Prolonged ICU Admission Research Articles

Poland syndrome: A case of difficult weaning of ventilation after surgery

IntroductionPoland syndrome is a rare congenital anomaly that occurs in 1 in 30,000 children. It is characterised by unilateral underdevelopment or lack of the chest wall muscle that is apparent at birth. Rarely is it discovered to involve a bilateral chest muscular deficit. Poland syndrome presents in a wide variety of ways, which can often make diagnosis challenging.AimWe would like to highlight the rarity of Poland syndrome, and the challenges of post-operative recovery, primarily the ventilation.Case studyWe presented a case of a 44-year-old female with non-investigated chest wall deformity, whom required emergency surgical intervention under general anaesthesia. Post-operatively, she required prolonged ventilatory support, and was then diagnosed with Poland syndrome.Results and discussionThe patient had undergone an emergency laparotomy and left lateral hepatectomy for left hepatolithiasis with liver abscess. Post-operation, she required prolonged ventilation, with gradual weaning of oxygen. Imaging studies showed absence of left pectoralis major, thus a diagnosis of Poland syndrome. Gradually she was weaned off and had a successful post operative recovery.ConclusionsPoland syndrome is a rare congenital abnormality. In patients undergoing general anaesthesia, the normal mechanics of breathing while ventilated are absent. Their recovery is longer and requires prolonged ICU admission.

Impact of viral co-infection on clinical outcomes and mortality of COVID-19 patients: a study from Saudi Arabia.

In COVID-19 patients undetected co-infections may have severe clinical implications associated with prolonged hospitalization, ICU admission, and mortality. Therefore, we aimed to investigate the impact of viral coinfections on the outcomes of hospitalized patients with COVID-19 in a large tertiary Saudi Arabian Hospital. A total of 178 adult patients with confirmed SARS-CoV-2 who were hospitalized at the Armed Forces Hospital Southern Region (AFHSR), Saudi Arabia, from March 1st to June 30th 2022, were enrolled. Real-time PCR for the detection of viral co‑infections was carried out. Cases (SARS-CoV-2 with viral coinfections) and control (SARS-CoV-2 mono-infection) groups were compared. 12/178 (7%) of enrolled COVID-19 patients had viral coinfections. 82/178 (46%) of patients were males. 58% of patients had comorbidities. During the study period, 4/12 (33%) and 21/166 (13%) cases and control patients died, p=0.047, respectively. Duration of hospitalization was the only significant independent factor associated with SARS-CoV-2 coinfections, OR 1.140, 95% CI 1.020-1.274, p=0.021. The findings of this study from a large tertiary Saudi Arabian Center revealed a prevalence of 7% for SARS-CoV-2 viral coinfections. SARS-CoV-2 coinfected patients had a significantly prolonged duration of hospitalization and higher mortality than those with SARS-CoV-2 alone. Future studies are needed.

Clinical and Biochemical Characteristics of COVID-19 Patients During the Delta-Omicron Wave with Risk Assessment of Adverse Outcomes.

To compare clinical and biochemical characteristics of hospitalised COVID-19 patients and risk assessment of disease outcomes Study Design: Descriptive study. Place and Duration of the Study: Department of Pathology, Dow International Medical College and Sindh Infectious Diseases Hospital and Research Centre, from January to March 2022 Methodology: SARS CoV-2 PCR-positive hospitalised patients were enrolled. Delta or omicron variants infected patients were followed till the last recorded event of hospitalisation. After a detailed history, clinical and biochemical profiles were recorded during the hospitalisation. Length of hospitalisation, ICU admission and in-hospital mortality were taken as outcomes and odd ratios were calculated. During the study period, omicron was the predominant SARS CoV-2 variant. Omicron-infected patient were older (67 vs. 62 years) and had a significantly shorter duration between appearance of symptoms and hospitalisation (5 vs. 8 days), when compared with the delta patients. Median values of LDH, ferritin and TLC were significantly higher in delta patients (p<0.05). Delta infected patients have a 3.9 times more risk of prolonged hospital stay. In patients with increased TLC, the risk of prolonged hospitalisation and ICU admission was found 16% and 23%, respectively. However, the aOR for ICU admission and in- Hospital mortality were not found significant for the delta and omicron-infected patients. The clinical course and biochemical profiles are diverse in delta and omicron patients. Hospitalised patients with omicron infection exhibit shorter stays. High values of TLC are found associated with an increased risk of longer hospital stay and ICU admissions. COVID-19, Delta variant, Omicron variant, Hospitalised patients, Outcomes, In-hospital mortality, Biochemical markers, Clinical severity.

