Persistent Hemodynamic Instability Research Articles

Algorithm of High-Risk Massive Pulmonary Thromboembolism with Extracorporeal Membrane Oxygenation

Objective: Massive pulmonary embolism (PE) remains a life-threatening condition, often leading to acute respiratory and cardiac failure. This study evaluates the role of extracorporeal membrane oxygenation (ECMO) as a supportive treatment for high-risk patients undergoing surgical pulmonary embolectomy or catheter-based thrombectomy. Methods: Between January 2018 and December 2023, 27 patients with high-risk massive PE were treated at our center. Surgical embolectomy (n = 7) and catheter-based thrombectomy (n = 5) were performed, with ECMO support (veno-arterial [VA] or veno-arterial-venous [VAV]) initiated preoperatively, intraoperatively, or postoperatively, based on hemodynamic instability. ECMO was used as a bridge to recovery, and outcomes were assessed in terms of mortality, hemodynamic stabilization, and recovery. Results: Of the 27 patients, 20 were supported with ECMO, with 7 requiring VA-ECMO intraoperatively due to difficulties in weaning from cardiopulmonary bypass (CPB). Nine patients were later transitioned to VAV-ECMO due to Harlequin syndrome and persistent hemodynamic instability. The in-hospital mortality rate was 18.5% (n = 5), with survivors showing significant improvements in hemodynamic and biochemical parameters post-ECMO, including reduced lactate levels, improved right ventricular function, and the stabilization of mean arterial pressure. The mean follow-up time was 10.2 ± 3.9 months, with no late deaths or complications observed. Conclusions: ECMO provides effective life support in high-risk patients with massive PE who are undergoing surgical embolectomy or thrombectomy. It stabilizes hemodynamics, improves cardiac and pulmonary function, and facilitates recovery in critically ill patients. Further research is needed to refine patient selection, optimize ECMO timing, and assess long-term outcomes to determine its definitive role in the management of high-risk PE.

Dilemma Diagnosis Between Pulmonary Embolism and Amniotic Fluid Embolism During First Stage of Labor—A Case Report

ABSTRACTWe report the sudden onset of dyspnea and loss of consciousness and fetal bradycardia in a middle‐aged obese nulliparous woman at 39 weeks of gestation during first stage of labor leading to the decision for emergency cesarean section. Still during surgery, the mother underwent cardiac arrest. Transesophageal echocardiography during resuscitation showed right ventricular failure leading to the diagnosis of pulmonary embolism. Return of spontaneous circulation was achieved after emergency administration of thrombolysis with alteplase and cardiopulmonary resuscitation after 40 min. Severe bleeding, coagulopathy and persistent right ventricular failure resulted in persistent hemodynamic instability leading to supracervical hysterectomy and veno‐arterial extracorporal life support. Both mother and baby survived without hypoxic brain injury.

Understanding ST equivalents on ECG part II

In reality, many acutemyocardial infarction patients with ST deviations observed in other conditions in which the characteristics of these ECG do not meet the criteria of STEMI. They are called: ST equivalents. STEMI equivalents represent coronary occlusion without meeting the traditional STE criteria and are equally important to recognize in a timely fashion. Emergency physicians must know to involve interventional cardiologists for patients with dynamic ECG changes, persistent ischemic chest pain, hemodynamic instability, and STEMI equivalent patterns that require emergent PCI to minimize morbidity and mortality. This is the reason why we would like to propose this review to present some common ST equivalents for physicians and cardiologists to apply to the clinical practice. These are: de Winter ST/T complex, Wellens syndromes, ST-elevation in lead AVR, LBBB with Sgarbossa criteria, isolated posterior MI, T waves upright in V1. This review is the part two of the topic.

Surgery for ulcerative colitis

Ulcerative colitis (UC) has a more severe presentation and rapid progression in pediatric patients, resulting in a greater need for surgical intervention compared to adults. Though medical management of UC has advanced with new biologic therapies, surgery continues to play an important role when disease progresses in the form of worsened or persistent symptoms, hemodynamic instability, or sepsis. The goals of surgical management are to restore intestinal continuity with a functional pouch when possible. While the literature has been growing regarding studies of pediatric patients with UC, high level of evidence studies are limited and most recommendations are based on adult studies. Similar to adults, pediatric patients who have ileal pouches created require surveillance for recurrent disease and cancer surveillance. Unique issues for pediatric patients include monitoring of growth and appropriate transition to adult care after adolescence. This review includes indications for surgical management, overview of staged surgical approaches, and the technical details of the three-stage approach.

