, maybe even in different countries, knows that there are local ‘dogmas’ that are not evidence-based.( 1 Hofmaenner D.A. Singer M. Challenging management dogma where evidence is non-existent, weak or outdated. Intensive Care Med. 2022; 48: 548-558 Crossref PubMed Scopus (7) Google Scholar ) Indeed, one may identify dogmas as such only once one has been confronted with other, possibly opposing ‘dogmas’ elsewhere. The question of whether, for which patients, at what interval(s), and how often to repeat blood cultures in the case of Gram-negative bacteremia may be an example. We, the authors of this commentary, are used to settings where local culture holds that follow-up blood cultures (FUBCs) should be reserved for Staphylococcus aureus bacteremia (for endovascular-infection risk stratification) or for patients without improvement despite antibiotic therapy (Fig. 1).

Clinical ground truth in machine learning for early sepsis diagnosis

Clinical ground truth in machine learning for early sepsis diagnosis

Parallel Venovenous Extracorporeal Membrane Oxygenation Circuits for Refractory Hypoxemia in a Super-Super-Obese Patient

VENOVENOUS EXTRACORPOREAL MEMBRANE OXYGENATION (VV ECMO) represents a rescue form of life support for refractory respiratory failure, shown to confer a mortality benefit. 1 Zhu Y Zhang M Zhang R et al. Extracorporeal membrane oxygenation versus mechanical ventilation alone in adults with severe acute respiratory distress syndrome: A systematic review and meta-analysis. Int J Clin Pract. 2021; 75: e14046 Crossref PubMed Scopus (5) Google Scholar ,2 Peek GJ Mugford M Tiruvoipati R et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): A multicentre randomised controlled trial. Lancet. 2009; 374: 1351-1363 Abstract Full Text Full Text PDF PubMed Scopus (2409) Google Scholar Although relative contraindications to VV ECMO have been evolving with technology and experience, they currently include mechanical ventilation for >7 days (with plateau pressure [Pplat] >30 cmH2O and/or fraction of inspired oxygen [FiO2] >90%), intracranial hemorrhage or systemic bleeding, irreversible and incapacitating central nervous system pathology, immunosuppression, terminal malignancy, and advanced age. 3 Tonna JE Abrams D Brodie D et al. Management of adult patients supported with venovenous extracorporeal membrane oxygenation (VV ECMO): Guideline from the Extracorporeal Life Support Organization (ELSO). ASAIO J. 2021; 67: 601-610 Crossref PubMed Scopus (114) Google Scholar The latest ECMO guidelines do not list obesity as a contraindication. 3 Tonna JE Abrams D Brodie D et al. Management of adult patients supported with venovenous extracorporeal membrane oxygenation (VV ECMO): Guideline from the Extracorporeal Life Support Organization (ELSO). ASAIO J. 2021; 67: 601-610 Crossref PubMed Scopus (114) Google Scholar In fact, studies support the use of VV ECMO in patients with obesity in light of similar or even better survival outcomes compared to their nonobese counterparts. 4 Lazzeri C Bonizzoli M Cianchi G et al. Body mass index and echocardiography in refractory ARDS treated with veno-venous extracorporeal membrane oxygenation. J Artif Organs. 2017; 20: 50-56 Crossref PubMed Scopus (18) Google Scholar , 5 Swol J Buchwald D Dudda M et al. Veno-venous extracorporeal membrane oxygenation in obese surgical patients with hypercapnic lung failure. Acta Anaesthesiol Scand. 2014; 58: 534-538 Crossref PubMed Google Scholar , 6 Kon ZN Dahi S Evans CF et al. Class III obesity is not a contraindication to venovenous extracorporeal membrane oxygenation support. Ann Thorac Surg. 2015; 100: 1855-1860 Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar , 7 Al-Soufi S Buscher H Nguyen ND et al. Lack of association between body weight and mortality in patients on veno-venous extracorporeal membrane oxygenation. Intensive Care Med. 2013; 39: 1995-2002 Crossref PubMed Scopus (41) Google Scholar , 8 Zaidi SAA Saleem K. Obesity as a risk factor for failure to wean from ECMO: A systematic review and meta-analysis. Can Respir J. 2021; 20219967357 Crossref PubMed Scopus (5) Google Scholar , 9 Cho WH OH JY Yeo HJ et al. Obesity survival paradox in pneumonia supported with extracorporeal membrane oxygenation: Analysis of the national registry. J Crit Care. 2018; 48: 453-457 Crossref PubMed Scopus (15) Google Scholar , 10 Galvagno Jr., SM Pelekhaty S Cornachione CR et al. Does weight matter? Outcomes in adult patients on venovenous extracorporeal membrane oxygenation when stratified by obesity class. Anesth Analg. 2020; 131: 754-761 Crossref PubMed Scopus (24) Google Scholar However, skepticism still exists, especially for those with extreme body mass index (BMI), defined as super-obese (BMI >50) or super-super obese (BMI >60). Apart from practical challenges, such as cannulation and proning difficulties, the complex pulmonary and cardiovascular pathophysiology associated with extreme obesity carries the risk of inadequate ECMO flows for the body surface area (BSA), with resultant hypoxemia, as well as hemolysis with secondary coagulopathy from required high flows. The study authors report the successful implementation of 2 in-parallel VV ECMO circuits to overcome the limitations encountered in a super-super-obese patient undergoing conventional VV ECMO for refractory respiratory failure.