Abstract 15653: Impact of Atrial Fibrillation on Hospital Outcomes Among Covid-19 Patients - Insight From the 2020 California State Inpatient Database

Introduction: Recent estimates of COVID-19 in the US include over 84 million cases with over 1 million deaths. The association between new-onset atrial fibrillation (AF) and COVID-19 has been reported, but hospital outcomes has not been studied among COVID-19 patients with AF. Hypothesis: AF among COVID-19 hospitalizations is not associated with higher rates of adverse in-hospital outcomes. Methods: Using data from the 2020 California State Inpatient Database, we conducted a retrospective analysis of all hospitalized COVID-19 patients ≥18 years of age. Primary outcomes were: prolonged length of stay (LOS) [defined as LOS ≥75th percentile of the population], ICU admission, mechanical ventilation, vasopressor use, and in-hospital mortality. We examined the differences in adverse hospital outcomes among those with AF versus those without. Multivariate logistic regression analyses were used to estimate the association between AF and outcomes after adjusting for cofactors. Results: Our analysis had a total of 94,114 COVID-19 hospitalizations and 9,391 (10.0%) had AF. Adverse hospital outcomes such as prolonged LOS (40.0% versus 27.1%, P &lt;0.001), ICU admission (18.4% versus 8.8%, P &lt;0.001), mechanical ventilation (19.0% versus 9.1%, P &lt;0.001), vasopressor use (4.4% versus 1.9%, P &lt;0.001), and mortality (27.2% versus 9.6%, P &lt;0.001) were significantly higher among COVID-19 hospitalizations with AF. The adjusted odds ratio (aOR) of adverse outcomes such as prolonged LOS (aOR, 1.37, 95% CI: 1.31-1.44), ICU admission (aOR, 2.01, 95% CI: 1.88-2.15), mechanical ventilation (aOR, 1.95, 95% CI: 1.72-2.20), vasopressor use (aOR, 1.98, 95% CI: 1.86-2.11), and mortality (aOR, 2.04, 95% CI: 1.92-2.16) were statistically significantly higher among COVID-19 hospitalizations with AF compared to those without AF. Conclusions: In 2020, AF occurred in about 10% of COVID-19 hospitalizations in California, USA, and was associated with significantly greater risk of adverse hospital outcomes and mortality. COVID-19 patients should be closely monitored for development of AF, and promptly managed like contemporary AF. More studies are however needed to understand the best approach to managing AF in COVID-19 patients.

Prophylactic versus therapeutic dose anticoagulation effects on survival among critically ill patients with COVID-19.

Although patients with severe COVID-19 are known to be at high risk of developing thrombotic events, the effects of anticoagulation (AC) dose and duration on in-hospital mortality in critically ill patients remain poorly understood and controversial. The goal of this study was to investigate survival of critically ill COVID-19 patients who received prophylactic or therapeutic dose AC and analyze the mortality rate with respect to detailed demographic and clinical characteristics. We conducted a retrospective, observational study of critically ill COVID-19 patients admitted to the ICU at Stony Brook University Hospital in New York who received either prophylactic (n = 158) or therapeutic dose AC (n = 153). Primary outcome was in-hospital death assessed by survival analysis and covariate-adjusted Cox proportional hazard model. For the first 3 weeks of ICU stay, we observed similar survival curves for prophylactic and therapeutic AC groups. However, after 3 or more weeks of ICU stay, the therapeutic AC group, characterized by high incidence of acute kidney injury (AKI), had markedly higher death incidence rates with 8.6 deaths (95% CI = 6.2-11.9 deaths) per 1,000 person-days and about 5 times higher risk of death (adj. HR = 4.89, 95% CI = 1.71-14.0, p = 0.003) than the prophylactic group (2.4 deaths [95% CI = 0.9-6.3 deaths] per 1,000 person-days). Among therapeutic AC users with prolonged ICU admission, non-survivors were characterized by older males with depressed lymphocyte counts and cardiovascular disease. Our findings raise the possibility that prolonged use of high dose AC, independent of thrombotic events or clinical background, might be associated with higher risk of in-hospital mortality. Moreover, AKI, age, lymphocyte count, and cardiovascular disease may represent important risk factors that could help identify at-risk patients who require long-term hospitalization with therapeutic dose AC treatment.