Intensive Care Treatment of Pulmonary Embolism: An Update Based on the Revised AWMF S2k Guideline.

Acute pulmonary embolism (PE) remains a significant cause of morbidity and requires prompt diagnosis and management. The prognosis of affected patients depends on the clinical severity. Therefore, risk stratification is imperative for therapeutic decision-making. Patients with high-risk PE need intensive care. These include patients who have successfully survived resuscitation, with obstructive shock or persistent haemodynamic instability. Bedside diagnostics by means of sonographic procedures are of outstanding importance in this high-risk population. In addition to the treatment of hypoxaemia with noninvasive and invasive techniques, the focus is on drug-based haemodynamic stabilisation and usually requires the elimination or reduction of pulmonary vascular thrombotic obstruction by thrombolysis. In the event of a contraindication to thrombolysis or failure of thrombolysis, various catheter-based procedures for thrombus extraction and local thrombolysis are available today and represent an increasing alternative to surgical embolectomy. Mechanical circulatory support systems can bridge the gap between circulatory arrest or refractory shock and definitive stabilisation but are reserved for centres with the appropriate expertise. Therapeutic strategies for patients with intermediate- to high-risk PE in terms of reduced-dose thrombolytic therapy or catheter-based procedures need to be further evaluated in prospective clinical trials.

Open Fixation After Preperitoneal Pelvic Packing Is Associated With a High Surgical Site Infection Rate.

To evaluate the incidence of pelvic space surgical site infection (SSI) after preperitoneal pelvic packing (PPP) for persistent hemodynamic instability. Retrospective comparative study. Urban Level 1 trauma center. 83 patients who received PPP and 55 patients who had open reduction and internal fixation (ORIF) of the anterior pelvic ring without PPP. Operative fixation. Pelvic space SSI. The SSI rate in the PPP group was 31.3% (26/83) compared with 10.9% (6/55) in the control group (proportional difference 20.4%, confidence interval (CI) 6.4-32.5, P = 0.007). Patients in the PPP group (n = 43) were 1:1 propensity score matched with patients in the control group to account for differences in Injury Severity Score and American Society of Anesthesiologists score. In this matched cohort, the rate of pelvic space SSI remained higher in the PPP group compared with that in the control group (30.2% vs. 9.3%; proportional difference 20.9%, CI, 3.7-36.3; P = 0.02). On multivariate analysis of the PPP group, anterior ORIF (odds ratio 6.56, CI, 2.00-21.47, P = 0.002) was found to be independently associated with SSI. PPP is an independent risk factor of space SSI. The likelihood of SSI after PPP is increased with anterior ORIF. The morbidity of SSI after PPP must be weighed against the risk of exsanguination. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Predictors of hemodynamic instability during and persistent after carotid artery stenting

ObjectivesThe risk factors for post-carotid artery stenting severe hemodynamic instability remain elusive. This study aimed to identify the predictors of severe hemodynamic instability during and persisted after carotid artery stenting. Materials and methodsConsecutive patients who underwent carotid artery stenting for extracranial carotid artery stenosis at a single-center between September 2018 and July 2021 were retrospectively assessed. The predictive factors of severe hemodynamic instability intraoperation and post-operation were analyzed. ResultsAmong the 139 patients included, 63 experienced severe hemodynamic instability, with 45 and 18 cases occurring intra and postoperatively, respectively. Persistent was observed in 21 patients. Smoke exposure (odds ratio [OR], 2.38; p=0.039), carotid bifurcation stenosis (OR, 0.91; p=0.018), and large-diameter balloon (>4 mm) dilatation (OR, 11.95; p<0.001) were identified as independent risk factors for hemodynamic instability at any stage of carotid artery stenting. Intraoperatively, large-diameter balloon (>4 mm) dilatation was associated with an increased risk of hemodynamic instability occurrence (OR, 4.67; p=0.01), whereas general anesthesia (OR, 0.19; p=0.001) and a longer distance from the stenosis to the carotid bifurcation (OR, 0.89; p=0.01) were negatively associated with hemodynamic instability. Furthermore, smoking exposure (OR, 3.73; p=0.03), large diameter balloon dilatation (OR, 6.12; p=0.032), distance from stenosis to bifurcation (OR, 0.85; p=0.047) and long-stent (40 mm) implantation (OR, 0.84 [95% confidence interval, 0.74–0.95]; p=0.007) could independently predict persistent hemodynamic instability. ConclusionPatients with a smoking history, lesions near the carotid bulb, or dilatation using a large-diameter balloon were most likely to suffer severe hemodynamic instability. General anesthesia can protect against severe hemodynamic instability only intraoperatively. Long-term stent implantation may reduce persistent hemodynamic instability.