Intermittent non-invasive ventilation to prevent post-extubation treatment failure in patients with obesity

Over the past 20 years, the use of non-invasive ventilation (NIV) has increased in acutely ill patients. More recently, the use of high flow nasal cannula (HFNC) has received clinical interest. NIV or HFNC, or both, is used either to avoid endotracheal intubation or to prevent re-intubation in patients at risk for extubation failure. Clinical practice guidelines inform the appropriate use of NIV 1 Rochwerg B Brochard L Elliott MW et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017; 501602426 Crossref PubMed Scopus (728) Google Scholar and HFNC. 2 Rochwerg B Einav S Chaudhuri D et al. The role for high flow nasal cannula as a respiratory support strategy in adults: a clinical practice guideline. Intensive Care Med. 2020; 46: 2226-2237 Crossref PubMed Scopus (104) Google Scholar Effect of non-invasive ventilation after extubation in critically ill patients with obesity in France: a multicentre, unblinded, pragmatic randomised clinical trialAmong critically ill adults with obesity undergoing extubation, the use of NIV was effective to reduce treatment-failure within 3 days. Our results are relevant to clinical practice, supporting the use of NIV after extubation of critically ill patients with obesity. However, most of the difference in the primary outcome was due to patients in the oxygen therapy group switching to NIV, and more evidence is needed to conclude that an NIV strategy leads to improved patient-centred outcomes. Full-Text PDF

1199 PREVENTION AND TREATMENT OF CRITICAL ILLNESS ACQUIRED WEAKNESS IN THE ELDERLY

Abstract Introduction Critical Illness Acquired weakness (ICU-Acquired Weakness (ICU-AW)) is an umbrella term used to describe Critical Illness Myopathy (CIM) and Critical Illness Polyneuropathy (CIP). The condition exerts high prevalence in the elderly admitted in the ICU and is associated with deteriorating patient outcomes, namely mortality and morbidity. The prevalence of the syndrome is highly variable in the current literature hindering our ability to objectively quantify the scale of the problem. Moreover, several preventative methods and treatment for ICU-AW as a result of sarcopenia have been proposed in literature with some of them providing favourable outcomes. Objectives 1. Evaluate the prevalence of ICU-AW in the elderly through a systematic review; and 2. Explore the treatment options currently available. Methods We conducted a systematic review using the PubMed, Embase and Cochrane databases to explore the current studies available on the diagnosis of ICU-AW syndromes. Cochrane’s Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was our template. Results Overall, twenty-one studies (1544 patients) were included. The minimum reported prevalence is 20%, whereas the maximum is 76%. The overall median prevalence was 52% (Q1: 32% and Q3: 61%) with an interquartile range (IQR) of 29%. The highest IQR was found in studies using clinical examination (IQR=37%) whereas the lowest in studies using electrophysiological assessment (IQR= 21%). Moreover, several preventative measures for ICU-AW were identified and analyzed namely: nutritional alterations (high protein dies), glucose control, early mobilization, neuromuscular electrical stimulation and the ABCDEF bundle. Conclusion The variability in the diagnostic modalities used to measure the syndrome as well as the inconsistency in the diagnostic parameters within each modality prevent us from objectively quantifying the prevalence of ICU-AW. With regards to treatment early mobilization protocols offer promising evidence. Reference Vanhorebeek, Latronico, Van den Berghe G. ICU-acquired weakness. Intensive Care Med. 2020;46(4):637-53.

Pro: Does Every Anesthesiologist Need to Learn Point-of-Care Ultrasound?