COVID-19 pandemic: the impact on Canada’s intensive care units

The COVID-19 pandemic has exposed the precarious demand-capacity balance in Canadian hospitals, including critical care where there is an urgent need for trained health care professionals to dramatically increase ICU capacity. The impact of the pandemic on ICUs varied significantly across the country with provinces that implemented public health measures later and relaxed them sooner being impacted more severely. Pediatric ICUs routinely admitted adult patients. Non-ICU areas were converted to ICUs and staff were redeployed from other essential service areas. Faced with a lack of critical care capacity, triage plans for ICU admission were developed and nearly implemented in some provinces. Twenty eight percent of patients in Canadian ICUs who required mechanical ventilation died. Surviving patients have required prolonged ICU admission, hospitalization and extensive ongoing rehabilitation. Family members of patients were not permitted to visit, resulting in additional psychological stresses to patients, families, and healthcare teams. ICU professionals also experienced extreme psychological stresses from caring for such large numbers of critically ill patients, often in sub-standard conditions. This resulted in large numbers of health workers leaving their professions. This pandemic is not yet over, and it is likely that new pandemics will follow. A review and recommendations for the future are provided.

Association of use of remote patient monitoring (RPM) with reduced hospitalizations in cancer patients with COVID-19.

1503 Background: Patients with cancer and COVID-19 are at risk for poor clinical outcomes. An established multi-site remote patient monitoring (RPM) service was rapidly adapted to support a novel, interdisciplinary COVID-19 program for outpatient management of patients at high-risk for severe illness. The goal of this study was to assess the impact of the RPM program on clinical outcomes and acute care utilization in cancer patients diagnosed with COVID-19. Methods: This is a cross-sectional analysis following a multi-site prospective observational study performed at Mayo Clinic Cancer Center (MCCC). All adult patients with active cancer – defined as currently receiving cancer-directed therapy or in recent remission on active surveillance – and PCR-confirmed SARS-CoV-2 infection between March 18 and July 31, 2020 were included. RPM was comprised of in-home technology to assess symptoms and physiologic data with centralized nurse and physician oversight. Results: During the study timeframe 224 cancer patients were diagnosed with COVID-19 at MCCC. Initial management included urgent hospitalization (within 48 hours of diagnosis) in 34 patients (15%). Of the remaining 190 patients (85%) initially managed in the outpatient setting, those who did not receive RPM were significantly more likely to experience hospitalization than those receiving RPM (OR 3.6, 95% CI 1.036 to 12.01, P = 0.044). Following balancing of patient characteristics by inverse propensity weighting, rates of hospital admission for RPM and non-RPM patients were 3.1% and 11% respectively, implying that RPM was associated with an 8% reduction in hospital admission rate (-0.077; 95% CI: -0.315 to -0.019, P = 0.009). Use of RPM was also associated with lower rates of prolonged hospitalization, ICU admission, and mortality, though these trends did not reach statistical significance. Conclusions: In the midst of a global pandemic associated with inpatient bed, ventilator, and PPE shortages, the RPM program provided an effective strategy for outpatient clinical management and was associated with decreased rates of hospitalization, ICU admission, and mortality in cancer patients with COVID-19. This care model enabled simultaneous opportunity to mitigate the increased risks of exposure, transmission, and resource utilization associated with conventional care.

Panton-valentine leukocidin staphylococcus causing necrotising pneumonia in a young male

Panton–Valentine leukocidin (PVL) is among one of the many toxins associated with Staphylococcus aureus infection. It commonly causes recurrent skin and soft tissue infections (SSTIs), but can sometimes be associated with severe invasive infections, including necrotising haemorrhagic pneumonia in otherwise healthy young people. Here we report a case of young male patient who presented with community acquired pneumonia that very rapidly progressed to necrotising haemorrhagic pneumonia leading to septic shock with multi-organ failure. His chest imaging showed extensive right sided cavitatory pneumonia &amp; his bronchial washings confirmed the presence of PVL positive Staph aureus. He was managed in Intensive care where he was resuscitated with organs support along with broad spectrum antibiotics. He later developed renal impairment needing renal replacement therapy. Patient gradually showed clinical signs of improvement after prolonged ICU admission. He was later stepped down to the Respiratory ward following improvement in clinical condition. Hence medical physicians need to know about Panton–Valentine leukocidin (PVL) producing staphylococcus aureus as early detection and treatment can save lives of patients.

