Intensive Care Therapy Research Articles

Clinical Profile of Multisystem Inflammatory Syndrome in Children Associated with SARS-CoV-2 Admitted to Pediatric Intensive Care Unit

Abstract Objectives Multisystem inflammatory syndrome in children (MIS-C) is a post Severe Acute Respiratory Syndrome Coronavirus2 (SARS CoV2) immune dissonance seen in the pediatric population. The current study is an attempt to understand the subtleties of diverse phenotypes, immunotherapeutics, and short-term outcome parameters of MIS-C. Materials and Methods Children admitted to the pediatric intensive care unit (PICU) between 1 month and 18 years, satisfying MIS-C criteria, were enrolled in this retrospective observational study. They were stratified into different phenotypes like shock, Kawasaki disease, and nonspecific phenotypes. Respiratory, vasoactive support, and outcomes were analyzed using appropriate statistical methods. Results Seventy-five children presented with MIS-C during the study period. The mean age was 66 months with 54.6% females. Coronavirus disease (COVID) antibody was positive for 41 (54%), real time-reverse rranscription polymerase chain reaction (RT-PCR) positivity was positive in 16 (21.3%), and rapid antigen test was positive in 10 (13%). Common symptoms included fever (100%), rash (30%), conjunctival congestion (29.7%), and cardiovascular (68% with shock) involvement. Notable differences in shock phenotype were identified including Pediatric Risk of Mortality III score, inflammatory markers, cardiac involvement, need for inotropes, and ventilation. In total, 32% received intravenous immunoglobulin and 48% glucocorticoids. The overall mortality in children with MIS-C was 9 (12%). The need for mechanical ventilation (odds ratio 10.94, confidence interval [2.06, 58.06], p-value <0.005) was noted as an independent predictor of mortality by logistic regression. Conclusion MIS-C showed a significant cardiovascular involvement at presentation, necessitating intensive care and immunomodulatory therapies. There were higher odds of mortality in the ventilated cohort.

Clinical Profile, Intensive Care Needs, and Short-Term Outcome of Toxic Shock Syndrome Among Children:A 10-Year Single-Centre Experience from North India.

ObjectiveTo describe the clinical and laboratory profile, management, intensive care needs, and outcome of children with toxic shock syndrome (TSS) admitted to the pediatric intensive care unit (PICU) of a tertiary care center in North India.MethodsThis retrospective study was conducted in the PICU of a tertiary care hospital in North India over a period of 10 y (January 2011–December 2020) including children < 12 y with TSS (n = 63).ResultsThe median (interquartile range, IQR) age was 5 (2–9) y, 58.7% were boys, and Pediatric Risk of Mortality III (PRISM-III) score was 15 (12–17). The primary focus of infection was identified in 60.3% children, 44.5% had skin and soft tissue infections, and 17.5% (n = 11) had growth of Staphylococcus aureus. Common manifestations were shock (100%), rash (95.2%), thrombocytopenia (79.4%), transaminitis (66.7%), coagulopathy (58.7%), and acute kidney injury (AKI) (52.4%); and involvement of gastrointestinal (61.9%), mucus membrane (55.5%), respiratory (47.6%), musculoskeletal (41.3%), and central nervous system (CNS) (31.7%). The treatment included fluid resuscitation (100%), vasoactive drugs (92.1%), clindamycin (96.8%), intravenous immunoglobulin (IVIG) (92.1%), blood products (74.6%), mechanical ventilation (58.7%), and renal replacement therapy (31.7%). The mortality was 27% (n = 17). The duration of PICU and hopsital stay was 5 (4–10) and 7 (4–11) d, respectively. Higher proportion of nonsurvivors had CNS involvement, transaminitis, thrombocytopenia, coagulopathy, and AKI; required mechanical ventilation and blood products; and had higher vasoactive–inotropic score.ConclusionTSS is not uncommon in children in Indian setup. The management includes early recognition, intensive care, antibiotics, source control, and adjunctive therapy (IVIG and clindamycin). Multiorgan dysfunction and need for organ supportive therapies predicted mortality.

Complications of severe acute respiratory syndrome coronavirus 2 infection in children.

Although during the initial stages of COVID-19 pandemic, the pediatric population seemed to be less affected, a number of SARS-CoV-2-related manifestations emerged over time, the principal of which is the multisystem inflammatory syndrome in children (MIS-C). Here we provide an update on the main pediatric disorders associated with SARS-CoV-2 infection. MIS-C is novel postinfectious manifestation with clinical features similar to Kawasaki disease and characterized by intense systemic inflammation affecting multiple organs. Many children required intensive care therapy because of circulatory shock, usually of myocardial origin. Appropriate treatment with immunomodulatory therapies led to favorable outcomes in most patients, with recovery of overall health and cardiac dysfunction. In addition to MIS-C, a variety of other complications of COVID-19 in children have been described, including thrombotic events, neurologic manifestations, and chilblain-like lesions. There is still uncertainty about the true prevalence of long COVID in children and its distinction from pandemic-related complaints. The experience gained so far with MIS-C and the other SARS-CoV-2-related complications in children and adolescents will facilitate accurate diagnosis and appropriate treatment. Further studies are needed to elucidate the pathophysiology of MIS-C and to determine the real impact of long-COVID in the pediatric age group.