Role of fibrinolysis after the generalization of the primary percutaneous coronary intervention in the setting of ST-Elevation Acute Myocardial Infarction

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Primary percutaneous coronary intervention (PCI) is the treatment of choice in patients with ST-Elevation Acute Myocardial Infarction (STEMI). Fibrinolysis is relegated to situations in which the intervention cannot be performed in the appropriate time. The indications for fibrinolysis and the criteria for reperfusion were established long ago. Furthermore, in many areas, patients undergoing fibrinolysis therapy represent a minority due to increased access to primary PCI-centres. Purpose We sought to evaluate the effectiveness of fibrinolysis and its safety compared to primary PCI in a real-world analysis. Methods This is a retrospective, observational, single-centre study in which we included patients with STEMI diagnosis admitted to the coronary unit from June-2011 to August-2022. It was differentiated if the patients underwent primary PCI or fibrinolysis (time to catheterization room &amp;gt;2 hours). The efficacy of fibrinolysis regarding the coronary reperfusion capability was analysed using the TIMI coronary grade flow scoring system. Similarly, the need for rescue PCI (&amp;lt;50% ST normalization, persistent chest pain or hemodynamic instability) was observed. We compared the baseline characteristics of the patients who underwent fibrinolysis versus those who only underwent a primary angioplasty strategy and the results in terms of complications and in-hospital mortality. Results 1604 patients were included with an average age of 62 years, in which 137 (8,4%) of them underwent a fibrinolysis strategy. The rate of patients with coronary occlusion (TIMI 0) at the time of PCI was significantly lower in the fibrinolysis group (77.1% vs 36.1%; p&amp;lt;0.001), which represents an estimated effectiveness of coronary recanalization of 53.2%. Initially, we found more smokers (46,0% vs 57,4% p = 0.01), and a younger age (62 vs 58, p&amp;lt;0,01) among patients who underwent fibrinolysis. No other differences were found in the remaining baseline characteristics (Table). A higher rate of ventricular arrhythmias (10,4% vs 16,0%; p=0.04) was demonstrated in the fibrinolysis group, but without showing differences in terms of mortality (5.7% vs 2.1%; p= NS.). No significant differences in bleeding (8.9% vs 10.9%; p=NS.) or intracranial hemorrhage (0.1% vs 0.7%, p= NS.) were found. Regarding rescue-PCI, it was necessary in 81 (59,12%) of the patients who underwent fibrinolysis. 70% of the patients who underwent rescue PCI had TIMI 0-1. In the patients treated with fibrinolysis who underwent early-PCI but not rescue-PCI, only 3 patients (6,5%) presented coronary occlusion (TIMI 0) at catheterization. Conclusion Fibrinolysis should continue to play an important role in patients who cannot reach PCI on time, given its effectiveness and because it does not represent a significant increase in mortality or adverse effects, except for ventricular arrhythmias. Likewise, the reperfusion criteria seem to be effective in differentiating patients with coronary reperfusion.