VTE in ICU Patients With COVID-19

VTE in ICU Patients With COVID-19

QSOFA as predictor of mortality and prolonged ICU admission in Emergency Department patients with suspected infection

PurposeWe assessed the quick Sequential Organ Failure Assessment (qSOFA) score as a predictor of in-hospital mortality or prolonged ICU stay in Emergency Department (ED) patients with suspected infection. Patients and methodsWe measured qSOFA in a cohort of 11,205 ED patients with suspected infection. The primary outcome was in-hospital mortality and/or ICU stay ≥3 days. ResultsThe qSOFA score was positive in 2429 (21.7%) patients. In-hospital mortality, and in-hospital mortality or ICU stay ≥3 days were 12.8% and 17.2% respectively for qSOFA positive patients vs 2.2% and 4.2% for qSOFA negative patients (p < .0001). For the prediction of in-hospital mortality, a positive qSOFA had a positive predictive value (PPV) of 13% (95% CI, 11–14) and a negative predictive value (NPV) of 98% (95% CI, 97–98). For the prediction of in-hospital mortality or ICU stay ≥3 days, the PPV and NPV of a positive qSOFA were 17% (95% CI, 16–19) and 96 (95% CI, 95–96), respectively. ConclusionAmong ED patients with suspected infection, a positive qSOFA identified those at much greater risk of mortality and longer ICU stay.

Actinomyces neuii infection following ovarian cystectomy

Background: Abdominal Actinomyces infections are rare complications of surgery. A case of Actinomyces neuii presenting as a severe postoperative pelvic infection is described.Case: A 30 year-old nulligravid female was transferred from an outside hospital for a postoperative fluid collection, fever, leukocytosis, and abdominal pain following exploratory laparotomy and bilateral ovarian cystectomy. She rapidly decompensated requiring emergent exploratory laparotomy, bilateral salpingooophorectomy, and abdominal washout. Cultures isolated A. neuii. Following a prolonged ICU admission, she was treated with prolonged antibiotics and made a complete recovery.Conclusions: Rare pathogens, such as A. neuii, may cause severe infections following gynecologic surgery. Multidisciplinary care at tertiary care facilities is critical.

PD34 São Paulo Congenital Heart Corrections: Three-Years' Assist Registry

Introduction:Death from congenital heart disease (CHD) can be avoided, contributing to reduced infant mortality. The objective of this study was to identify the profile of patients undergoing surgical correction for CHD in three São Paulo State hospitals, and to determine factors that contribute to morbidity and mortality.Methods:The Voluntary Pediatric Cardiovascular Surgery Multicenter Registry (ASSIST) was created in 2014 through a Research Grant Program for the Public Healthcare System (Pesquisas para o Sistema Único de Saúde, PPSUS)* project, a federal-state joint strategic public policies research grant, coordinated by the Hospital das Clínicas of Faculdade de Medicina of Universidade de São Paulo (InCor-HCFMUSP-SP) and Ribeirão Preto's Hospital das Clínicas, both linked to the São Paulo University Medical School.Results:We analyzed 1,842 patients, with an average age of 1.2 (range 0.4–8.6) years, 50.9 percent were male. Procedural complexity was classified as “Risk Adjustment in Congenital Heart Surgery” version 1 score, RACHS-1: 18.2 percent RACHS1, 25.5 percent RACHS2, 41.2 percent RACHS3, 9.6 percent RACHS4 and 5.4 percent RACHS5–6. Overall hospital mortality was 12.2 percent, and preoperative risk factors included: age &lt;30 days (Odds Ratio, OR = 1.7 p = 0.012), prolonged ICU admission (OR = 3.3 p = 0.001). Other significant factors were RACHS score &gt;4 (OR = 5.3 p &lt; 0.001), heart dysfunction (OR = 3.4 p = 0.001), sepsis (OR = 3 p = 0.001), hemodynamic or surgical re-intervention required (OR = 6.2 p &lt; 0.001), cardiorespiratory arrest (CPR, OR = 24.9 p &lt; 0.001) and renal failure (OR = 5.4 p&lt;0.001). The frequency of related morbidity was 16.2 heart failure, 7.1 percent arrythmia, 5.9 percent pneumonia, 5.9 percent pneumotórax, 4.2 percent pleural and pericardial effusion, 10 percent mechanical ventiation &gt; 7 days, 13.2 percent late sternal closure, 2.8 percent had wound infection, 3.7 percent neurological alterations, 2.3 percent diaphragmatic dysfunction, 11.5 percent CPR, 3.2 percent renal failure, 4.5 percent sepsis, 55.1 percent length of hospital stay longer than 5 days with 45.8 percent postoperative hospital admission longer than 15 days and 6.1 percent needed surgical or hemodynamic re-intervention.Conclusions:The information collected in the ASSIST registry was of great importance in the São Paulo State CHD surgical practice evaluation. Morbi-mortality related factors elicited critical points and allowed improvement actions. Excluding age and intrinsic procedure complexity, identified outcome modifier factors can be manageable, aiming to increase patient safety and program resolubility or performance.

