Intensive Care Support Research Articles

PROFOUND HYPOGLYCEMIA AND BLOOD GLUCOSE TESTING METHODOLOGIES IN FLORIDA MANATEES (TRICHECHUS MANATUS LATIROSTRIS) PRESENTED TO A CRITICAL CARE CENTER.

Florida manatees (Trichechus manatus latirostris) continue to experience pressure from various stressors that frequently result in the need for rescue and veterinary assistance. Interestingly, a subset of rescued manatees in critical condition exhibits profound hypoglycemia. The goals of this study were to enhance our understanding of this important aspect of manatee care by 1) characterizing the clinical presentation and factors associated with manatees that present with profound hypoglycemia, and 2) assessing agreement across blood glucose testing modalities [glucometer (whole blood), in-house bench-top analyzer (whole blood), a point of care analyzer (whole blood), and a local human hospital laboratory analyzer (serum)]. Twenty-five manatees were admitted to the Jacksonville Zoo and Gardens from 2017 to 2021. Seven manatees were profoundly hypoglycemic on presentation with blood glucose concentrations of < 30 mg/dL. Hypoglycemic manatees were admitted due to cold stress syndrome (n = 3; 1 calf, 2 adults) or emaciation consistent with an unusual mortality event (n = 4; 2 calves, 2 adults). Physical examination findings in hypoglycemic animals included emaciation (n = 7, 100%), lethargy (n = 7, 100%), and intermittent mild muscle fasciculations of the muzzle (n = 3, 42.8%). Hypoglycemia resolved with intense supportive care and monitoring in all affected animals within 32 h of admission. No associations were identified between hypoglycemia on presentation and life-stage, sex, transport distance to JZG's critical care facility, or rehabilitation outcome (death/euthanasia vs. release). Statistical agreement was observed between all blood glucose testing modalities except for the glucometer vs. the human hospital analyzer. Despite the limited sample size, these findings inform on the clinical presentation of severe hypoglycemia, the importance of close blood glucose monitoring after admission, blood glucose testing modalities, and clinical decision-making in Florida manatees admitted to critical care centers.

Assessing the Impact of COVID-19 on Pregnancy and Maternal Outcomes: A Slovak National Study

Background: The COVID-19 pandemic highlighted the global challenge of inadequate data on SARS-CoV-2’s effects on pregnant women and their infants. In response, Slovakia, along with other countries, launched a nationwide study to assess the incidence, characteristics, and outcomes of SARS-CoV-2 infection during pregnancy. Methods: We conducted a national observational descriptive study of SARS-CoV-2 positive cases among pregnant women from the pandemic’s onset to its conclusion. In collaboration with the Public Health Office of the Slovak Republic, we identified 1184 pregnant women who tested positive for SARS-CoV-2 and contacted them for participation. Results: Among the 240 participating SARS-CoV-2-positive pregnant women, 13 required hospitalizations, with an increased need for intensive care and respiratory support. However, the absolute risk of poor outcomes remained low. Higher maternal age and infection during the third trimester emerged as key risk factors for hospitalization. A symptomatic course was dominant, with fatigue (70%), headache (58%), and fever (56%) as the leading symptoms. While maternal and neonatal outcomes were generally favourable, a slight increase in caesarean sections and preterm births suggests an indirect impact on maternity care. Vaccination during pregnancy correlated with reduced symptoms and no hospitalizations. Elevated CRP levels were common among infected women, while ultrasound findings remained normal. Conclusions: This study offers a multi-dimensional view of pregnancy during the pandemic, capturing both the mother’s personal concerns and the objective insights from prenatal and labour care settings. The findings suggest that most pregnant women with SARS-CoV-2 experience mild to moderate illness, offering reassurance to clinicians about generally favourable maternal and neonatal outcomes while underscoring the need for vigilance in rare severe cases.