Intraoperative Infusion of Dextran Confers No Additional Benefit after Carotid Endarterectomy but Is Associated with Increased Perioperative Major Adverse Cardiac Events

Intraoperative dextran infusion has been associated with reduction of an embolic risk in patients undergoing carotid endarterectomy (CEA). Nonetheless, dextran has been associated with adverse reactions including anaphylaxis, hemorrhage, cardiac and renal complications. Herein, we aimed to compare the perioperative outcomes of CEA stratified by the use of intraoperative dextran infusion using a large multi-institutional dataset. Patients undergoing CEA between 2008 and 2022 from the Vascular Quality Initiative database were reviewed. Patients were categorized by use of intraoperative dextran infusion, and demographics, procedural data and in-hospital outcomes were compared. Logistic regression analysis was utilized to adjust for differences in patients while assessing the association between postoperative outcomes and intraoperative infusion of dextran. Of 140,893 patients undergoing CEA, 9,935 (7.1%) patients had intraoperative dextran infusion. Patients with intraoperative dextran infusion were older with lower rates of symptomatic stenosis (24.7% vs 29.3%; P<0.001) and preoperative use of antiplatelets, anticoagulants and statins. Additionally, they were more likely to have severe carotid stenosis (> 80%; 49% vs 45%; P<0.001) and undergo CEA under general anesthesia (96.4% vs 92.3%; P<0.001) with more frequent use of shunt (64.4% vs 49.5%; P<.001). After adjustment, multivariable analysis showed that intraoperative dextran infusion was associated with higher odds of in-hospital major adverse cardiac events (MACE) including myocardial infarction (MI; odds ratio [OR], 1.76, 95% confidence interval [CI]: 1.34-2.3, P<0.001), congestive heart failure (CHF; OR, 2.15, 95% CI: 1.67-2.77, P=0.001) and hemodynamic instability requiring vasoactive agents (OR, 1.08, 95% CI: 1.03-1.13, P=0.001). However, it was not associated with decreased odds of stroke (OR, 0.92, 95% CI: 0.74-1.16, P=0.489) or death (OR, 0.88, 95% CI: 0.58-1.35, P=0.554). These trends persisted even when stratified by symptomatic status and degree of stenosis. Intraoperative infusion of dextran was associated with increased odds of MACE including MI, CHF and persistent hemodynamic instability without decreasing the risk of stroke perioperatively. Given these results, judicious use of dextran in patients undergoing CEA is recommended. Furthermore, careful perioperative cardiac management is warranted in select patients receiving intraoperative dextran during CEA.

Analysis of the efficacy and safety of conservative treatment of blunt abdominal trauma in children: retrospective study. Conservative treatment of blunt abdominal trauma in children.

in Brazil, trauma is responsible for 40% of deaths in the age group between 5 and 9 years old, and 18% between 1 and 4 years, and bleeding is the leading cause of preventable death in the traumatized child. Conservative management of blunt abdominal trauma with solid organs injury - started in the 60s - is the current world trend, with studies showing survival rates above 90%. The objective was to assess the efficacy and safety of conservative treatment in children with blunt abdominal trauma treated at the Clinical Hospital of the University of Campinas, in the last five years. retrospective analysis of medical records of patients classified by levels of injury severity, in 27 children. only one child underwent surgery for initial failure of conservative treatment (persistent hemodynamic instability), resulting in a 96% overall success rate of the conservative treatment. Five other children (22%) developed late complications that required elective surgery: a bladder injury, two cases of infected perirenal collections (secondary to injury of renal collecting system), a pancreatic pseudocyst and a splenic cyst. Resolution of the complications was attained in all children, with anatomical and functional preservation of the affected organ. There were no deaths in this series. the conservative initial approach in the treatment of blunt abdominal trauma was effective and safe with high resolution and low rate of complications leading to a high preservation rate of the affected organs. Level of evidence III - prognostic and therapeutic study.

Is prehospital intubation of severely injured children in accordance with guidelines?