A severe anti-NMDA-receptor encephalitis case with extensive cortical and white matter changes, cerebral atrophy and communicating hydrocephalus

A 21-year-old woman presented with a viral prodrome, abnormal behaviours, confusion and short-term memory loss, followed by status epilepticus that later evolved to orofacial dyskinesias, autonomic dysfunctions and hypoventilation requiring prolonged ventilator support and ICU admission. Cerebrospinal fluid (CSF) and serum analysis confirmed the presence of anti-NMDAR autoantibodies. A left salpingoopherectomy was performed on day 35 of admission revealing an immature ovarian teratoma. Following surgical and two courses of intravenous immunoglobulin therapy, her response remained poor. Initial brain magnetic resonance imaging (MRI) during the acute stage showed enlarged left hippocampus. Further MRI follow-up 13 weeks after admission showed unusual findings of extensive cortical and white matter changes, generalised cerebral atrophy, dilated ventricles and possible transependymal CSF seepage of communicating hydrocephalus. A ventriculo-peritoneal shunt was performed subsequently and she was discharged 6 months after admission without significant change in her clinical status. Follow-up 4 months later showed some improvement but patient remained severely disabled.

Diagnostic performance of transluminal attenuation gradient and non-invasive fractional flow reserve derived from 320 detector computed tomography angiography to diagnose haemodynamically significant coronary stenosis- a NXT substudy

Background: Currently no systematic Australian preoperative protocols exist for morbidly obese patients. We investigated theeffect of both clinical factors andpreoperative investigations on early adverse outcomes from this bariatric procedure. Methods: 266 consecutive patients were sampled retrospectively from a single centre. Pre-operative, operative and post-operative data was collected up to 30 days after surgery. Results: There were no Major Adverse Cardiovascular Events (MACE). Both age (ORper year of increased age 1.029; 95% CI: 1.000-1.058, p = 0.048) and BMI (OR for BMI: 1.066; 95% CI: 1.014-1.120, p = 0.012) were significantly associated withdesaturationpost-operatively.Diastolic dysfunction and left atrial enlargement appear to predict a worse outcome, including difficulty in intubation (“difficult airway”), the need for prolonged ICU admission, and the development of atrial arrhythmias. Sleep study (PSG) and carotid intimal scans did not effect post-operative outcome. Conclusions:Acombination of clinical factors (age, gender and BMI) and echocardiography (left atrial volume index, an indicator of diastolic dysfunction) appear to be the most useful tools in predicting perioperative risk within 30 days of sleeve gastrectomy surgery.