The Role of Circadian Clock Genes in Critical Illness: The Potential Role of Translational Clock Gene Therapies for Targeting Inflammation, Mitochondrial Function, and Muscle Mass in Intensive Care.

The Earth’s 24-h planetary rotation, with predictable light and heat cycles, has driven profound evolutionary adaptation, with prominent impacts on physiological mechanisms important for surviving critical illness. Pathways of interest include inflammation, mitochondrial function, energy metabolism, hypoxic signaling, apoptosis, and defenses against reactive oxygen species. Regulation of these by the cellular circadian clock (BMAL-1 and its network) has an important influence on pulmonary inflammation; ventilator-associated lung injury; septic shock; brain injury, including vasospasm; and overall mortality in both animals and humans. Whether it is cytokines, the inflammasome, or mitochondrial biogenesis, circadian medicine represents exciting opportunities for translational therapy in intensive care, which is currently lacking. Circadian medicine also represents a link to metabolic determinants of outcome, such as diabetes and cardiovascular disease. More than ever, we are appreciating the problem of circadian desynchrony in intensive care. This review explores the rationale and evidence for the importance of the circadian clock in surviving critical illness.

The role of lung ultrasound in procalcitonin-guided antibiotic discontinuation in ventilator-associated pneumonia.

ABSTRACTBackground and Aims:Starting antibiotic therapy at the proper time is the cornerstone of the management of ventilator-associated pneumonia (VAP). However, using antibiotics for a long duration of therapy in intensive care leads to increased bacterial resistance, financial burden and adverse drug reactions. We hypothesised that lung ultrasound may have a role in guiding antibiotic discontinuation in patients with VAP that will help to reduce the antibiotic duration and decrease the resistance.Methods:This was a prospective blinded cohort study from October 2020 to September 2021 in which 62 VAP patients were recruited. Antibiotics were started, procalcitonin (PCT) level and clinical pulmonary infection score were estimated and lung ultrasound (US) was performed on day 1 and repeated on day 7. On day 7, discontinuation of antibiotics was recommended if the PCT level was <0.25 μg/L. A lung reaeration score was recorded.Results:Based on the PCT levels, antibiotics were discontinued in 40 patients. The computed tomography findings of VAP had improved in all. The ultrasound reaeration score showed a highly significant negative correlation with the PCT on day 7 (-0.718, P < 0.001). A cut-off of 5 for the US score showed a sensitivity of 92.5%, specificity of 95.5%, positive predictive value of 97.4% and negative predictive value of 87.5% in detecting a low PCT score on day 7.Conclusion:Lung US is a non-invasive and safe method that can be used to guide antibiotic therapy in VAP.

EVALI-RELATED PULMONARY TOXICITY

TYPE: Case Report TOPIC: Occupational and Environmental Lung Diseases INTRODUCTION: E-cigarette or vaping induced lung injury (EVALI) among those using tetrahydrocannabinol (THC) containing liquid products has been associated with additive Vitamin E Acetate (VEAc), the only common compound bronchoalveolar lavage (BAL) identified. We present a case of acute respiratory failure attributed to EVALI where treatment was based on VEAc role. CASE PRESENTATION: A 44 year old female complaining of dyspnea, cough, and hemoptysis presented with acute hypoxic respiratory failure requiring high flow nasal oxygen therapy in intensive care. She endorsed frequent vaping of THC containing liquid products. Further history revealed recent change in product supplier. CT chest demonstrated diffuse ground glass infiltrates (Figure 1). Labs showed increased white blood cells 12.6 THOU/mcL (3.6-10.5) and C- reactive protein 313 mg/L (<5). BAL deferred for unfavorable respiratory status. Initial treatment included methylprednisolone and bronchodilators. Hypoxia and dyspnea improved on prednisone taper enabling complete weaning of supplemental oxygen. DISCUSSION: As of 2020, 82% of EVALI cases have been attributed to THC containing liquid products. Suspected pathogenesis is linked to VEAc’s pulmonary effects including surfactant layer and viscosity alterations with lipid laden macrophages (LLM), however the driving element remains unclear. Despite routine bronchoscopy, nonspecific LLM findings challenge its diagnostic contribution in cases without suspcious alternative diagnoses. Characterizing radiographic patterns, including organizing pneumonia, ground glass opacities and subpleural sparing, may be advantageous. Continued investigation into EVALI pathogenesis and radiology can improve diagnosis and treatment. CONCLUSIONS: Understanding VEAc's influence on gas exchange can help focus treatment on alveolar recruitment through high flow oxygen therapy and anti-inflammatories. DISCLOSURE: Nothing to declare. KEYWORD: E- cigarette or vaping induced lung injury

Capillary leak syndrome: A rare cause of acute respiratory distress syndrome.