BackgroundThe current German S3 guideline for polytrauma lists five criteria for prehospital intubation: apnea, severe traumatic brain injury (GCS ≤8), severe chest trauma with respiratory failure, hypoxia, and persistent hemodynamic instability. These guideline criteria, used in adults in daily practice, have not been previously studied in a collection of severely injured children. The aim of this study was to assess the extent to which the criteria are implemented in clinical practice using a multivariate risk analysis of severely injured children.MethodsData of 289,698 patients from the TraumaRegister DGU® were analyzed. Children meeting the following criteria were included: Maximum Abbreviated Injury Scale 3+, primary admission, German-speaking countries, years 2008–2017, and declaration of intubation. Since children show age-dependent deviating physiology, four age groups were defined (years old: 0–2; 3–6; 7–11; 12–15). An adult collective served as a control group (age: 20–50). After a descriptive analysis in the first step, factors leading to prehospital intubation in severely injured children were analyzed with a multivariate regression analysis.ResultsA total of 4489 children met the inclusion criteria. In this cohort, young children up to 2 years old had the significantly highest injury severity (Injury Severity Score: 21; p ≤ 0.001). Falls from both high (> 3 m) and low heights (< 3 m) were more common in children than in adults. The same finding applied to the occurrence of severe traumatic brain injury. When at least one intubation criterion was formally present, the group up to 6 years old was least likely to actually be intubated (61.4%; p ≤ 0.001). Multivariate regression analysis showed that Glasgow Coma Scale score ≤ 8 in particular had the greatest influence on intubation (odds ratio: 26.9; p ≤ 0.001).ConclusionsThe data presented here show for the first time that the existing criteria in the guideline for prehospital intubation are applied in clinical practice (approximately 70% of cases), compared to adults, in the vast majority of injured children. Although severely injured children still represent a minority of all injured patients, future guidelines should focus more on them and address them in a specialized manner.

A modified Sequential Organ Failure Assessment score for dengue: development, evaluation and proposal for use in clinical trials

BackgroundDengue is a neglected tropical disease, for which no therapeutic agents have shown clinical efficacy to date. Clinical trials have used strikingly variable clinical endpoints, which hampers reproducibility and comparability of findings. We investigated a delta modified Sequential Organ Failure Assessment (delta mSOFA) score as a uniform composite clinical endpoint for use in clinical trials investigating therapeutics for moderate and severe dengue.MethodsWe developed a modified SOFA score for dengue, measured and evaluated its performance at baseline and 48 h after enrolment in a prospective observational cohort of 124 adults admitted to a tertiary referral hospital in Vietnam with dengue shock. The modified SOFA score included pulse pressure in the cardiovascular component. Binary logistic regression, cox proportional hazard and linear regression models were used to estimate association between mSOFA, delta mSOFA and clinical outcomes.ResultsThe analysis included 124 adults with dengue shock. 29 (23.4%) patients required ICU admission for organ support or due to persistent haemodynamic instability: 9/124 (7.3%) required mechanical ventilation, 8/124 (6.5%) required vasopressors, 6/124 (4.8%) required haemofiltration and 5/124 (4.0%) patients died. In univariate analyses, higher baseline and delta (48 h) mSOFA score for dengue were associated with admission to ICU, requirement for organ support and mortality, duration of ICU and hospital admission and IV fluid use.ConclusionsThe baseline and delta mSOFA scores for dengue performed well to discriminate patients with dengue shock by clinical outcomes, including duration of ICU and hospital admission, requirement for organ support and death. We plan to use delta mSOFA as the primary endpoint in an upcoming host-directed therapeutic trial and investigate the performance of this score in other phenotypes of severe dengue in adults and children.

How Learning from Trauma Benefits the Obstetric Population? Damage Control Surgery

Abstract The recent implementation of trauma-validated damage control strategies in severe postpartum hemorrhage proves the importance of interdisciplinary management in the obstetric patient. Massive hemorrhage control techniques and damage control surgery are clear examples of how learning from trauma can benefit the obstetric population. Currently, most obstetric programs do not include training in this type of interventions. Nevertheless, it has been shown that these interventions are useful in the management of severe postpartum hemorrhage. The aim of this article is to introduce the application of damage control surgery principles in the management of massive obstetric hemorrhage. We propose to include appropriate training and the implementation of damage control surgery in obstetric management protocols. The prompt application of damage control principles can be considered in patients with persistent hemodynamic instability despite control of the source of bleeding.

A Care Step Pathway for the Diagnosis and Treatment of COVID-19-Associated Invasive Fungal Infections in the Intensive Care Unit.