Determining the role of pre-operative investigations in predicting adverse outcomes from bariatric surgery

Background: Currently no systematic Australian preoperative protocols exist for morbidly obese patients. We investigated theeffect of both clinical factors andpreoperative investigations on early adverse outcomes from this bariatric procedure. Methods: 266 consecutive patients were sampled retrospectively from a single centre. Pre-operative, operative and post-operative data was collected up to 30 days after surgery. Results: There were no Major Adverse Cardiovascular Events (MACE). Both age (ORper year of increased age 1.029; 95% CI: 1.000-1.058, p = 0.048) and BMI (OR for BMI: 1.066; 95% CI: 1.014-1.120, p = 0.012) were significantly associated withdesaturationpost-operatively.Diastolic dysfunction and left atrial enlargement appear to predict a worse outcome, including difficulty in intubation (“difficult airway”), the need for prolonged ICU admission, and the development of atrial arrhythmias. Sleep study (PSG) and carotid intimal scans did not effect post-operative outcome. Conclusions:Acombination of clinical factors (age, gender and BMI) and echocardiography (left atrial volume index, an indicator of diastolic dysfunction) appear to be the most useful tools in predicting perioperative risk within 30 days of sleeve gastrectomy surgery.

Diagnostic accuracy of semi-automated transluminal attenuation gradient (2nd-Generation-TAG320) on CT coronary angiography for identification of functionally significant coronary artery stenosis: a comparison with Fractional Flow Reserve (FFR)

Background: Currently no systematic Australian preoperative protocols exist for morbidly obese patients. We investigated theeffect of both clinical factors andpreoperative investigations on early adverse outcomes from this bariatric procedure. Methods: 266 consecutive patients were sampled retrospectively from a single centre. Pre-operative, operative and post-operative data was collected up to 30 days after surgery. Results: There were no Major Adverse Cardiovascular Events (MACE). Both age (ORper year of increased age 1.029; 95% CI: 1.000-1.058, p = 0.048) and BMI (OR for BMI: 1.066; 95% CI: 1.014-1.120, p = 0.012) were significantly associated withdesaturationpost-operatively.Diastolic dysfunction and left atrial enlargement appear to predict a worse outcome, including difficulty in intubation (“difficult airway”), the need for prolonged ICU admission, and the development of atrial arrhythmias. Sleep study (PSG) and carotid intimal scans did not effect post-operative outcome. Conclusions:Acombination of clinical factors (age, gender and BMI) and echocardiography (left atrial volume index, an indicator of diastolic dysfunction) appear to be the most useful tools in predicting perioperative risk within 30 days of sleeve gastrectomy surgery.

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Introduction: In the United States, where the average American can expect to undergo seven surgical operations during her lifetime, each year at least 150,000 patients die and 1.5 million develop a medical complication within 30 days after surgery. The purpose of this study is to find out the association between demographics and clinical predictors and the outcome of higher number of postoperative complications (PC) in various types of surgical procedures. Methods: Using a single-center retrospective cohort of 50,314 adult surgical patients admitted between 2000 and 2010, we fit ordinal response models (proportional odds model, partial proportional odds model, stereotype model, and multinomial logistic models). We modeled number of major PC (acute kidney injury, severe sepsis, prolonged mechanical ventilation and ICU admission, cardiovascular complications) grouped as 0, 1, 2, and 3 or more using small set of readily available preoperative variables (age group, gender, African-American ethnicity, primary insurance payer, Charlson comorbidity index, surgery type (cardiothoracic, non-cardiac general and vascular surgery, neurologic surgery, orthopedics and gynecologic surgery), emergency surgery status, and weekend admission status). Adjusted odds ratios (OR) were calculated along with their 95% confidence intervals (CI). Results: Multinomial logistic model performed the best among the four tested models. Age older than 65 (OR 1.5, 95%CI 1.4-1.6), male gender (OR 1.2, 95%CI 1.2-1.3), Charlson comorbidity index of at least 1 (OR 3.0, 95%CI 2.3-1.6), emergency surgery (OR 3.5, 95%CI 3.3-3.7), and weekend admission (OR 1.4, 95%CI 1.3-1.5) were more likely to have 3 or more number of PC compared to no PC. Cardiothoracic surgery had the highest odds of having 3 or more PC (OR 22.9, 95% CI 20.7-25.3) compared to specialty surgery group. Medicare insurance had the largest adjusted OR of any number of PC even after adjusting for age. Area under receiver operating curve (AUC) of the model was 0.72 showing a good discriminatory ability of the model considering the simplicity of the model. Conclusions: Using a set of readily available preoperative demographic and clinical variables and novel modeling technique we can predict the number of major PC after surgery. The simple score can be developed for the use in clinical practice.