Capillary leak syndrome (CLS) is a rare clinical syndrome associated with significant morbidity and mortality. Intensive care and supportive therapy constitute the mainstay of the treatment, along with judicious use of crystalloids and colloids such as dextran and starch during the leak phase. The advantages of proning, steroids, and intravenous immunoglobins are worth contemplating in patients with such a presentation. Extracorporeal membrane oxygenation appears to be an excellent strategy to surmount the impediments of the leak and post leak phase of CLS, especially in patients with severe or refractory hypoxemia.

MO312: Long-Term Kidney Function Outcome After COVID-19 Associated Acute Kidney Injury and Kidney Replacement Therapy in Intensive Care

BACKGROUND AND AIMSAcute kidney injury (AKI), frequently with concurrent albuminuria and haematuria, is common and increases mortality in COVID-19 infection. We present the clinical course and long-term outcomes of COVID-19 survivors with AKI and continuous kidney replacement therapy (CKRT) with follow-up of kidney function at 6 and 12 months.METHODA total of 29 non-CKD COVID-19 infected patients with AKI required mechanical ventilation and CKRT at the intensive care unit (ICU). Of those, 15 died (52%) and 14 survived. Written informed consent to collect and publish data was obtained from 13 survivors.We estimated eGFR with CKD-EPI creatinine in population-based healthy controls (n = 80, median age 62 years) for comparison.RESULTSA total of 13 survivors, median age 58 years, 85% male, 15% diabetes and median BMI 30 kg/m2. None had CKD before admission or at admission following rehydration.The typical scenario was a normal or slightly elevated creatinine level at admission, normalizing after IV fluids, but rising creatinine from day 8 (median) and the start of CKRT on day 10 (median). Urine analysis was available in 7 patients, of which only 1 had no urinary findings, 6 had albuminuria and/or haematuria and/or leukocyturia. Dialysis could be weaned in all 13 survivors after a median time of 16 days in dialysis (range 1–40 days). The median length of stay at the ICU was 41 days (range 10–72 days) and the median weight loss was 16 kg (range 8–27 kg).The survivors had a median eGFR of 100 mL/min/1.73 m2 (range 66–113) at baseline and a median eGFR of 69 mL/min/1.73 m2 (range 49–97) at 12 months estimated with CKD-EPI creatinine. Population-based control subjects had a median eGFR of 85 mL/min/1.73 m2 estimated CKD-EPI creatinine. Urine analysis was available in 11 patients at 12 months, of which 5 had no urinary findings, 3 had microalbuminuria and 3 had haematuria and/or leukocyturia.Since the weight loss was accompanied by a decline in creatinine, we used both creatinine-based, and cystatin C-based eGFR to evaluate kidney function at 6 month follow-up. At 6 months, the survivors had a median eGFR of 70 mL/min/1.73 m2 (range 44–111) estimated with CKD-EPI creatinine as compared with 46 mL/min/1.73 m2 (range 36–65) estimated with cystatin C eGFR, suggesting that cystatin C-based formulae are clinically more useful after COVID-19 associated critical illness.CONCLUSIONThe AKI mortality in COVID-19 despite CKRT is high, but a substantial number of patients survive and can be weaned off dialysis. Kidney function at 12 months did improve substantially but did not return to its baseline values and was lower compared with healthy age-matched population-based control subjects. Kidney outcome follow-up after COVID-19 and AKI is likely to be important for assessing long-term CKD prognosis and is proposed to be evaluated with both creatinine and cystatin C as well as urinalysis.

V13-09 TRICUSPID INSUFFICIENCY CAUSED BY RENAL ANGIOMYOLIPOMA WITH EXTENSION TO THE INFERIOR VENA CAVA AND RIGHT ATRIUM. A MULTIDISCIPLINARY APPROACH