Acute fatty liver of pregnancy: An atypical case report

HIGHLIGHTS Acute Fatty Liver of Pregnancy (AFLP) is an uncommon condition but life-threatening obstetric emergency, that increases the risk of fetal death due to preterm birth. AFLP can be challenging for primary health workers (especially for general practitioners (GP) and midwives) since it mimics preeclampsia, viral hepatitis, intrahepatic cholestasis of pregnancy, and HELLPS syndrome, so more concern is needed in this case. ABSTRACT Objective: To present an atypical case of acute fatty liver of pregnancy. Case Report: A 33-year-old woman was referred to the Emergency department of Dr. Soedarso Tertiary Referral Hospital, Pontianak, Indonesia, previously from the district hospital over 580 KM with diagnosis of multigravida (gravida 3 para 2) at 31 weeks gestation, suspected acute fatty liver disease (AFLP), severe oligohydramnios, and intrauterine growth restriction (IUGR). The patient had a history of nausea, vomiting, epigastric pain, polydipsia and polyuria, and seizure for less than 5 minutes with loss of consciousness. The patient originally did not know she was pregnant and using a contraceptive implant. She missed her period in the last six months ago, which was the first onset of epigastric pain. Further clinical examination resulted in pitting oedema but jaundice as a cardinal sign was not present. Laboratory data showed leukocytosis, normal haemoglobin level, normal blood glucose, hyperuricemia, increased function liver test with high transaminase and bilirubin, normal coagulation profile. Urinalysis showed proteinuria. The viral hepatitis and HIV tests were negative. Transabdominal ultrasound demonstrated a single intrauterine pregnancy with no echogenic liver features. Cardiotocography (CTG) showed category 2. This patient was diagnosed with AFLP based on Swansea Criteria (7 out of 10) and terminated pregnancy two days after diagnosis. A baby boy was born with birth weight 1.100 gr, birth length 34 cm, apgar score (AS) 9 and 10 at 1 and 5 minutes. The mother had a good prognosis, while the baby died on day 23 of life. Conclusion: Acute Fatty Liver during Pregnancy is an uncommon but life-threatening obstetric emergency. Early screening, diagnosis, timely handling delivery, and intensive supportive care are essential to decrease morbidity and mortality for both mother and fetus. Multidisciplinary opinion needed for the best management of this case.

Disease Pattern and Clinical Profile of Admitted Patients in Pediatric Intensive Care Unit of a Tertiary Care Hospital in Chattogram

Background: The care of critically ill children remains one of the most demanding and challenging aspects in the field of pediatrics. Pediatric Intensive Care Unit (PICU) aims at promoting early intervention and quality care for achieving good results and better prognosis. With the advancement in intensive care facilities, there is a dramatic increase in survival of critically ill children. It is usually offered to patients whose condition is potentially reversible and who have a good chance of surviving with intensive care support. Since these patients are critically ill, the outcome of intervention is sometimes difficult to predict. This study is aimed to assess the clinical profile of critically ill children presenting to the pediatric emergency room and then their admission pattern to the pediatric intensive care unit. This may help to assist intensivist and planners to pay due attention for better utilization of healthcare facilities. Better understanding leads to better management. Materials and methods: This is a cross-sectional study, conducted at the Pediatric Intensive Care Unit of Chattagram Maa Shishu-O-General Hospital from January to June of 2019. A total of 100 admitted cases were recruited and their symptoms and signs, clinical findings and diagnosis were recorded accordingly. All the patients were aged within 28 days to below 14 years. Results: Among the 100 study subjects, 66 were male and 34 were female. The mean age was 1.73 ± 2.6 years. Most children were admitted with respiratory distress though there were other accompanying signs and symptoms. The symptoms subjects commonly presented with were respiratory distress(76%), tachycardia(70%), lung crepitations (69%), tachypnea (68%), fever (67%), lethargy (59%), feeding difficulty (59%), convulsions (48%), low blood pressure (24%), hepatomegaly (19%), cyanosis (14%), edema (6%), congenital anomalies (4%). The clinical findings that led them to PICU admissions were bronchiolitis (4%), bronchopneumonia (42%), respiratory failure of any cause (4%), heart failure (7%), cyanotic congenital heart disease (8%), acyanoticcongenital heart disease (7%), meningitis (13%), encephalitis (12%), cerebral palsy with seizure disorder (21%), status epilepticus (2%), Gullein Barre Syndrome (3%), hyponatremic dehydration (6%), acute kidney injury (2%), acute leukemia (2%).In this study, neurological disorders such as cerebral palsy with seizure disorder and encephalitis and meningitis were among the top five in the diagnosis list. Septicemia with shock was also a very common finding promoting admission to PICU. GCS was found to be significantly lower in the above-mentioned disease conditions making admission to the ICU quite plausible. Conclusion: Children admitted to PICU may have multiple clinical findings and disease patterns. However, some diseases predominate the patient population admitted to PICU.The knowledge of clinical spectrum and epidemiological profile of critically ill children plays a significant role in the planning of health policies that would mitigate various factors related to the evolution of diseases prevalent in these sectors. Descriptive epidemiology focuses on identifying and reporting the pattern and frequency of events related to the health of a population. IAHS Medical Journal Vol 7(1), June 2024; 44-49