Dramatic improvement in hypoxemic respiratory failure after patent foramen ovale closure in a patient with obesity hypoventilation syndrome

We report a case of a patient with pulmonary hypertension who presented with acute hypoxemic respiratory failure. The patient had continued refractory hypoxemia despite a prolonged ICU admission that included ventilatory support, and empiric therapy for pulmonary embolism and pneumonia. Transthoracic echocardiography (TTE) revealed a patent foramen ovale (PFO), which after percutaneous closure resulted in profound improvement in hypoxemia and clinical status.

Gabapentin Neurotoxicity Including Posterior Reversible Leucoencephalopathy Syndrome (PRES) (P06.118)

Objective: To raise awareness of serious toxicity, including respiratory depression and PRES (posterior reversible encephalopathy syndrome) caused by gabapentin in the setting of overdose and abuse. Background Gabapentin, a structural analog of γ-aminobutyric acid, although developed for epilepsy, is often used for pain, insomnia and anxiety. It is considered very safe, with neurotoxicity mostly limited to renally-impaired patients. Design/Methods: Case Report. Results: A 50 year-old woman with several year history of overuse of gabapentin, even after prolonged ICU admission with intubation, continued to seek prescriptions from ER staff after denial by neurology staff. History included substance abuse, bipolar disease, epilepsy (including nonepileptic seizures), COPD, CHF and two years previously an admission for agitation and respiratory alkalosis. After ingestion of up to 80 capsules of 300mg GBP, she was admitted with status epilepticus, respiratory depression and uncontrolled hypertension. CT and MR showed PRES, EEG was slow, serum ammonia was normal, and recovery occurred after two weeks. For the next five months she came frequently to the ER with injuries, pain and seizures, seeking gabapentin. After obtaining 25 capsules (300mg) she had a three-day hospitalization for obtundation and bizarre movements with normal CT and EEG. Conclusions: Gabapentin is considered very safe, with failure to absorb more than 3600mg. Abuse is rarely reported, with one suicide described despite its use by psychiatric patients. PRES has not been described, and neurotoxicity, including metabolic encephalopathy is usually described in dialysis or renally-impaired patients. For years our patient tolerated 4,800mg daily, became critically ill after an overdose of approximately 24,000 mg, and finally was briefly encephalopathic after 7,500mg. Although further prescribing is banned by marking her EMR as “allergic”, we hope to alert others of the potential for serious GBP-induced toxicity. Since blood levels are rarely obtained, clinical suspicion of systemic complications is required. Disclosure: Dr. Kleiman has nothing to disclose. Dr. Koppel has nothing to disclose. Dr. Akfirat has nothing to disclose. Dr. Chiechi has nothing to disclose.

Continent-wide anaesthesia guideline

De Hert S, Imberger G, Carlisle J, et al. Preoperative latest evidence-based medical knowledge to simplify and/or eliminate unnecessary steps. Physicians are expected to be familiar with clinical guidelines, but should note that they are advisory in nature and are there to help with safer decision making, something which might vary according to the patient’s condition and the available resources. Practice guidelines should be revised periodically to accommodate newly published data. In 2007, the Anaesthesiology Board of European Union of Medical Specialists published guidelines for the safety and quality of anaesthesia. A more recent milestone was the Helsinki Declaration on Patient Safety in Anaesthesiology published in June 2010. This represented a European consensus on measures to improve patient care and it set out a framework for good practice. In order to constrain costs and standardise practice across Europe, the European Society of Anaesthesiologists (ESA) took a giant step forward by committing to the development of evidenced-based clinical guidelines and recommendations. In this issue, the unique specific task force, led by Professor Stefan De Hert, has published an outstanding guideline for the preoperative evaluation of adult patients undergoing elective non-cardiac surgery. Their recommendations are very comprehensive. They cover a wide range of topics that include cardiovascular disease, respiratory disease, obstructive sleep apnoea (OSA), renal disease, diabetes, obesity, coagulation disorders, anaemia, the elderly patient, alcohol addiction and allergy. They also cover concurrent medication, and preoperative testing. In addition, there is a very useful section on airway evaluation.