You have accessJournal of UrologyCME1 May 2022V13-09 TRICUSPID INSUFFICIENCY CAUSED BY RENAL ANGIOMYOLIPOMA WITH EXTENSION TO THE INFERIOR VENA CAVA AND RIGHT ATRIUM. A MULTIDISCIPLINARY APPROACH Ruben Santiago, Omar Vieyra, Rodrigo Perez, Victor Osornio, Gerardo Garza, Roberto Lopez, and Mario Ortega Ruben SantiagoRuben Santiago More articles by this author , Omar VieyraOmar Vieyra More articles by this author , Rodrigo PerezRodrigo Perez More articles by this author , Victor OsornioVictor Osornio More articles by this author , Gerardo GarzaGerardo Garza More articles by this author , Roberto LopezRoberto Lopez More articles by this author , and Mario OrtegaMario Ortega More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002646.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Renal angiomyolipoma (AML) is a mesenchymal tumor benign composed by vascular, smooth muscle and adipose tissue. There are two types of AMLs: The classic variant is the most common and is characterized by thick walled vessels, spindle smooth-muscle-like cells and adipose tissue. The epithelioid variant has an epithelial cell component to it with minimal adipose tissue and has the potential to undergo malignant transformation. The objective of this video is presented the multidisciplinary approach from surgical technique to medical intensive care during and after the surgery. METHODS: A 44-year-old woman was referred by his primary care physician with symptoms characterized by shortness of breath, tachycardia, intermittent hematuria and right lumbar pain. Physical examination with holosystolic murmur. Computerized tomography (CT) scan demonstrated a 6.1x5.1cm right renal tumor, the attenuation was - 83 Hounsfield Units (HU) with tumor thrombus invasion into the inferior vena cava, which extended from renal vein ostium to right atrium. Magnetic resonance imaging (MRI) showed non-infiltration of the vena cava wall. Echocardiogram presented systolic protrusion of the thrombus towards the right ventricle, developing moderate tricuspid regurgitation. RESULTS: With multidisciplinary management (Urology, cardiology, cardiothoracic surgery, perfusionists and intensive care therapy) were performed an open right radical nephrectomy, sternotomy, cavotomy with extraction of intra-atrial thrombus and primary cavorrhaphy. With support of cellular recuperator and extracorporeal circulation pump (pump time 100 min) trans-surgical transfusions were: 3 erythrocyte concentrates, 2 fresh frozen plasmas and 1 platelet apheresis. Surgical time was 380 min. During the surgery a real-time transesophageal echocardiogram was used. Bleeding was 2500 ml and no intraoperative complications were reported. Hospital stay of 20 days, discharged without complications with serum creatinine 1.0 mg / dl and hemoglobin 11.5 g / dl. Pathology report was renal classic AML, size 8.0x6.0x4.0cm, immunohistochemistry: HMB45 (+) and smooth muscle actin (+). CONCLUSIONS: This is a rare case of a classic AML presenting with a venous tumor thrombus involving the inferior vena cava from renal vein ostium to right atrium. Radical nephrectomy with tumor thrombectomy is the most widely accepted surgical treatment following established vascular principles of venous tumor thrombectomy. Source of Funding: Non Disclousure © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e1033 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ruben Santiago More articles by this author Omar Vieyra More articles by this author Rodrigo Perez More articles by this author Victor Osornio More articles by this author Gerardo Garza More articles by this author Roberto Lopez More articles by this author Mario Ortega More articles by this author Expand All Advertisement PDF DownloadLoading ...

Physiological Effects of Music Therapy in Neonatal Intensive Care Setting Observational Study

Neonatal Intensive Care Unit (NICU) infants are known to experience pain and anxiety during the multiple procedures they undergo in the first two weeks of life [1,2-5]. These stressors often result in a decline in oxygen saturation, increase in heart rate, increase in blood pressure, and elevation in pain scores. It is imperative to mitigate added stress in this population due to the long-term developmental ramifications of this physical stress. Previous literature demonstrates that music therapy-based interventions can return these physiologic parameters to baseline and even improve them. Studies on music therapy in the neonatal population are scarce, with two to four publications per year, and typically involve the high severity group that are intubated. Many of these studies have focused on the effects of music therapy on physiological vital signs such as heart rate, blood pressure, and oxygen saturation. While some studies examine the pain levels in NICU intubated patients, many base their measurements for stress on a patient’s vital signs [3,6,7]. However, few research teams have studied non-intubated NICU patients, and have rarely utilized standardized pain scales such as the Face Legs Activity Cry Consolability (FLACC) Scale or the Neonatal Infant Pain Scale (NIPS) to determine their results. Our study aims to address these gaps in knowledge by observing music therapy interventions based on time of the session, non-intubated neonates, and using perceived stress scales. According to the American Music Therapy Association (AMTA), music therapy is an evidence-based intervention offered as part of the multidisciplinary healthcare team [4]. For neonatal patients, interventions include parental songwriting with instruments, music-assisted relaxation, and womb sounds. Unlike many other studies in established literature,our study was exclusively facilitated by board-certified NICU trained Music Therapists.

Chronic Critical Illness in Patients with COVID-19: Characteristics and Outcome of Prolonged Intensive Care Therapy.