Epilepsy or Eclampsia in Differential Diagnosis of Recurrent Seizures in Pregnancy Aisyiyah Bojonegoro Hospital: A Diagnostic Dilemma? A Case Report

Seizures in pregnancy can lead to adverse maternal and perinatal outcomes, often arising from various factors necessitating clear diagnosis for effective therapy. Concurrent occurrence of multiple causative factors can complicate diagnostic and therapeutic decisions. We present a case of a 32-week pregnant woman with poorly managed epilepsy who experienced eclampsia and recurrent seizures. Treatment involved multiple medications and emergency cesarean delivery with meticulous blood pressure control. Close monitoring and therapy adjustment were crucial. Managing seizures in such cases poses a dilemma, necessitating initial focus on airway, breathing, and circulation stabilization. Immediate delivery of a viable fetus and maternal health maintenance are paramount. Anesthetic goals encompass seizure and blood pressure control, hemodynamic stability, and intensive care support for potential complications. While eclampsia is a significant factor, seizures in pregnancy may arise from diverse causes, demanding early diagnosis and tailored treatment for optimal patient outcomes.

Clinical characteristics and in-hospital outcomes associated with RSV-ALRI compared to other viral ALRI in hospitalised children under two years old.

Respiratory syncytial virus (RSV) is the leading cause of acute lower respiratory infections (ALRIs) associated hospitalisations in children. It is unclear if hospitalized RSV-ALRI differs in clinically from other viral ALRIs. We aimed to compare the disease impact of hospitalised RSV with other viral ALRI in children under 2 years. We conducted a retrospective study using electronic medical records of children under 2 hospitalized with ALRIs at Sydney Children's Hospitals Network from 2020-2022. We compared demographics and clinical features between RSV-positive and RSV-negative (positive for other viruses) cases. Poisson quasi-likelihood regression was used to estimate adjusted prevalence ratios (aPRs) for three in-hospital outcomes: length of stay, need for respiratory support and intensive care. We examined 330 children under 2 years hospitalized with RSV-positive ALRIs and 330 with RSV-negative ALRIs (positive for other viruses). RSV-positive cases were older (12 vs. 8 months, p<0.001) and more often presented with cough (99% vs. 92%), fever (80% vs. 58%), crackles (89% vs. 76%), hypoxia (50% vs. 36%), and lethargy (36% vs. 20%). They were also more likely to undergo chest x-rays (74% vs. 49%) and receive antibiotics (65% vs. 35%). Adjusted analysis showed RSV-positive children had a higher likelihood of LOS > 2 days (aPR 1.95, 95% CI 1.14-3.36).). However, there were no differences in the need for intensive care or respiratory support. Children with RSV-ALRI exhibited more severe symptoms, received more antibiotics, and had longer hospital stays compared to those with other viral ALRIs, underscoring the need for effective prevention and treatment strategies for RSV.

Progressive Encephalomyelitis With Rigidity and Myoclonus With Glycine Receptor and GAD65 Antibodies: Case Report and Potential Mechanisms.

Progressive encephalomyelitis with rigidity and myoclonus (PERM) is a severe form of stiff-person spectrum disorder that can be associated with antibodies against surface antigens (glycine receptor (GlyR), dipeptidyl-peptidase-like-protein-6) and intracellular antigens (glutamate decarboxylase (GAD65), amphiphysin). We report clinico-pathologic findings of a PERM patient with coexisting GlyR and GAD65 antibodies. A 75-year-old man presented with myoclonus and pain of the legs, subsequently developed severe motor symptoms, hyperekplexia, a pronounced startle reflex, hallucinations, dysautonomia, and died 10 months after onset despite extensive immunotherapy, symptomatic treatment, and continuous intensive care support. Immunotherapy comprised corticosteroids, IVIG, plasmapheresis, immunoadsorption, cyclophosphamide, and bortezomib. Intensive care treatment and permanent isoflurane sedation was required for more than 20 weeks. CNS tissue revealed neuronal loss, astrogliosis and microgliosis, representing a pallido-nigro-dentato-bulbar-spinal degeneration pattern, specifically along GlyR and GAD expression sites. Neurons showed pSTAT1, MHC class I, and GRP78 upregulation. Inflammation was moderate and characterized by CD8+ T cells and single CD20+/CD79a+ B/plasma cells. Focal tau-positive thread-like deposits were detected in gliotic brainstem areas. In the spinal cord, GlyR, glycine transporter-2, and GAD67 expression were strongly reduced. A possible potentiating effect of pathogenic GlyR antibodies together with T cells directed against neurons may have led to the severe and progressive clinical course.