In March 2020, the World Health Organization declared COVID-19, caused by the SARS-CoV-2 virus, a pandemic. Patients with severe cases resulting in hospitalization and mechanical ventilation are at risk for COVID-19-associated pulmonary aspergillosis, an invasive fungal infection, and should be screened for aspergillosis if they have persistent hemodynamic instability and fever. Early detection and treatment of this fungal infection can significantly reduce morbidity and mortality in this population. To develop an evidence-based care step pathway tool to help intensive care unit clinicians assess, diagnose, and treat COVID-19-associated pulmonary aspergillosis. A panel of 18 infectious disease experts, advanced practice registered nurses, pharmacists, and clinical researchers convened in a series of meetings to develop the Care Step Pathway tool, which was modeled on a tool developed by advanced practice nurses to evaluate and manage side effects of therapies for melanoma. The Care Step Pathway tool addresses various aspects of disease management, including assessment, screening, diagnosis, antifungal treatment, pharmacological considerations, and exclusion of other invasive fungal coinfections. The Care Step Pathway tool was applied in the care of a patient with COVID-19-associated aspergillosis. The patient was successfully treated. The Care Step Pathway is an effective educational tool to help intensive care unit clinicians consider fungal infection when caring for COVID-19 patients receiving mechanical ventilation in the intensive care unit, especially when the clinical course is deteriorating and antibiotics are ineffective.

Role of extracorporeal membrane oxygenation and surgical embolectomy in acute pulmonary embolism.

Purpose of reviewSurgery is an important option to consider in patients with massive and submassive pulmonary emboli. Earlier intervention, better patient selection, improved surgical techniques and the use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) have contributed to improve the safety of surgery for pulmonary emboli.Recent findingsVA ECMO is rapidly changing the initial management of patients with massive pulmonary emboli, providing an opportunity for stabilization and optimization before intervention. The early and long-term consequences of acute pulmonary emboli are better understood, in particular with regard to the risks of chronic thromboembolic pulmonary hypertension (CTEPH), an entity that should be identified in the acute setting as much as possible. The presence of chronic thromboembolic pulmonary disease can be associated with persistent haemodynamic instability despite removal of the acute thrombi, particularly if pulmonary hypertension is established. The pulmonary embolism response team (PERT) is an important component in the management of massive and submassive acute pulmonary emboli to determine the best treatment options for each patient depending on their clinical presentation.SummaryThree types of surgery can be performed for pulmonary emboli depending on the extent and degree of organization of the thrombi (pulmonary embolectomy, pulmonary thrombo-embolectomy and pulmonary thrombo-endarterectomy). Other treatment options in the context of acute pulmonary emboli include thrombolysis and catheter-directed embolectomy. Future research should determine how best to integrate VA ECMO as a bridging strategy to recovery or intervention in the treatment algorithm of patients with acute massive pulmonary emboli.

Peri-procedural variables and outcomes of long-period hemodynamic instability after carotid artery angioplasty and stenting.

The aim of this study is to identify the peri-procedural risk factors and outcomes of hemodynamic instability (HI) after carotid artery stenting (CAS). A single-center, retrospective study was performed in 168 patients who underwent CAS procedure between September 2017 and September 2020. The presence of HI, as defined by hypertension (systolic blood pressure >160mmHg), hypotension (systolic blood pressure <90mmHg), and/or bradycardia (heart rate <60bpm), was recorded. Long-period HI was defined as persistent HI lasting more than 24h. Patient demographics, comorbidities, peri-procedural variables, and risk factors were recorded. Clinical outcomes including cerebral hyperperfusion syndrome, hemorrhage, transient ischemic attack (TIA), stroke, myocardial infarction, and mortality within 30days of the procedure were evaluated. Logistic regression was used to analyze the independent risk factors of long-period HI following CAS. Among 168 patients (mean age, 68.2 ± 8.3years; 81.5% male), the frequency of post-procedural long-period HI was noted in 42 patients (25.0%). Male was prone to experience HI (odds ratio, 9.156, p = 0.021). Aggressive inflation pressure (>7atm) and 5mm balloon for pre-dilatation were risk factors of long-period HI (OR, 7.372, p = 0.035; OR, 3.527, p = 0.023). Intraoperative peak blood pressure and larger-sized stents remained independent predictors for the development of HI (OR, 1.043, p = 0.027, and OR, 1.973, p = 0.015). Patients with prolonged HI were more likely to suffer TIA and stroke compared to other patients and significant difference was found in the occurrence of TIA (p < 0.05). Non-significance was found in mortality rate and other outcomes. CAS-induced HI occurs in a considerable percentage while several peri-procedural variables are determined as independent predictors to develop long-period HI. Patients with prolonged HI are associated with increased risk of neurologic events and thus standardized intervention as well as management of long-period HI are of critical importance during clinical process.