The spread of SARS-CoV-2 caused a worldwide healthcare threat. High critical care admission rates related to Coronavirus Disease 2019 (COVID-19) respiratory failure were observed. Medical advances helped increase the number of patients surviving the acute critical illness. However, some patients require prolonged critical care. Data on the outcome of patients with a chronic critical illness (CCI) are scarce. Single-center retrospective study including all adult critically ill patients with confirmed COVID-19 treated at the Department of Intensive Care Medicine at the University Medical Center Hamburg-Eppendorf, Germany, between 1 March 2020 and 8 August 2021. We identified 304 critically ill patients with COVID-19 during the study period. Of those, 55% (n = 167) had an ICU stay ≥21 days and were defined as chronic critical illness, and 45% (n = 137) had an ICU stay <21 days. Age, sex and BMI were distributed equally between both groups. Patients with CCI had a higher median SAPS II (CCI: 39.5 vs. no-CCI: 38 points, p = 0.140) and SOFA score (10 vs. 6, p < 0.001) on admission. Seventy-three per cent (n = 223) of patients required invasive mechanical ventilation (MV) (86% vs. 58%; p < 0.001). The median duration of MV was 30 (17–49) days and 7 (4–12) days in patients with and without CCI, respectively (p < 0.001). The regression analysis identified ARDS (OR 3.238, 95% CI 1.827–5.740, p < 0.001) and referral from another ICU (OR 2.097, 95% CI 1.203–3.654, p = 0.009) as factors significantly associated with new-onset of CCI. Overall, we observed an ICU mortality of 38% (n = 115) in the study cohort. In patients with CCI we observed an ICU mortality of 28% (n = 46) compared to 50% (n = 69) in patients without CCI (p < 0.001). The 90-day mortality was 28% (n = 46) compared to 50% (n = 70), respectively (p < 0.001). More than half of critically ill patients with COVID-19 suffer from CCI. Short and long-term survival rates in patients with CCI were high compared to patients without CCI, and prolonged therapy should not be withheld when resources permit prolonged therapy.

An Outpatient Management Strategy Using a Coronataxi Digital Early Warning System Reduces Coronavirus Disease 2019 Mortality.

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic has caused sudden, severe strain to healthcare systems. Better outpatient management is required to save lives, manage resources effectively, and prepare for future pandemics.MethodsThe Coronataxi digital early warning (CDEW) system deployed in Rhein-Neckar County and Heidelberg, Germany is an outpatient care system consisting of remote digital monitoring via a mobile application, a medical doctor dashboard, and medical care delivery to COVID-19 patients in home quarantine when indicated. Patients reported their symptoms, temperature, breathing rate, oxygen saturation, and pulse via the app. This single-center cohort study compared outcomes of the population with and without using the CDEW system. The primary outcome was mortality; the secondary outcomes were hospitalization, duration of hospitalization, intensive care therapy, and mechanical ventilation.ResultsMortality rate was 3- to 4-fold lower and hospitalization rate was higher in the CDEW cohort (459 patients) compared with the cohort without CDEW in the same test area and other regions (Mannheim, Karlsruhe town, Karlsruhe district, and Germany), (mortality rate: 0.65% [95% confidence interval {CI}, .13%–1.90%] versus 2.16%, 2.32%, 2.48%, 2.82% and 2.76%, respectively, P < .05 for all; hospitalization rate: 14.81% [95% CI, 11.69%–18.40%] versus 6.89%, 6.93%, 6.59%, 6.15%, and 7.22%, respectively, P < .001 for all). The median duration of hospitalization in the CDEW cohort was significantly lower compared with a national sentinel cohort (6 days [interquartile range {IQR}, 4–9.75 days] versus 10 days [IQR, 5–19 days]; Z = −3.156; P = .002). A total of 1.96% patients needed intensive care and 1.09% were mechanically ventilated.ConclusionsThe CDEW system significantly reduced COVID-19 mortality and duration of hospitalization and can be applied to the management of future pandemics.

Heparin versus citrate anticoagulation for continuous renal replacement therapy in intensive care: the RRAM observational study.