42 Clinical features and severity of COVID-19 with respiratory virus coinfections versus SARS-CoV-2 monoinfection in hospitalized children: A Canadian national surveillance study

Abstract Background The co-circulation of SARS-CoV-2 alongside other respiratory viruses has led to the risk of coinfections, potentially intensifying the severity of cases, especially in children. Objectives This study examined the epidemiology, clinical characteristics, and outcomes of SARS-CoV-2 respiratory virus coinfections in comparison to SARS-CoV-2 monoinfections in hospitalized children. Design/Methods A nationwide surveillance study was conducted to assess paediatric COVID-19-related hospitalizations across Canada from April 2020 to May 2022. Data were captured through two datasets covering ~90% of all Canadian tertiary-care paediatric beds: The Canadian Paediatric Surveillance Program and the Canadian Immunization Monitoring Program, ACTive. Coinfections were defined as the simultaneous detection of SARS-CoV-2 and ≥1 other respiratory virus. Severe infection was defined as intensive care, ventilatory, or hemodynamic support needs, organ systems complications, or death. Variables and outcomes were summarized and compared, and risk ratios were computed using Poisson regression, adjusting for age, gender, comorbid conditions, SARS-CoV-2 lineage, and vaccination status. Results Out of 1501 COVID-19-related hospitalizations, 163 (10.9%) had documented coinfections with 44/163 [27%] involving SARS-COV-2 plus ≥2 other respiratory viruses. The majority of SARS-CoV-2 monoinfections (1176/1501, 87.9%) and coinfections (139/163, 85.3%) belonged to the Omicron era (Figure A). RSV (66/163, 40.5%) and Enterovirus/rhinovirus (61/163, 37.4%) coinfections were the most common. Coinfection cases were significantly younger than monoinfection cases (median age 1.2 [IQR:0.3-3.3] vs 1.6 [IQR:0.3-7.0] years, p=0.04). Overall, severe disease was more common among cases with any coinfection (38.0%) than SARS-CoV-2 monoinfection (25.7%; adjusted risk ratio 1.45, 95% confidence interval 1.17-1.80) (Figure B). In particular, we observed that severe outcomes were significantly higher in SARS-CoV-2 coinfections compared to monoinfections during the Omicron era (Figure C-D). Overall, 26/61 (42.6%) Enterovirus/Rhinovirus and 20/66 (30.3%) RSV coinfections were associated with severe outcomes. Conclusion Children with documented coinfections had more severe respiratory disease compared to SARS-COV-2 monoinfections. However, children with severe COVID-19 may have been more likely tested for multiple viruses, leading to a risk of underestimation of coinfections among children with milder disease. Further work is needed to assess how different virus coinfections may affect children and which, if any, may be a predominant driver of disease severity. 1Severe disease was defined as intensive care, ventilatory, or hemodynamic support requirements, organ system complications, or death. 2Lineage was first assigned based on available genetic sequencing data. If missing, lineage was imputed based on the dominant circulating lineage at the provincial level according to the GISAID database.

Evaluation of Infants Hospitalized in Intensive Care Unit Due to Acute Severe Bronchiolitis in Terms of Recurrent Wheezing or Asthma Development

Objective: Bronchiolitis stands out as the most prevalent lower respiratory tract infection among young children. Severe bronchiolitis, or bronchiolitis requiring admission to the hospital, affects 2-3% of all infants. The aim of this study was to evaluate individuals who were followed up in the pediatric intensive care unit (PICU) due to severe bronchiolitis in terms of asthma development. Material and Methods: Patients who were admitted Ankara Bilkent City Hospital PICU between January 2013 and December 2022, who were diagnosed with severe bronchiolitis and who had no additional systemic disease were included in the study. Demographic and clinical characteristics of patients, intensive care support treatments, duration of hospital stays, atopic conditions, and respiratory viral panel cultures was documented. The current clinical condition of the patients was documented through hospital records and telephone interviews conducted with their caregivers. The existence of asthma symptoms and the utilization of treatments within the last 12 months were evaluated according to the guidelines of the Global Initiative for Asthma (GINA) and the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire. Results: The mean age of the 60 patients admitted to the intensive care unit who met the study criteria was 13.5±7.2 months. The mean age of the children at the time of the study was 42.5 months. Male gender was more predominant (n=39, 65%). The mean number of days that respiratory support was received in intensive care was 4.9 (±3.5) days and the mean number of days of systemic steroid therapy was 3.8 (±1.7) days. In the viral respiratory tract, Respiratory Syncytial Virus (RSV) was isolated at the highest frequency in 27 patients, accounting for 45%, followed by rhinovirus (n=6, 10%) and Bocavirus (n=5, 8.3%). The number of patients receiving current asthma treatment was (n=33, 55%). Upon assessing the current status, it was found that there had been 25 (41.6%) patients with asthma attacks over the past 12 months. Conclusion: This study revealed that over half of the patients who experienced severe bronchiolitis subsequently developed asthma, with some not being referred to an allergy clinic. Furthermore, it was observed that certain patients, despite presenting with asthma symptoms, were unaware that these symptoms were attributable to asthma. We recommend that patients admitted to the PICU with a diagnosis of severe bronchiolitis be closely monitored for the potential development of asthma and that families be thoroughly informed at the time of discharge.