Macrophage activation syndrome in a young adult patient with a background of systemic lupus erythematosus: a case report

Background: Macrophage activation syndrome (MAS) is a rare but potentially life-threatening condition associated with systemic lupus erythematosus (SLE), as well as several other autoimmune conditions. Case Presentation: We present a case of MAS in a 30-year-old patient with a background of SLE presenting with persistent fever and hemodynamic instability. Broad-spectrum antibiotics were initially started for possible sepsis of unknown origin, but a lack of response or evidence of an infection source led to further laboratory investigations and additional diagnostic imaging. Hyperferritinemia, a low fibrinogen, hypertriglyceridemia, and pancytopenia raised the suspicion of MAS. Echocardiography revealed a pericardial effusion requiring pericardiocentesis. With rapid disease progression, multiorgan failure ensued, and shortly after a high dose, methylprednisolone was commenced; the patient’s condition worsened and she died after a cardiac arrest. Conclusion: This case highlights the challenges involved in diagnosing MAS and in differentiating it from more common presentations such as sepsis or autoimmune disease flares, and demonstrates the possible rapid disease progression. Therefore, early recognition of certain clinical features and laboratory markers are essential to enable early diagnosis, commencement of immunosuppressive treatment, and to ultimately improve outcomes in such critically unwell patients.

Ultrasound‐guided point‐of‐care ablation for atrial fibrillation in intensive care

Cha et al1 reported short learning curve and low complication rate of radiofrequency catheter ablation for atrial fibrillation (AF) without using fluoroscopy based on a series of 30 cases. Their study confirms other reports of feasibility and safety to perform AF ablation using imaging guidance with intracaradiac echocardiography (ICE). ICE was previously reported to be vastly superior to fluoroscopy in defining cardiac anatomy, directing the position of the ablation catheter, identifying proper electrode-tissue contact, detecting electrode migration during ablation, recognizing pulmonary vein stenosis, detecting pericardial effusion, and visualizing microbubble and coagulum formation. This was further confirmed by a recent meta-analysis evaluating the use of imaging with real-time ICE during endocardial ablation showed improvements in efficiency compared with the use of traditional fluoroscopy, without compromising clinical effectiveness or safety2. Cha et al1 discussed the avoidance of radiation hazard as an important advantage. We believe that another important advantage of this innovative approach deserves better highlight. Utilization of ICE could become a game changer for point-of-care atrial ablation in critically ill population, particularly during current pandemic. The overall incidence of AF in patients in the intensive care unit is close to 6%, with the new onset of AF being a marker of poor short-term and long-term prognosis.3 The reported incidence of AF in patients with sepsis or after cardiac valve surgery is disproportionately high (33% and 60%, respectively). It is important to acknowledge that in general, the causes of AF in intensive care are multifactorial and often rapidly reversible through simple measures or the passing of time. However, some patients with persistent AF and hemodynamic instability require pharmacological therapy and/or cardioversion, both of which are associated with iatrogenic risks, variable success rate, and frequent recurrence of AF. Despite growing knowledge of structural and electrical atrial remodeling during critical illness,4 the use of catheter ablation in patients with AF who are in intensive care has not been adequately investigated. Which subgroups of intensive care patients could benefit in short or long term from early catheter ablation remains speculative. The barriers to investigating the potential role of catheter ablation for AF in patients who are critically ill include the long procedural time and the need to transfer patients who have hemodynamic and/or respiratory instability or who are highly infectious to the catheterization laboratory. The latter has profound importance during SARS-CoV-2 pandemic, as intrahospital transfer of highly contagious patients presents major risk for other noninfected hospital patients, multiple staff, and the visitors. Major technological advances improved ICE capabilities in quality of imaging and in ability to integrate with CARTOSOUND system. Recent introduction of commercially available, live, 3D ICE imaging with a wide-angle elevation displays the complete cardiac structures, including the pulmonary veins and intracardiac devices. Identified limitations of 3D ICE related to the spatial resolution5 should not present problems for visualizing ablation catheters. Transesophageal echocardiography was used for point-of-care guidance of atrial ablation in AF, but the procedure presents additional risks associated with aerosol generation in patients suffering from coronavirus or other virulent respiratory pathology. Modern ICE technology offers viable alternative to transesophageal echocardiography, minimizing aerosol-related risks while maintaining comparable spatial and temporal resolution adequate for guiding ablation. In summary, the investigation by Cha et al1 opens new and exciting opportunities for expansion of zero-fluoroscopy approach to catheter ablation in AF. Short learning curve and shorter procedural time expands opportunities for long overdue research on ICE-guided catheter atrial ablation in subgroups of critically ill patients, particularly when pharmacological intervention fails to control persistent AF with hemodynamic instability. The study further expands available solutions for patients who present major epidemiological risk by adding point-of-care ICE-guided atrial ablation as an option of modern clinical armamentarium. The author declares no conflict of interest.