In the UK, 10% of admissions to intensive care units receive continuous renal replacement therapy with regional citrate anticoagulation replacing systemic heparin anticoagulation over the last decade. Regional citrate anticoagulation is now used in > 50% of intensive care units, despite little evidence of safety or effectiveness. The aim of the Renal Replacement Anticoagulant Management study was to evaluate the clinical and health economic impacts of intensive care units moving from systemic heparin anticoagulation to regional citrate anticoagulation for continuous renal replacement therapy. This was an observational comparative effectiveness study. The setting was NHS adult general intensive care units in England and Wales. Participants were adults receiving continuous renal replacement therapy in an intensive care unit participating in the Intensive Care National Audit & Research Centre Case Mix Programme national clinical audit between 1 April 2009 and 31 March 2017. Exposure - continuous renal replacement therapy in an intensive care unit after completion of transition to regional citrate anticoagulation. Comparator - continuous renal replacement therapy in an intensive care unit before starting transition to regional citrate anticoagulation or had not transitioned. Primary effectiveness - all-cause mortality at 90 days. Primary economic - incremental net monetary benefit at 1 year. Secondary outcomes - mortality at hospital discharge, 30 days and 1 year; days of renal, cardiovascular and advanced respiratory support in intensive care unit; length of stay in intensive care unit and hospital; bleeding and thromboembolic events; prevalence of end-stage renal disease at 1 year; and estimated lifetime incremental net monetary benefit. Individual patient data from the Intensive Care National Audit & Research Centre Case Mix Programme were linked with the UK Renal Registry, Hospital Episode Statistics (for England), Patient Episodes Data for Wales and Civil Registrations (Deaths) data sets, and combined with identified periods of systemic heparin anticoagulation and regional citrate anticoagulation (survey of intensive care units). Staff time and consumables were obtained from micro-costing. Continuous renal replacement therapy system failures were estimated from the Post-Intensive Care Risk-adjusted Alerting and Monitoring data set. EuroQol-3 Dimensions, three-level version, health-related quality of life was obtained from the Intensive Care Outcomes Network study. Out of the 188 (94.9%) units that responded to the survey, 182 (96.8%) use continuous renal replacement therapy. After linkage, data were available from 69,001 patients across 181 intensive care units (60,416 during periods of systemic heparin anticoagulation use and 8585 during regional citrate anticoagulation use). The change to regional citrate anticoagulation was not associated with a step change in 90-day mortality (odds ratio 0.98, 95% confidence interval 0.89 to 1.08). Secondary outcomes showed step increases in days of renal support (difference in means 0.53 days, 95% confidence interval 0.28 to 0.79 days), advanced cardiovascular support (difference in means 0.23 days, 95% confidence interval 0.09 to 0.38 days) and advanced respiratory support (difference in means, 0.53 days, 95% CI 0.03 to 1.03 days) with a trend toward fewer bleeding episodes (odds ratio 0.90, 95% confidence interval 0.76 to 1.06) with transition to regional citrate anticoagulation. The micro-costing study indicated that regional citrate anticoagulation was more expensive and was associated with an estimated incremental net monetary loss (step change) of -£2376 (95% confidence interval -£3841 to -£911). The estimated likelihood of cost-effectiveness at 1 year was less than 0.1%. Lack of patient-level treatment data means that the results represent average effects of changing to regional citrate anticoagulation in intensive care units. Administrative data are subject to variation in data quality over time, which may contribute to observed trends. The introduction of regional citrate anticoagulation has not improved outcomes for patients and is likely to have substantially increased costs. This study demonstrates the feasibility of evaluating effects of changes in practice using routinely collected data. (1) Prioritise other changes in clinical practice for evaluation and (2) methodological research to understand potential implications of trends in data quality. This trial is registered as ClinicalTrials.gov NCT03545750. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 13. See the NIHR Journals Library website for further project information.

Evaluation of a diluted lipid emulsion solution as a lubricant for improved peripherally inserted central catheter guidewire removal in a neonatal population.

BackgroundMedical management of neonates is often established upon safe and reliable vascular access, frequently utilized to provide physiological monitoring, parenteral and supportive treatments, and diagnostic and/or procedural purposes. For this, peripherally inserted central catheters (PICCs) are often used to provide safe vascular access and infusion-related therapies in the neonatal intensive care (NICU) setting.PurposeDifficult PICC guidewire removal is understood to cause catheter damage, causing luminal rupture or possible breakage of the catheter or guidewire itself. The aim of this study was to assess and compare the incidence of therapy failures with use of a preflush fluid using normal saline (NSS) versus a diluted lipid solution (DLS) prior to device insertion, to assist with guidewire removal and prevent unnecessary catheter damage.Method and settingA retrospective, observational study was performed in the Neonatal Intensive Care Unit (NICU) of the Women’s Wellness and Research Centre, Hamad Medical Corporation, Qatar. This single site study included 507 neonates who required intravenous therapy administered via a PICC during the study period.ResultsResults demonstrated the use of a diluted lipid solution preflush (DLS) resulted in significantly lesser failures, when compared with the control group (NSS). This highlights a clinical significance after adjusting for day of insertion, gestational age, birth weight and catheter type.ConclusionDLS preflush demonstrated a benefit over the use of a NSS preflush to enhance PICC guidewire removal in neonatal patients in the NICU. The risk for development of maintenance-related complications leading to premature device removal decreased significantly if the DLS preflush was used. During the study period, no complications related to the use of a lipid preflush solution were identified.Implications for practice and researchThis may be the first study published investigating and supporting guidewire removal enhancement by using a diluted lipid/saline preflush solution. When the requirement for vascular access is most pertinent in the neonate, using a diluted lipid preflush may provide an effective method to assist in guidewire removal to prevent malposition and vascular device complications in the neonatal population.

Polycystic Kidney Disease in 3 Juvenile Rainbow Lorikeets (Trichoglossus moluccanus).