THE APPLICATIONS OF ULTRASOUND for the anesthesiologist are diverse and expanding rapidly. Although national society guidelines governing the appropriate use of ultrasound in anesthesiology have been available only for transesophageal echocardiography (TEE) and vascular access imaging, clinical guidance has more recently been published describing the use of focused cardiac ultrasound in multiple clinical contexts. 1 Troianos CA Hartman GS Glas KE et al. Guidelines for performing ultrasound guided vascular cannulation: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr. 2011; 24: 1291-1318 Abstract Full Text Full Text PDF PubMed Scopus (257) Google Scholar , 2 American Society of Anesthesiologists and Society of Cardiovascular Anesthesiologists Task Force on Transesophageal EchocardiographyPractice guidelines for perioperative transesophageal echocardiography. An updated report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Anesthesiology. 2010; 112: 1084-1096 Crossref PubMed Scopus (391) Google Scholar , 3 Spencer KT Kimura BJ Korcarz CE et al. Focused cardiac ultrasound: Recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr. 2013; 26: 567-581 Abstract Full Text Full Text PDF PubMed Scopus (398) Google Scholar , 4 Via G Hussain A Wells M et al. International evidence-based recommendations for focused cardiac ultrasound. J Am Soc Echocardiogr. 2014; 27 (683.e1-683.e33) Abstract Full Text Full Text PDF PubMed Scopus (368) Google Scholar Additionally, numerous point-of-care ultrasound (POCUS) protocols now exist to guide the examination of nearly every organ system and area, including cardiac, pulmonary and/or pleural, abdominal, genitourinary, ocular, and airway. 4 Via G Hussain A Wells M et al. International evidence-based recommendations for focused cardiac ultrasound. J Am Soc Echocardiogr. 2014; 27 (683.e1-683.e33) Abstract Full Text Full Text PDF PubMed Scopus (368) Google Scholar , 5 Haskins SC Bronshteyn Y Perlas A et al. American Society of Regional Anesthesia and Pain Medicine expert panel recommendations on point-of-care ultrasound education and training for regional anesthesiologists and pain physicians-part I: Clinical indications. Reg Anesth Pain Med. 2021; 46: 1031-1047 Crossref PubMed Scopus (15) Google Scholar , 6 Haskins SC Bronshteyn Y Perlas A et al. American Society of Regional Anesthesia and Pain Medicine expert panel recommendations on point-of-care ultrasound education and training for regional anesthesiologists and pain physicians-part II: Recommendations. Reg Anesth Pain Med. 2021; 46: 1048-1060 Crossref PubMed Scopus (14) Google Scholar , 7 Holm JH Frederiksen CA Johl-Olsen P et al. Perioperative use of focus assessed transthoracic echocardiography (FATE). Anesth Analg. 2012; 115: 1029-1032 Crossref PubMed Scopus (71) Google Scholar , 8 Lichtenstein DA Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: The BLUE protocol. Chest. 2008; 134: 117-125 Abstract Full Text Full Text PDF PubMed Scopus (1146) Google Scholar , 9 Volpicelli G Elbarbary M Blaivas M et al. International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med. 2012; 38: 577-591 Crossref PubMed Scopus (1758) Google Scholar , 10 Scalea TM Rodriguez A Chiu WC et al. Focused Assessment with Sonography for Trauma (FAST): Results from an international consensus conference. J Trauma. 1999; 46: 466-472 Crossref PubMed Google Scholar , 11 Perlas A Van de Putte P Van Houwe P et al. I-AIM framework for point-of-care gastric ultrasound. Br J Anaesth. 2016; 116: 7-11 Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar

The Continuing Search for the Right Balance

Anesthesiologists are currently viewed as airway experts. Interestingly, advanced airway management were initially primarily performed to resuscitate victims of drowning and patients afflicted with diphtheria infection by non-anesthesiologists.1,2 In 1878, the first elective use of endotracheal intubation for anesthesia was performed by Dr. William Macewen, a Scottish surgeon, using an awake, digital blind intubation technique.1The invention of the Macintosh and Magill laryngoscope blades as well as the introduction of curare in the 1940’s facilitated tracheal intubation such that it already became a routine component of anesthetic management for major surgeries.2 Advancements involving flexible fiberoptic cables paved the way for flexible fiberoptic bronchoscope in the late 1960’s.3 Later on, the need for a wider angle of view to address difficult intubation cases gave birth to a variety of videolaryngoscopes in the 2000s.As early as 2004, there were already reports combining airway equipment to facilitate intubation.4 However, it was not until 2011 that Boet et al. coined the term “multimodal airway approach”.5 Since then, this practice has been explored further by anesthesiologists and is now included as an option in the American Society of Anesthesiologists difficult airway algorithm for both adult and pediatric patients.6The second article in this special issue described how a non-traditional combination of advanced airway equipment easily circumvented the difficulty posed by the initial sole airway equipment technique. Meanwhile, the third article incorporated a twist in the multimodal airway approach by employing two different techniques at different stages of the surgery.These two articles are particularly encouraging since an awake intubation for anticipated difficult airway is hardly applicable for the pediatric population. In addition, the combination described in the second article is reproducible in other parts of the country. The COVID-19 pandemic already created a rapid paradigm shift favoring the acceptance and availability of videolaryngoscopes in routine practice.7-9 Bonfils intubating fiberscope does not have a steep learning curve.10 It also requires less maintenance compared to a fiberoptic bronchoscope.Synergism is a pharmacologic principle that has long been used by anesthesiologists in maintaining homeostasis through the provision of “balanced anesthesia” and “multimodal analgesia”.11,12 The time has come to extend this concept to nonpharmacologic entities as well.As the field of anesthesiology continues to expand in coverage and complexity, the search continues for the perfect complement that will provide the right balance encompassing all elements.&#x0D; &#x0D; Evangeline K. Villa, MDDepartment of Anesthesiology College of Medicine and Philippine General HospitalUniversity of the Philippines Manila &#x0D; REFERENCES1. Szmuk P, Ezri T, Evron S, Roth Y, Katz J. A brief history oftracheostomy and tracheal intubation, from the Bronze Age to theSpace Age. Intensive Care Med. 2008 Feb;34(2):222-8. doi: 10.1007/s00134-007-0931-5.2. Doyle J. A brief history of clinical airway management. Rev Mex Anest.2009;32(Suppl: 1):164-167.3. Pieters BM, Eindhoven GB, Acott C, van Zundert AAJ. Pioneers oflaryngoscopy: indirect, direct and video laryngoscopy. Anaesth IntensiveCare. 2015 Jul;43 Suppl:4-11. doi: 10.1177/0310057X150430S103.4. John Doyle D. GlideScope-assisted fiberoptic intubation: a new airwayteaching method (letter). Anesthesiology. 2004 Nov; 101(5):1252.doi: 10.1097/00000542-200411000-00046.5. Boet S, Dylan Bould M, Diemunsch PA. Combined rigidvideolaryngoscopy-flexible bronchoscopy for intubation. Korean JAnesthesiol. 2011 May;60(5):381-2. doi: 10.4097/kjae.2011.60.5.381.6. Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M,Dutton RP, et al. 2022 American Society of Anesthesiologists PracticeGuidelines for Management of the Difficult Airway. Anesthesiology.2022 Jan 1;136(1):31-81. doi: 10.1097/ALN.0000000000004002.7. Davies M, Hodzovic I. Videolaryngoscopy post COVID-19. TrendsAnaesth Crit Care. 2021 Feb;36:49–51. doi: 10.1016/j.tacc.2020.09.0068. De Jong A, Pardo E, Rolle A, Bodin-Lario S, Pouzeratte Y, JaberS. Airway management for COVID-19: a move towards universalvideolaryngoscope? Lancet Respir Med. 2020 Jun;8(6):555. doi:10.1016/S2213-2600(20)30221-6.9. Saoraya J, Musikatavorn K, Sereeyotin J. Low-cost Videolaryngoscopein Response to COVID-19 Pandemic. West J Emerg Med. 2020 May22;21(4):817-818. doi: 10.5811/westjem.2020.5.47831.10. Falcetta S, Pecora L, Orsetti G, Gentili P, Rossi A, Gabbanelli V, et al.The Bonfils fiberscope: a clinical evaluation of its learning curve andefficacy in difficult airway management. Minerva Anestesiol. 2012Feb;78(2):176-84.11. Lundy JS. Balanced anesthesia. Minnesota Med J. 1926; 9:399-404.12. Kehlet H, Dahl JB. The value of "multimodal" or "balanced analgesia"in postoperative pain treatment. Anesth Analg. 1993 Nov; 77(5):1048-56. doi: 10.1213/00000539-199311000-00030.