Peptic Ulcer Bleeding: Update on Standards from International Guidelines

We review the latest advances in management of peptic ulcer bleeding and the updates from international guidelines. A low Glasgow Blatchford score of ≤ 1 can safely identify low-risk patients to manage in out-patient settings. Except patients with persistent haemodynamic instability, early endoscopy within 24 h appears safe when compared with earlier intervention. Over-the-scope-clips (OTSC) show promising result as first-line and second-line endoscopic haemostaic therapy, while haemostatic spray can be considered as a stop-gap treatment. After endoscopic intervention, high-dose oral proton-pump-inhibitor (PPI) is an alternative to intravenous use in selected cases. Retrospective data shows new-generation P2Y12 inhibitors (prasugrel and ticagrelor) have higher risk of bleeding when compared with clopidogrel. Vonoprazan, a potassium-competitive acid blocker and a potent acid suppressor, shows encouraging initial results in management of gastrointestinal bleeding. Endoscopic therapy remains the mainstay of treatment of peptic ulcer bleeding and future research will clarify the role of new endoscopic treatment modalities such as OTSC. Good peri-endoscopic treatment remains crucial, and more data is needed to guide management in patients on new generation anti-platelet drugs and direct oral anti-coagulants.

Effectiveness of Intrauterine Bakri Balloon® Tamponade for Placenta Previa and Placenta Accreta Spectrum.

To investigate the effectiveness and success rate of Bakri balloon tamponade (BBT) for postpartum haemorrhage (PPH) in patients with placenta previa and placenta accreta spectrum (PAS). Descriptive study. Department of Obstetrics and Gynaecology, Bursa Yüksek Ihtisas Education and Research Hospital, Bursa, Turkey, from June 2016 to June 2019. Patients treated with BBT for severe PPH and uncontrollable bleeding due to treatment failure with uterotonic agents were retrospectively analysed. Exclusion criteria were age <18 years and >46 years, having multiple pregnancies, less amount of bleeding than indicated in the definition of PPH and requiring no BBT and those with hemodynamic instability before BBT requiring emergency postpartum hysterectomy, and having missing obstetric and laboratory data. The main outcome was the rate of surgical exploration and peripartum hysterectomy following the use of BBT as an adjunct treatment for refractory PPH. Secondary outcome was the need for blood transfusion. The BBT was considered to fail, if the bleeding from drainage catheter was continued and more than 100 mL during failure was 10 minutes. In case of BBT failure, C-section hysterectomy was performed. Of the 128 patients, 14 (10.9%) had vaginal birth and 109 (85.2%) had Cesarean section delivery. Of patients with cesarean section delivery, 84 (65.6%) had multiple repeat cesarean deliveries and 22 (17.2%) were previous cesarean cases. Ninety-one patients (71.1%) had placental site abnormality. Twenty patients (15.6%) underwent hypogastric and uterine artery ligation. Eleven patients (8.7%) with persistent uterine bleeding and hemodynamic instability underwent hysterectomy. Success rate of BBT was found to be 91.3% in PPH. No mortality was observed. BBT is an effective tool for management of postpartum uterine atony and prevention of persistent PPH in patients with placenta previa and placenta accreta spectrum due to increased cesarean section and uterine surgeries in recent years. Key Words: Placenta previa, Placenta accreta spectrum, Postpartum haemorrhage, Balloon tamponade, Bakri balloon.