Severe Hypoxemia Research Articles

Complicaciones del decúbito prono en pacientes con covid19 desde octubre de 2020 a agosto de 2021 en la unidad de terapia intensiva adultos

The SARS Covid 19 pandemic has required a rapid response from the health team in intensive care units worldwide. The use of well-known therapeutic strategies such as the prone position (PD) for the care of patients with respiratory distress and severe refractory hypoxemia brought with it a series of complications, which is why their registration is crucial for their subsequent analysis. The general objective of this research was to analyze the complications of prone decubitus in patients with Covid19 from October 2020 to August 2021 at the Adult Intensive Care Unit - Sanatorio Allende Córdoba. Specific objectives describe the population according to socio-demographic conditions, identify and categorize the main complications recorded. The type of study was descriptive, retrospective and cross-sectional. The patient population (n = 235), the document analysis technique, the medical records instrument The following results were obtained: The sociodemographic characteristics of the studied population, 26% were women and 74% were men. Of days of hospitalization, 31% correspond from 3 to 10 days, 26% between 21 to 30 days, 23% between 11 to 20 days, 12% comprise from 31 to 40 days; 6% between 41 to 50 days and only 2% required 60 to 70 days. The presence of obesity corresponded to 51% in this population. Duration of the prone decubitus technique, it stands out that 45% were between 16 to 36 hours, 41% between 6 to 12 hours. and the remaining 14% between 40 to 74 hours. Regarding the appearance of pressure ulcers and location, the following results: 37% corresponded to the lip area, 29% to the forehead area, 23% were located in the knee area, only 11% corresponded to the wall anterior thorax. Presence of edema or mucosal lesions, 55% presented facial edema and 45% conjunctival edema. 69% presented lingual mucosa lesions and 31% corneapl ulcers.

The relationship between ventilatory ratio (VR) and 28-day hospital mortality by restricted cubic splines (RCS) in 14,328 mechanically ventilated ICU patients

BackgroundPrevious studies found that high levels of ventilatory ratio (VR) were associated with a poor prognosis due to worse ventilatory efficiency in acute respiratory distress syndrome patients. However, relatively few large studies have assessed the association between VR and intensive care unit (ICU) mortality in the general adult ventilated population.MethodsThe present study is a retrospective cohort study. Patients mechanically ventilated for more than 12 h were included. VR was calculated based on a previously reported formula. Restricted cubic spline models were used to fit the relationship between VR and mortality risks.ResultsA total of 14,328 mechanically ventilated ICU patients were included in the study, of which 1311 died within 28 days. The results of the study are as follows: (1) In the general adult ventilated population, VR was positively associated with 28-day mortality when VR ≥ 1.3 (increase of 0.1 per VR; HR 1.05, p < 0.001). The same tendency was also observed in the populations of severe hypoxemia with a PaO2/FiO2 (P/F) ratio < 200 mmHg. (2) However, in the population with a P/F ratio ≥ 200, a J-shaped dose–response association between VR and the risk of mortality was observed, with the risk of death positively associated with VR when VR ≥ 0.9 (10% increase in HR for every 0.1 increase in VR, p = 0.000) but negatively associated with VR when VR < 0.9 (10% decrease in HR for every 0.1 increase in VR, p = 0.034). In the population of P/F ratio ≥ 200 with VR less than 0.9, compared to the survival group, the nonsurvival group had a lower level PCO2 (33 mmHg [29.1, 37.9] vs. 34.4 mmHg [30.6, 38.5]), rather than a significant level of measured minute ventilation or P/F ratio.ConclusionsVR was positively associated with the risk of death in the general ICU population; however, VR was inversely associated with 28-day mortality in the population with a P/F ratio ≥ 200 and low VR . Further research should investigate this relationship, and VR should be interpreted with caution in clinical practice.