A Quality Improvement Initiative for Inpatient Advance Care Planning

The Centers for Medicare & Medicaid Services (CMS) implemented advance care planning (ACP) billing codes in 2016 to encourage practitioners to conduct and document ACP conversations, and included ACP as a quality metric in the CMS Bundled Payments for Care Improvement Initiative in 2018. Use of this billing code in the inpatient setting has not been studied. To determine whether a quality improvement intervention to increase inpatient ACP is effective in increasing ACP billing rates or changing hospital treatment plans or patient outcomes. This nationwide cohort study and difference-in-differences analyses compared changes in ACP billing, treatment, and outcomes in Medicare fee-for-service beneficiaries aged 65 years and older who were hospitalized and cared for by 3 different groups: practitioners employed by a national acute care staffing organization who underwent an ACP quality improvement intervention, nonintervention practitioners at the same hospital, and control group practitioners from other hospitals. Using data from the Master Beneficiary Summary File, acute care hospital stays for nonsurgical conditions were linked to Medicare enrollment, claims, and vital status data from 1-year preadmission to 1-year postadmission from 2015 to 2019. The ACP billing rates for each group were assessed for associations with 6 inpatient treatments and 4 outcomes. Data analyses were performed from January 2022 to December 2024. Billed ACP conversations, receipt of intensive care and life support (intensive care unit admission, gastrostomy tube placement, mechanical ventilation, tracheostomy), treatment limitations (newly initiated do-not-resuscitate orders) and outcomes (discharge to hospice, inpatient death, 30-day postadmission death, and 1-year postadmission death). The total study sample included 109 intervention hospitals, 1691 control hospitals, nearly 12 million Medicare fee-for-service beneficiaries aged 65 years and older, and 738 309 practitioners associated with admissions from 2016 to 2018. ACP billing rates increased more for the intervention (1.3% in preintervention to 14.0% in postintervention; P < .001) than for the nonintervention (same hospitals) and control groups (odds ratio [OR], 2.6; 95% CI, 1.7-4.1 intervention vs control). Increased ACP billing rates were significantly associated with decreased rates of inpatient death in the intervention group (OR, 0.95; 95% CI, 0.90-1.00) compared to the nonintervention (OR, 1.10; 95% CI, 1.04-1.17) and control groups (reference). All other associations were nonsignificant. This nationwide cohort study suggests that while the ACP quality initiative increased ACP billing, changes in clinical outcomes were inconsistent with the hypotheses. Further study is needed to address questions regarding confounding by unobserved measures of care quality.