THERAPEUTIC MANUAL ASPIRATION OF LARGE VENOUS AIR EMBOLISM IN A PATIENT WITH SHOCK

THERAPEUTIC MANUAL ASPIRATION OF LARGE VENOUS AIR EMBOLISM IN A PATIENT WITH SHOCK

COVID-19 and mental health

British Journal of Healthcare AssistantsVol. 16, No. 8 Mental HealthCOVID-19 and mental healthSarah Jane PalmerSarah Jane PalmerRegistered Nurse and Freelance WriterSearch for more papers by this authorSarah Jane PalmerPublished Online:19 Aug 2022https://doi.org/10.12968/bjha.2022.16.8.380AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Asthma and Lung UK. What treatment can I expect if I have long COVID symptoms? 2021 https://www.blf.org.uk/support-for-you/long-covid/long-covid-care-in-the-nhs/what-treatment-can-I-expect-if-I-have-Long-COVID-symptoms (accessed 22 July 2022) Google ScholarDouaud G, Lee S, Alfaro-Almagro F et al. SARS-CoV-2 is associated with changes in brain structure in UK Biobank. Nature. 2022;604(7907):697-707. https://doi.org/10.1038/s41586-022-04569-5 Crossref, Google ScholarLi X, Ma X. Acute respiratory failure in COVID-19: is it “typical” ARDS? Crit Care. 2020;24(1):198. https://doi.org/10.1186/s13054-020-02911-9 Crossref, Google ScholarNabavi N. Long covid: How to define it and how to manage it. BMJ. 2020;370:m3489. https://doi.org/10.1136/bmj.m3489 Crossref, Google ScholarNHS. Long-term effects of coronavirus (long COVID). 2021a. https://www.nhs.uk/conditions/coronavirus-covid-19/long-term-effects-of-coronavirus-long-covid/ (accessed 22 July 2022) Google ScholarNHS. Long COVID: the NHS plan for 2021/22. 2021b. https://www.england.nhs.uk/coronavirus/documents/long-covid-the-nhs-plan-for-2021-22/ (accessed 29 July 2022) Google ScholarPandharipande PP, Ely EW, Arora RC et al. The intensive care delirium research agenda: a multinational, interprofessional perspective. Intensive Care Med. 2017;43(9):1329-1339. https://doi.org/10.1007/s00134-017-4860-7 Crossref, Google ScholarRogers JP, Chesney E, Oliver D. Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic. Lancet Psychiatry. 2020;7(7):611-627. https://doi.org/10.1016/S2215-0366(20)30203-0. Crossref, Google ScholarTaquet M, Geddes J, Husain M et al. 6-month neurological and psychiatric outcomes in 236,379 survivors of COVID-19: a retrospective cohort study using electronic health records. Lancet Psychiatry. 2021a;8(5):416-427. https://doi.org/10.1016/S2215-0366(21)00084-5 Crossref, Google ScholarTaquet M, Luciano S, Geddes JR, Harrison PJ. Bidirectional associations between COVID-19 and psychiatric disorder: retrospective cohort studies of 62 354 COVID-19 cases in the USA. Lancet Psychiatry. 2021b;8(2):130-140. https://doi.org/10.1016/S2215-0366(20)30462- Crossref, Google ScholarTorales J, O'Higgins M, Castaldelli-Maia JM, Ventriglio A. The outbreak of COVID-19 coronavirus and its impact on global mental health. International Journal of Social Psychiatry. 2020;66(4):317-320. https://doi.org/10.1177/0020764020915212 Crossref, Google ScholarWeir K. How COVID-19 attacks the brain. 2020. https://www.apa.org/monitor/2020/11/attacks-brain (accessed 22 July 2022) Google Scholar FiguresReferencesRelatedDetails 2 August 2022Volume 16Issue 8ISSN (print): 1753-1586ISSN (online): 2052-4420 Metrics History Published online 19 August 2022 Published in print 2 August 2022 Information© MA Healthcare LimitedPDF download

P1673: THROMBOTIC COMPLICATIONS IN MERS-COV COMPARED TO COVID-19

Background: Several observational studies have reported the rate of thrombotic events in patients infected with coronavirus disease 2019 (COVID-19), with conflicting results. Middle east respiratory syndrome (MERS-COV) is another coronavirus had been initially reported in Saudi Arabia in 2012. A genome scan has shown a 50% similarity between covid-19 and. Several common features of covid-19 and MERS-COV including transmissibility, and clinical presentation have been identified. However, data about thrombotic complications in patients with MERS-COV are limited. Aims: To compare the rate of thrombotic events between COVID-19 and MERS-COV. Methods: We included all confirmed COVID-19 patients who were admitted to intensive care unit (ICU) in 3 major hospitals in Saudi Arabia between February to July 2020. We included all confirmed cases of MERS-COV who were admitted to ICU from these centers between March to May 2014. Patients were excluded if they were transferred in or out from one of these three hospital to another hospitals. Patients also excluded is they were admitted for less than 24 hours. Data were collected retrospectively from the first day of admission until discharge or death. The primary outcome was the rate of venous thromboembolism (VTE). The secondary outcomes were the rate of arterial events, the rate of composite events (venous and arterial) and the rate of bleeding. VTE included all symptomatic or incidentally diagnosed cases of pulmonary embolism (PE), deep vein thrombosis (DVT) and thrombosis in unusual sites (cerebral, mesenteric, portal, splenic, hepatic, and renal veins). Screening for VTE in asymptomatic patients was not performed. If more than on type of VTE occurred in the same patient, it was considered one event. Arterial events included cerebrovascular accidents (CVAs), mesenteric ischemia, and limb ischemia and were confirmed by the appropriate imaging modality. Myocardial infarction (MI) was diagnosed based on the suspicion of the attending physician using clinical criteria as well as biomarker elevations or electrocardiographic changes. Composite events were defined as any VTE or arterial event. Bleeding events were classified as major and nonmajor based on the definition of international society of thrombosis and hemostasis (ISTH)5. Informed consent was waived. Results: After exclusion, 234 COVID-19 and 58 MERS-COV patients were included. The majority of patients with COVID-19 (97%, n=230) and more than (67%,n =39) of those with MERS-COV group received pharmacological prophylaxis according to local hospital practice. The most frequently prescribed regimen in both groups was enoxaparin (40 mg twice per day). Over a median length of stay in the COVID-19 group of 22 days, the rate of VTE 9.8 (6.64–14.3) and was 3.4 (0.95–11.7) in the MESR-COV group over median length of stay of 10 days. Image:Summary/Conclusion: Conclusions: To our knowledge, this is the first study compared thrombotic risk between COVID-19 and MERS-COV critically ill patients. We found unexpected similar rate of composite thrombotic events (venous and arterial) between COVID-19 and MERS-COV with higher rate of venous thrombosis in COVID-19 and higher arterial thrombosis in MERS-COV. This may indicate that thrombotic complication is a unique complication of coronaviruses. These result needs to be confirmed in studies with larger sample size. Helms J, et al. Intensive Care Med. 2020;46:1089-98. Schulman S, et al. J Thromb Haemost. 2005;3:692-4.