This case series describes polycystic kidney disease in 3 (2 male, 1 female) 2-month-old, juvenile rainbow lorikeets (Trichoglossus moluccanus). The lorikeets diagnosed with polycystic kidney disease were the progeny of full sibling parents that were being intentionally line bred for the purpose of establishing a rainbow lorikeet with the blue color mutation. Clinically the juvenile lorikeets were presented with clinical signs of lethargy, dehydration, regurgitation, anorexia, polyuria, and pelvic limb paresis. Multiple abnormalities were identified on the complete blood count and plasma biochemistry panel, including a normocytic normochromic nonregenerative anemia, hyperuricemia, hyperphosphatemia, hypercalcemia, and azotemia. Severe renal dysfunction was diagnosed in all birds on the basis of clinical presentation, physical examination, and complete blood count and plasma biochemistry results. Radiographically marked renomegaly was noted in one of the cases. Although intensive critical care and supportive therapy was provided, 1 lorikeet died, and the remaining 2 were euthanatized because of client financial constraints and a rapid deterioration of their clinical condition associated with severe renal dysfunction. Postmortem pathology results found that all birds had marked renomegaly, visceral gout, and polycystic kidney disease. Because of the age of the birds and the line breeding within this group of lorikeets, the disease was believed to be inherited. Polycystic kidney disease should be considered as a possible differential diagnosis in juvenile psittacine birds with a history of line breeding when presented with severe renal dysfunction. From the current case series, polycystic kidney disease appears to carry a grave prognosis in juvenile rainbow lorikeets.

Associated Factors of High Sedative Requirements within Patients with Moderate to Severe COVID-19 ARDS.

The coronavirus pandemic continues to challenge global healthcare. Severely affected patients are often in need of high doses of analgesics and sedatives. The latter was studied in critically ill coronavirus disease 2019 (COVID-19) patients in this prospective monocentric analysis. COVID-19 acute respiratory distress syndrome (ARDS) patients admitted between 1 April and 1 December 2020 were enrolled in the study. A statistical analysis of impeded sedation using mixed-effect linear regression models was performed. Overall, 114 patients were enrolled, requiring unusual high levels of sedatives. During 67.9% of the observation period, a combination of sedatives was required in addition to continuous analgesia. During ARDS therapy, 85.1% (n = 97) underwent prone positioning. Veno-venous extracorporeal membrane oxygenation (vv-ECMO) was required in 20.2% (n = 23) of all patients. vv-ECMO patients showed significantly higher sedation needs (p < 0.001). Patients with hepatic (p = 0.01) or renal (p = 0.01) dysfunction showed significantly lower sedation requirements. Except for patient age (p = 0.01), we could not find any significant influence of pre-existing conditions. Age, vv-ECMO therapy and additional organ failure could be demonstrated as factors influencing sedation needs. Young patients and those receiving vv-ECMO usually require increased sedation for intensive care therapy. However, further studies are needed to elucidate the causes and mechanisms of impeded sedation.

Stable Patients With STEMI Rarely Require Intensive-Care-Level Therapy After Primary PCI

BackgroundThe disposition of patients presenting with ST-elevation myocardial infarction (STEMI) is commonly the coronary care unit. Recent studies have suggested that low-risk STEMI patients could be managed in a lower-acuity setting immediately after percutaneous coronary intervention (PCI). We sought to determine the frequency of downstream intensive-care therapy used in our “stable” STEMI patients post-PCI. MethodsA single-centre, retrospective review was completed of consecutive patients who underwent primary PCI for STEMI between 2013 and 2016. Post-PCI, patients were defined as being stable if they had not required intensive-care therapy or suffered significant complications. Intensive-care therapies and complications were defined as invasive/noninvasive ventilation, pacing, cardiac arrest, use of vasopressors/inotropes, dialysis, stroke, or major bleeding. This group of stable patients had their course followed to discharge. ResultsA total of 731 patients presented with STEMI for primary PCI. Of these, 132 patients (18%) required intensive-care therapies and/or had complications prior to PCI and were excluded. After PCI, 599 STEMI patients (82%) were defined as stable, according to the above definition. Of these, 11 patients (1.8%) required intensive-care therapies during their hospitalization. Zwolle scores were significantly higher in patients with complications (6.3 ± 4.4 vs 2.0 ± 1.5, P < 0.0001). The most frequent intensive-care complications and therapies were cardiac arrest (7 patients, 1%) and vasopressor use (4 patients, 0.7%). These complications most frequently occurred on the first admission day (6 patients, 1%). ConclusionsPatients who are stable at the completion of their primary PCI rarely develop complications that require intensive care. These patients are easily identified for triage to a lower-acuity setting, alleviating congestion in cardiac care units and reducing hospitalization costs.

Is cystatin C a good predictor of acute kidney injury after elective aortic surgery?