Respiratory Syncytial Virus and US Pediatric Intensive Care Utilization

Bronchiolitis is the most common diagnosis necessitating respiratory support and pediatric intensive care, and respiratory syncytial virus (RSV) is the most common cause of bronchiolitis. In 2023, the monoclonal antibody nirsevimab and the maternal RSVpreF vaccine were implemented to prevent RSV in infants. To determine the potential association of novel RSV prevention strategies with pediatric intensive care unit (ICU) utilization. This retrospective cross-sectional study examined US pediatric ICU encounters with and without RSV from January 1, 2017, to June 1, 2023. Data were from Oracle Cerner RealWorld Data, a national electronic health record database. All children (aged >1 day and <18 years) admitted to an ICU during the study period were included in the analysis. Statistical analysis was performed from February to May 2024. The primary outcomes were ICU encounters with RSV and ICU encounters with RSV eligible for RSV prevention. There were 119 782 ICU encounters from 53 hospitals; 65 757 encounters (54.9%) were male; median (IQR) age was 4.5 (1.1-12.5) years, median (IQR) ICU length of stay was 1.8 (1.0-3.9) days; 13 702 ICU encounters (11.4%) had RSV, of which 38.6% (5217) were eligible for prevention (4.4% of total ICU encounters). Encounters with RSV accounted for 21.1% (109 334) of ICU days, of which 43.8% (47 888) were eligible for prevention (9.2% of total ICU days). Encounters with RSV were associated with a greater use of positive pressure ventilation (4074 [29.7%] vs 18 821 [17.7%]; P < .001) and vasoactive medications (3057 [22.3%] vs 18 570 [17.5%]; P < .001) compared with those without RSV. The findings of this retrospective cross-sectional study of RSV and US pediatric intensive care utilization suggest that if 65% to 85% of eligible children received RSV prevention, an estimated 2.1% to 2.8% reduction in pediatric ICU encounters and an estimated 4.5% to 5.9% reduction in pediatric ICU days could be achieved.

Intraoperative infusion support in surgery and intensive care

The article analyzes the principles of intraoperative infusion therapy and the pathophysiology of water-electrolyte disorders in children. Patients in critical condition especially need infusion therapy. The rules for calculating the volume of infusion therapy during surgery are given and the liberal and restrictive strategies of infusion are reflected, the negative consequences of hypervolemia and infusion of hypoosmolar solutions are demonstrated based on the results of numerous studies. The historical and practical aspect of intraoperative infusion therapy to prevent dehydration and shock manifestations is highlighted.

Clinical characteristics of Chinese children with EV-D68-associated pneumonia: A single-center retrospective analysis.

Human enterovirus D68 (EV-D68) has been associated with an increase in mild-to-severe pediatric respiratory diseases in western countries. However, the prevalence and clinical characteristics of EV-D68-associated pneumonia in China remain understudied. Between January 2022 and January 2024, 28 patients with EV-D68-associated pneumonia were enrolled. We described the prevalence, demographic, and clinical characteristics of patients with EV-D68-associated pneumonia. Among the 28 enrolled patients, the male-to-female ratio was 1.5:1, and the average age at onset was 4.6 ± 2.7 years. Four (14.3%) required intensive care support. Monoinfection occurred in 11 cases (39.3%), while coinfections were seen in 17 cases (60.7%). 82.1% of patients had a history of one or more atopic diseases. The primary symptoms of EV-D68-associated pneumonia included cough (100%), wheezing (53.6%), and fever (53.6%). Radiologically, patchy opacity was the predominant feature, observed in 72.7% of cases. No statistically significant differences were found in symptoms, laboratory tests, or imaging findings between the monoinfection and coinfection groups. Except for one case who developed quadriplegia sequelae, all patients had a favorable prognosis. EV-D68 is not a common pathogen for community-acquired pneumonia in China. It mainly affects young children, particularly those with atopic constitution. The overall prognosis is favorable, although neurological complications are rare and may lead to severe sequelae. This study is the first investigation into the prevalence and clinical characteristics of EV-D68-associated pneumonia in China.

WP4.8 - Separating the sheep from the goat - Outcomes Based on Low, High and Extreme Risk NELA scoring

Abstract Background According to the UK National Emergency Laparotomy Audit (NELA), high-risk emergency laparotomy is defined as any patient with a NELA risk score of ≥ 5%, indicating a predicted mortality rate of 5% or higher within 30 days after the procedure. However, scores ranging between 5%-100% fall within the similar ambit of requiring intensive care support. There is a lack of distinction among the patients in the high-risk group with measurable outcomes. Given the broad margin, we stratified NELA mortality into low risk (&amp;lt;5%), high risk (5-50%) and extreme risk (&amp;gt;50%). The study was retrospective, involving 150 laparotomies, and looked at the outcome amongst various stratifications. Methods A retrospective analysis of 150 patients who underwent emergency laparotomy was evaluated against the documented NELA scoring and stratified into categories. Baseline characteristics, encompassing age, usual place of residence, ASA physical status, and NELA score, were analyzed to compare the three groups (low, high and extreme risk). The outcomes under consideration included 30- and 90-day mortality, hospital length of stay, re-operation rates and the length of stay in critical care. Results There existed clear outcomes with the 30-day mortality and re-operation rates between the three groups. Our study highlighted the gap that exists in the clinical prognosis and shared decision-making in patients with high (5-50%) and extreme risk (&amp;gt;50%) NELA scores. Further, we worked out a risk stratification model that could guide consenting these patients. Conclusions Outcomes based on NELA score stratification will only strengthen the shared decision-making process for a patient with an objective understanding of the risks involved.