0832 Nocturnal Tachypnea with Non-Invasive Ventilation; A case report

Abstract Introduction We present a case of nocturnal tachypnea secondary to suspected auto-triggering in a patient on Bilevel device. Auto-triggering is a patient-ventilator asynchrony in which a ventilator breath is triggered in the absence of inspiratory muscle activity. This phenomenon was mostly described in postcardiac surgery and in brain dead patients on mechanical ventilation. Detecting this asynchrony is important as it can lead to patient discomfort, poor compliance and hypocarbia that can lead to apneic events. Report of Cases: An 82-year-old male with history of chronic atrial fibrillation, coronary artery disease (s/p bypass surgery) and Ischemic cardiomyopathy (EF 25-30%). He had moderate obstructive sleep apnea with central apnea. He was started on AutoPAP then was upgraded to BPAP (IPAP 16/EPAP 9 cmH2O). His wife reported episodes of nocturnal tachypnea and increased daytime somnolence. This was confirmed by the compliance reports from his BPAP device, and a portable sleep study obtained while using the BPAP (respiratory rate &amp;gt; 40 breaths/minute). Conclusion Vignaux et al estimated the incidence of auto-triggering with NIV to be 13%. This phenomenon can be caused by a major circuit leak or secondary to cardiogenic oscillations. Effect of cardiogenic oscillation on the pulmonary air flow was described by West and Hugh-Jones in 1961. Our patient had dilated cardiomyopathy with hyperdynamic circulation which we believe was the major cause of his auto-triggering asynchrony. Changes in intracardiac volume and cardiac movements during systole resulted in intrapulmonary flow oscillations exceeding the set flow-trigger threshold leading to the tachypnea. In our patient, the events resolved after cardiac resynchronization procedure that improved the overall cardiac function and adjusting the trigger sensitivity. Support (If Any) [1]Kondili E, Prinianakis G, Georgopoulos D.; Patient ventilator interaction, Br J Anaesth. 2003; 91: 106-119 [2] Richard Arbour; Cardiogenic Oscillation and Ventilator Autotriggering in Brain-Dead Patients: A Case Series. Am J Crit Care 1 September 2009; 18 (5): 496–488. doi: https://doi.org/10.4037/ajcc2009690 [3] Imanaka, Hideaki MD; Nishimura, Masaji MD; Takeuchi, Muneyuki MD; Kimball, William R. MD, PhD; Yahagi, Naoki MD; Kumon, Keiji MD Auto-triggering caused by cardiogenic oscillation during flow-triggered mechanical ventilation, Critical Care Medicine: February 2000 - Volume 28 - Issue 2 - p 402-407 [4]Vignaux L, Vargas F, Roeseler J, Tassaux D, Thille AW, Kossowsky MP, et al. Patient-ventilator asynchrony during non-invasive ventilation for acute respiratory failure: a multicenter study. Intensive Care Med 2009;35(5):840–846

Vaccination

Vaccination

From hydroxychloroquine to ivermectin: how unproven “cures” can go viral

From hydroxychloroquine to ivermectin: how unproven “cures” can go viral

Updates in Sepsis Management Show Thoughtful Approach

Updates in Sepsis Management Show Thoughtful Approach

Salivary pH, dental caries and Body Mass Index (BMI) in the middle school students in Eastern Makassar