Background/Aim. Acute kidney injury (AKI) is a frequent and serious complication after aortic surgery, which increases the length of hospital stay, costs, morbidity, and mortality. The aim of the study was to investigate the incidence of AKI and the most important preoperative and intraoperative predictive factors for AKI 72 hrs after elective infrarenal aortic surgery (IAS). Methods. This prospective observational study was performed at the Clinic of Anesthesia, Intensive Care and Pain Therapy, University Clinical Center of Vojvodina (UCCV), from October 2017 to April 2019. It included 140 adult patients who underwent an elective IAS. The occurrence of AKI was noted according to the Acute Kidney Injury Network (AKIN) criteria. A multivariate logistic regression model was used for potential predictive factors. Results. The incidence of AKI after the elective IAS at the Clinic of Anesthesia, Intensive Care and Pain Therapy, UCCV, was 28.56%. According to the receiver operating characteristic (ROC) curve analysis, the cut-off value of cystatin C serum concentration of 1.14 mg/L had the highest sensitivity (82.5%) and specificity (76%) in the differentiation of patients who will develop AKI. The final model contained the following variables: the presence of chronic kidney disease, the preoperative serum concentration of cystatin C &gt; 1.14 mg/L, the application of colloid solutions in volume &gt; 500 mL during the operation, and the total intra-vascular fluid replacement volume &gt; 59 mL/kg in the intraoperative period. Conclusion. The incidence of AKI at the Clinic of Anesthesia, Intensive Care and Pain Therapy, UCCV, is somewhat higher compared to the literature data. A presurgical value of cystatin C above 1.14 mg/L is a good predictor of AKI after the elective IAS.

Гемофагоцитарный лимфогистиоцитоз, ассоциированный с герпетической инфекцией

Hemophagocytic lymphohistiocytosis (HLH) is a potentially fatal disease affecting multiple organs and systems which is induced by the dysregulation of the immune response due to mutations in the genes controlling cytolytic function. This leads to the abnormal activation of cytotoxic T cells, monocytes/macrophages, and the development of a systemic inflammatory response. In some cases, patients with HLH require emergency therapy in intensive care or resuscitation units. The article highlights the issues of HLH etiopathogenesis, its clinical, diagnostic and treatment aspects. As association was found between secondary HLH and infections caused by the herpesvirus group. The diagnosis of this condition is challenging because of its nonspecific symptoms, especially in early stages of the disease, which leads to an uncertain prognosis. The authors present case reports of two pediatric patients with secondary HLH induced by herpesvirus mixed infection. The clinical cases were characterized by the manifestations of acute dual infection with Epstein-Barr virus and cytomegalovirus, and HLH symptoms that were consistent with the diagnostic criteria of the disease described in the article. For selecting an adequate therapy, it is necessary to conduct high-quality comprehensive diagnostic testing with the involvement of hematologists, rheumatologists. and oncologists. KEYWORDS: hemophagocytic lymphohistiocytosis, infectious diseases, herpes virus, Epstein-Barr virus, cytomegalovirus, hematology, mixed infection. FOR CITATION: Karpovich G.S., Shestakov A.E., Krasnova E.I. Hemophagocytic lymphohistiocytosis associated with herpes infection. Russian Journal of Woman and Child Health. 2022;5(3):262–269 (in Russ.). DOI: 10.32364/2618-8430-2022-5-3-262-269.

Intensive Volume Removal in Patients with Advanced Heart Failure and Chronic Kidney Disease: Pitfalls and Pearls

Congestive heart failure (CHF) and chronic kidney disease (CKD) represent concurrent chronic diseases. The presence of one condition appears to accelerate the presentation and progression of the other[1], having both conditions increase the risk of hospitalization, rehospitalization, need for intensive care or kidney replacement therapy, and death[2]. Intensive volume removal has been the core management to relieve pressure and volume overload in CHF and CKD. However, fluid removal in both concurrent conditions is very challenging. Many strategies have been used, including diuretics, vasopressin V2 receptor antagonist, ultrafiltration, and renal replacement therapy. There are many considerations in patients with advanced heart failure, including diuretic resistance, worsening kidney function, rate of fluid removal, electrolyte abnormalities, and the option of renal replacement therapy[3]. Congestive heart failure (CHF) and chronic kidney disease (CKD) represent concurrent chronic diseases. The presence of one condition appears to accelerate the presentation and progression of the other[1], having both conditions increase the risk of hospitalization, rehospitalization, need for intensive care or kidney replacement therapy, and death[2]. Intensive volume removal has been the core management to relieve pressure and volume overload in CHF and CKD. However, fluid removal in both concurrent conditions is very challenging. Many strategies have been used, including diuretics, vasopressin V2 receptor antagonist, ultrafiltration, and renal replacement therapy. There are many considerations in patients with advanced heart failure, including diuretic resistance, worsening kidney function, rate of fluid removal, electrolyte abnormalities, and the option of renal replacement therapy[3].