Survival of a young male patient with catastrophic acute left main coronary artery occlusion and cardiogenic shock

ABSTRACT Total occlusion of the left main coronary artery (LMCA) is a rare but highly lethal event in acute coronary syndrome. It can lead to extensive myocardial infarction and hemodynamic instability. Despite advancements in percutaneous coronary intervention (PCI), mortality remains high. A 35-year-old male presented with chest pain, dyspnea, and hemodynamic instability. Diagnostic workup revealed LMCA thrombotic occlusion with extensive myocardial involvement and cardiogenic shock (CS). Prompt intervention, including thrombus aspiration, angioplasty, and hemodynamic support with intra-aortic balloon pump and venoarterial extracorporeal membrane oxygenation, was initiated. The patient’s condition gradually improved with comprehensive management, including pharmacotherapy and intensive care support. LMCA occlusion presents challenges due to its extensive myocardial distribution and high mortality rates, particularly when complicated by CS. PCI combined with circulatory support is crucial for restoring perfusion and improving outcomes. Achieving optimal flow and providing postprocedural care significantly impact patient prognosis. Rapid diagnosis and intervention are critical in LMCA occlusion with CS. A multidisciplinary approach incorporating advanced circulatory support and timely revascularization are the keys in improving patient outcomes. Comprehensive postprocedural care is essential for ensuring successful recovery and survival.

Reverse takotsubo induced cardiogenic shock in the peripartum period: A case report and literature review.

Reverse takotsubo cardiomyopathy is a rare variant of a rare disease characterized by basal ballooning and dysfunction of the left ventricle. While it can render patients profoundly unwell and reliant on intensivist care, it is a transient phenomenon, with the worst symptoms subsiding after 2-3 days. At term, a young woman spontaneously entered labor prior to a planned repeat cesarean section. After experiencing physical and psychological distress during labor and a vacuum extraction, she developed cardiogenic shock from reverse takotsubo cardiomyopathy, quickly diagnosed with transthoracic echocardiogram. She required 2 days of intensive care support and made an excellent recovery. This very rare condition should be considered in systemically unwell women in the peripartum as it can be quickly diagnosed, providing patients with the best appropriate care.

ORAL HEALTH CARE IN PATIENTS OF THE INTENSIVE CARE UNITS.

Introduction: oral hygiene is considered a basic need to protect the health and well-being of the population, with more emphasis for patients under intensive care support. Objective: shortly review the literature about effective role of well-trained professional teams while performing oral care in patients managed in the Intensive Care Unity. Methods: scientific review article, taking as a source of information the current literature published in the PubMed database between 2004 and 2024 including, systematic reviews, meta-analysis, and review studies related with the buccal care procedures, and their relationships with the outcomes of critical ill patients under the infection risks. Results: 28 articles were analyzed, with data of children or adult patients of diverse continents who needed mechanical ventilation, enteral or parenteral feeding, or some invasive procedure favoring the hospital acquired infections, mainly the pneumonias. The reviewed literature most frequently described the lack or insufficient specialized care for the oral cavity of patient with very limited autonomy during hospitalizations. Conclusion: as a whole, there is a need for the dental specialists in the hospital team to personally perform, besides to train in service the nurse staffs and their assistants to carry on the correct methods for the patient daily buccal hygiene, with improvement of general health care and avoiding the worsening during the hospitalization period.

Autoimmune Manifestations in a Cohort of Egyptian COVID-19 Patients

Abstract Introduction COVID-19 infection can result in a range of symptoms, from asymptomatic to severe, requiring intensive care and ventilatory support. Research has explored the association between COVID-19 and autoimmune conditions, including the detection of autoantibodies in COVID-19 patients. However, results are not conclusive, prompting us to conduct a cross-sectional study to evaluate the prevalence of autoimmune rheumatic manifestations in a cohort of Egyptian individuals diagnosed with COVID-19. Methods Ninety individuals with COVID-19 were included in the study. Patients were classified based on WHO criteria and laboratory data was collected. Autoimmune markers (ANA, RF, ACL IgM, ACL IgG) were measured and patients were grouped based on positive and negative results. Correlational analysis was conducted to assess the association between each marker and clinical severity of COVID-19 and autoimmune rheumatological manifestations. Results Of the studied patients, 13.3% had a positive ANA, 15.6% had a positive RF, 8.9% had a positive ACL IgM, and 5.6% had a positive ACL IgG. However, there was no statistically significant difference between severity groups regarding the results of ANA, RF, ACL IgM, and IgG. All patients with a positive ANA were present among severe and critical COVID-19 cases, and all patients with positive RF, ACL IgM, or ACL IgG were among moderate, severe, and critical cases. Conclusion Our study provides insight into the prevalence of autoimmune rheumatic manifestations in COVID-19 patients. While our results were inconclusive regarding the association between autoimmune markers and severity of disease, we found a statistically significant higher prevalence of several symptoms in critical COVID-19 patients. Our study highlights the importance of further investigation into the relationship between COVID-19 and autoimmune conditions.