Objective: This study aimed to assess the association of salivary pH, dental caries and body mass index (BMI) in middle school students in eastern MakassarMaterial and Methods: This study included 60 middle school students from two schools in eastern Makassar. Data were collected by filling out a questionnaire, weight and height measurement, dental examination, and saliva collection. Body mass index was calculated by dividing weight and height in kg/m2, saliva was collected by draining method, and salivary pH was measured with Saliva-Check Buffer (GC Japan). Decay Missing Filled-Teeth (DMF-T) indexes are used to assess dental caries. Statistical analysis was performed by chi-square and ANOVA with a significance of 0.05.Results: This study showed that overweight and obesity are more prevalent in female students than male students. Salivary pH in underweight students and overweight and obese students were lower compared to normal BMI students, while DMF-T score in underweight, overweight, and obese students were higher than the normal BMI students.Conclusion: It can be concluded that BMI have a significant association with salivary pH and DMF-T score.1. Wang L, Zhou B, Zhao Z, et al. Body-mass index and obesity in urban and rural China: findings from consecutive nationally representative surveys during 2004–18. Lancet 2021;398: 53-63.2. Garrouste-Orgeas M, Troché G, Azoulay E, et al. Body mass index. Intensive Care Med 2004;30: 437-443.3. Barlian B, Azhari, Pramanik F. Correlation between mandibular trabeculae bone density on panoramic radiograph and body mass index of men aged 5-35 years old. J Dentomaxillofac Sci 2018;3: 166-168.4. Bellagambi FG, Lomonaco T, Salvo P, et al. Saliva sampling: Methods and devices. An overview. TrAC-Trends Anal Chem 2020;124: 115781.5. Zalewska A, Kossakowska A, Taranta-Janusz K,et al. Dysfunction of salivary glands, disturbances in salivary antioxidants and increased oxidative damage in saliva of overweight and obese adolescents. J Clin Med 2020;9: 548.6. Mosca AC, Stieger M, Neyraud E, et al. How are macronutrient intake, BMI, ethnicity, age, and gender related to the composition of unstimulated saliva? A case study. J Texture Stud 2019;50: 53-61.7. Pannunzio E, Amancio OMS, Vitalle MSDS, et al. Analysis of the stimulated whole saliva in overweight and obese school children. Rev Assoc Méd Bras 2010;56: 32-36.8. Primasari A, Hulu KP. Dryness of the oral cavity in the salivary status of overweight women. J Homeop Nat Med 2019;5: 50-53.9. Al-Hussaini A, Bashir MS, Khormi M, et al. Overweight and obesity among Saudi children and adolescents: Where do we stand today?. Saudi J Gastroenterol 2019;25: 229.10. Hruby A, Hu FB. The epidemiology of obesity: A big picture. Pharmaco Economics 2015;33: 673-689. 11. Alshihri AA, Rogers HJ, Alqahtani MA, et al. Association between dental caries and obesity in children and young people: A Narrative Review. Int J Dent 2019;2019: 1-8. 12. Groth SW, Morrison-Beedy D. Obesity risk in urban adolescent girls: nutritional intentions and health behavior correlates. J NY State Nurses Assoc 2011;42: 15-28.13. Baliga S, Muglikar S, Kale R. Salivary pH: A diagnostic biomarker. J Indian Soc Periodontol 2013;17: 461.14. Anamaria B, Eugen B, Daniela E, et al. Interrelation between salivary pH, buffer capacity and dental caries in underweight, normal weight and overweight children. Revista de Chimie 2017;68: 1353-1356.

Stylet, No?: December 2021 Annals of Emergency Medicine Journal Club

Jaber S, Rollé A, Godet T, et al. Effect of the use of an endotracheal tube and stylet versus an endotracheal tube alone on first-attempt intubation success: a multicentre, randomised clinical trial in 999 patients. Intensive Care Med. 2021;47:653-664.

FEVER OF UNKNOWN ORIGIN IN THE ICU: A CASE OF "GOUTY SEPSIS"

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Gout associated with systemic inflammatory response syndrome is well described but underappreciated in clinical practice. A prospective analysis of cases admitted to the hospital estimate that 4.5% are associated with fever. We present a case of a critically ill patient with persistent fever of unknown origin diagnosed with polyarticular gout two months into his hospitalization. CASE PRESENTATION: A 67-year-old man with a history of gout, atrial fibrillation, and type 2 diabetes was admitted with a left MCA territory stroke and underwent emergent thrombectomy. He had a period of relative neurologic recovery but became encephalopathic necessitating intubation for airway protection. He developed aspiration pneumonia and progressive renal failure requiring dialysis and underwent percutaneous tracheostomy. Over a period of several weeks, he demonstrated recurrent fevers and persistent leukocytosis and received multiple courses of empiric broad spectrum antimicrobials. Serial cultures, evaluation for atypical pathogens, cross-sectional imaging, lumbar puncture, and autoimmune serologies did not identify an etiology, and he was trialed on bromocriptine for presumed central fever. Repeat physical exam elicited multiple swollen and tender joints. Arthrocentesis was performed and notable for monosodium urate crystals. Acute polyarticular gout was diagnosed, and he was started on dexamethasone and later switched over to anakinra (due to uncontrolled hyperglycemia), with resolution of fevers and articular symptoms. After defervescing his neurologic status significantly improved and he was able to successfully liberate from the ventilator. He was ultimately discharged to rehab on hospital day 112. DISCUSSION: Fever is present in up to 70% of ICU patients and when prolonged is associated with increased morbidity and mortality. This case highlights the difficulty of recognizing non-infectious etiologies of fever in the critically ill patient and the potential harms in a missed diagnosis. These include unnecessary antimicrobial exposure, invasive procedures, and prolonged hospital stay. Sedation and encephalopathy often complicate history-taking and diagnosis. Here, careful physical examination led to the diagnosis of an underappreciated manifestation (fever) of a common condition (gout). While the incidence of gout flares in the ICU is unknown, medical stress, dehydration, and diuretics are frequent triggers and common in critically ill patients. Treatment may be challenging as high rates of renal insufficiency can preclude the use of common therapies such as NSAIDs or colchicine, and steroids may potentiate issues with glycemic control. CONCLUSIONS: Polyarticular gout should be routinely considered as a possible cause of fever in the ICU. REFERENCE #1: Schäfer VS. Systemic Inflammatory Polyarticular Gout Syndrome - Description of a Previously Neglected Entity. JSM Arthritis. 2017;2(2): 1024. REFERENCE #2: Circiumaru B, Baldock G, Cohen J. A prospective study of fever in the intensive care unit. Intensive Care Med. 1999. Jul;25(7): 668-73. REFERENCE #3: Raddatz DA, Mahowald ML and Bilka PJ. Acute polyarticular gout. Ann Rheum Dis. 1983;42: 112-117. DISCLOSURES: Speaker/Speaker's Bureau relationship with Boehringer-Ingelheim Pharmaceuticals Please note: $5001 - $20000 by Jaime Betancourt, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Vapotherm, Inc Please note: $5001 - $20000 by Jaime Betancourt, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Boehringer-Ingelheim Pharmaceuticals Please note: 2014-Present Added 04/21/2021 by Jaime Betancourt, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Vapotherm, Inc Please note: 2019-Present Added 04/21/2021 by Jaime Betancourt, source=Web Response, value=Honoraria Advisory Committee Member relationship with Vapotherm, Inc Please note: 2020 Added 04/21/2021 by Jaime Betancourt, source=Web Response, value=Honoraria No relevant relationships by Tracey Liu, source=Web Response No relevant relationships by Scott Oh, source=Web Response No relevant relationships by Jared Wilkinson, source=Web Response

THE "CLOT" THICKENS: HYPERKALEMIA DUE TO ACUTE LIMB ISCHEMIA IN COVID-19

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been implicated in a devastating inflammatory response resulting in thromboembolic events. Upwards of 40% of patients have been reported to have venous thromboembolism while the incidence of arterial thrombotic events, including acute limb ischemia (ALI), is estimated to be lower at 5%. This case highlights the importance of early recognition and treatment of ALI in COVID-19 to prevent significant morbidity and mortality. CASE PRESENTATION: A 59-year-old man with hypertension and pre-diabetes presented to our facility with tachypnea and hypoxia with oxygen saturation of 80%. He was placed on high flow nasal cannula but required intubation due to respiratory failure. Initial laboratory values revealed D-dimer 460 ng/mL, C-reactive protein 109 mg/L, ferritin 3,282 ng/mL, and creatine kinase 700 U/L. Right soleal vein thrombosis was identified on lower extremity ultrasound and he was started on intravenous heparin with therapeutic levels. On hospital day 4, he became acutely hypotensive and hyperkalemic to 7.9 mmol/L. Physical exam was notable for cold lower extremities with mottling while laboratory values showed lactate 4.1 mmol/L, D-dimer greater than 10,000 ng/mL, ferritin 23,712 ng/mL, and creatine kinase 21,078 U/L. Upon evaluation with lower extremity arterial duplex, there was no Doppler signal detected in the bilateral common femoral, superficial femoral, popliteal, posterior tibial, and anterior tibial arteries. A subsequent CT angiogram revealed extensive bilateral pulmonary emboli, acute total occlusion of the aorta beginning distal to the renal arteries, and extensive lower limb muscle stranding suggestive of ischemic injury. He was taken to the operating room and underwent emergent thrombolysis and thrombectomy. Unfortunately, he suffered severe reperfusion injury and expired shortly after the procedure. DISCUSSION: ALI presents with the 6 Ps: pain, pallor, paralysis, paresthesia, poikilothermia, and pulselessness. In COVID-19, it is estimated that 71% of arterial thrombotic events involve the lower extremities. Patients at risk are noted to be males over the age of 60 with diabetes and hypertension. Diagnosis can be made with duplex ultrasound, CT angiography, or MR angiography. After initiating therapeutic anticoagulation, vascular surgery should be consulted for management options such as catheter-directed thrombolysis, mechanical thrombectomy, or open surgery. CONCLUSIONS: This case highlights the significance of arterial thrombotic events in COVID-19 and the importance of early recognition of ALI. Unexplained hyperkalemia should be thoroughly investigated as it can be a presentation of myonecrosis secondary to ALI. Prompt initiation of anticoagulation and vascular surgery consult are vital in limiting morbidity and mortality. REFERENCE #1: Helms J, Tacquard C, Severac F, et al. High risk of thrombosis in patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study. Intensive Care Med. 2020;46(6):1089-1098. DISCLOSURES: No relevant relationships by Talha Demirci, source=Web Response No relevant relationships by Himanshu Deshwal, source=Web Response No relevant relationships by ron goldenberg, source=Web Response