Prospective, multicenter, Turkish out-of-hospital cardiac arrest study: TROHCA.

There is no sufficient data to provide a clear picture of out-of-hospital cardiac arrest (OHCA) across Türkiye. This study is the first to present the prognostic outcomes of OHCA cases and the factors associated with these outcomes. The study was conducted in a prospective, observational, multicenter design under the leadership of the Emergency Medicine Association of Turkey Resuscitation Study Group. OHCA cases aged 18 years and over who were admitted to 28 centers from Türkiye were included in the study. Survived event, return of spontaneous circulation (ROSC), survival to hospital discharge, and neurological outcome at discharge were investigated as primary outcomes. One thousand and three patients were included in the final analysis. 61.1% of the patients were male, and the average age was 67.0 ± 15.2. Cardiopulmonary resuscitation (CPR) was performed on 86.5% of the patients in the prehospital period by emergency medical service, and bystander CPR was performed on only 2.9% by nonhealth-care providers. As a result, the survived event rate was found to be 6.9%. The survival rate upon hospital discharge was 4.4%, with 2.7% of patients achieving a good neurological outcome upon discharge. In addition, the overall ROSC and sustained ROSC rates were 45.2% and 33.4%, respectively. In the multiple logistic regression analysis, male gender, initial shockable rhythm, a shorter prehospital duration of CPR, and the lack of CPR requirement in the emergency department were determined to be independent predictors for the survival to hospital discharge. Compared to global data, survival to hospital discharge and good neurological outcome rates appear to be lower in our study. We conclude that this result is related to low bystander CPR rates. Although not the focus of this study, inadequate postresuscitative care and intensive care support should also be discussed in this regard. It is obvious that this issue should be carefully addressed through political moves in the health and social fields.

A Comparative Study of Community-acquired Acute Kidney Injury and Hospital-acquired Acute Kidney Injury from a Tertiary Care Hospital in North India.

In this observational study, clinical characteristics, etiologies, and outcomes of patients admitted to the hospital with community-acquired acute kidney injury (CAAKI) have been compared in contrast to those who hospital-acquired Acute Kidney Injury (HAAKI). This was a prospective study of adults aged 18 years or above diagnosed with acute kidney injury (AKI) over a period of 17 months at a tertiary care hospital. 230 patients had AKI with the mean age of the study population being 45.33 ± 12.68 years. 178 (77.4%) patients were enrolled from medical unit, 25 (10.7%) from surgical unit, and 27 (11.7%) from obstetrical unit. The observed incidence of AKI was 15/1000 admissions. About 58.2% had CAAKI and 96 (43.7%) had HAAKI. Out of 230 patients, 170 (73.9%) patients were male and 60 (26.1%) were female. Sepsis was the most common (52.1%) etiology of AKI among the medical cases. Urosepsis, scrub typhus, and pneumonia were the most common causes of AKI. Sixty percent of AKI was Kidney Disease Improving Global Outcomes Stage 1 or 2 and 40% was in Stage 3. Oliguria was seen in 56.5%, hyperkalemia in 34.7%, fluid overload in 6.1%, and metabolic acidosis in 22.6%. The majority of patients had multiple organ involvement (52.1%) at the time of enrollment. About 116 (50.4%) had lung injury requiring mechanical ventilation and 95 (41.3%) were on inotropes. Mortality occurred in 19.5%. Anemia, the use of vasopressor drugs, and the need for intensive care support were independent predictive factors for mortality. AKI was common in hospitalized patients and leads to significant inhospital mortality. AKI is largely a CAAKI, and the lesser extent is due to HAAKI. Many causes are potentially preventable. Early fluid resuscitation, effective antibiotics, appropriate antidotes, and timely referral of established AKI patients to centers with dialysis facilities can improve AKI outcomes.