Strategies to fight COVID-19: Beyond the difference between SARS-CoV-2 and Influenza virus

Background: Since the outbreak of COVID-19 emerged in Wuhan, China, in December 2019, the epidemic has spread worldwide and posed a great threat to society. Despite great achievements in COVID-19 research, few studies have focused on the similarities and differences between SARS-CoV-2 and influenza viruses. Results: Through a review of the literature on SARS-CoV-2 and influenza viruses, we found that influenza occurs every year, and influenza pandemics occur irregularly. The uncomplicated human influenza viruses primarily affect the larger airways and rarely the alveoli. However, SARS-CoV-2 mainly involves the deep airways and lungs and can cause DAD, leading to severe hypoxemia. In general, SARS-CoV-2 is no less infectious than the influenza virus. However, its destructive power to the lungs is no less than the avian influenza virus. There is currently no clinical vaccine and specific inhibitor against SARS-CoV-2. Conclusions: SASR-CoV-2 damages lung function more severely than the influenza virus, with higher morbidity, mortality, and severe disease rates. Controlling the source of infection, cutting off the route of transmission, and protecting susceptible populations are critical to the fight against SARS-CoV-2.

Splenic Artery Embolization and Splenectomy for Spontaneous Rupture of Splenic Hemangioma and Its Imaging Features.

BackgroundSpontaneous splenic rupture (SSR) is a rare, often life-threatening, acute abdominal injury that requires immediate diagnosis and early treatment. SSR is mainly treated surgically or conservatively. A few cases of interventional embolization for SSRs have been reported.Case PresentationA 30-year-old male patient complaining mainly of left upper abdominal pain underwent emergency abdominal computed tomography (CT) and showed enlargement of the spleen with a massive mixed-density shadow approximately 10.0 × 8.0 × 12.5 cm in size. The boundary was unclear and showed obvious progressive enhancement. Considering the intrasplenic tumor lesions with rupture and hemorrhage, the possibility of vascular tumors was high, with intraperitoneal blood and fluid accumulation. Digital subtraction angiography of the splenic arteriography and embolization of the ruptured splenic artery branches were performed. Postoperative hemoglobin progressively decreased, inflammatory indicators, such as white blood cell counts, procalcitonin (PCT), and C-reactive protein (CRP) were significantly increased, and 2 days after embolization, the patient developed severe hypoxemia, shock, pulmonary edema, and acute respiratory distress syndrome. CT re-examination 9 days after embolization showed reduced lesion absorption. After stabilization of the condition, splenectomy was performed, and postoperative platelet count increase, anticoagulant improvement, and discharge were observed. Postoperative pathological examination revealed extensive hemorrhage and necrosis, vascular tissue with abnormal hyperplasia in the surrounding area, vascular tissue in the bleeding area and outer wall (elastic fiber staining +), and local myofibroblast hyperplasia. Immunohistochemistry showed actin (SM +) and Ki67 (10% +).ConclusionSSR caused by splenic hemangioma is rare, and the choice between surgical treatment or splenic artery embolization remains dependent on the patient's hemodynamic stability and imaging findings.

The Combination of Betahistine and Oxybutynin Increases Respiratory Control Sensitivity (Loop Gain) in People with Obstructive Sleep Apnea: A Randomized, Placebo-Controlled Trial.

RationaleThere are widespread histaminergic projections throughout the brain, including hypoglossal nuclei, that modulate pharyngeal muscle tone and respiratory control. Hence, histaminergic stimulation pharmacologically may increase pharyngeal muscle tone and stabilize respiratory control (loop gain) to reduce obstructive sleep apnea (OSA) severity. Antimuscarinics also increase REM pharyngeal muscle tone in rats. Thus, a combination of histaminergic and anti-muscarinic drugs may be a novel target for OSA pharmacotherapy. However, this has not been investigated. Accordingly, we aimed to test the effects of betahistine (Beta), an H3-autoreceptor antagonist which thereby increases histamine levels, in combination with the antimuscarinic oxybutynin (Oxy), on OSA severity, OSA endotypes, polysomnography parameters and next-day sleepiness and alertness.MethodsThirteen adults with OSA received either Beta-Oxy (96–5mg) or placebo according to a randomized, crossover, double-blind design, prior to polysomnography. Participants completed the Karolinska Sleep Scale and Leeds Sleep Evaluation Questionnaire and a driving simulation task to quantify next-day sleepiness and alertness. OSA endotypes were estimated through validated algorithms using polysomnography.ResultsCompared to placebo, Beta-Oxy increased respiratory control sensitivity (loop gain) (0.52[0.24] vs 0.60[0.34], median [IQR], P = 0.021) without systematically changing OSA severity (34.4±17.2 vs 40.3±27.3 events/h, mean±SD, P = 0.124), sleep efficiency, arousal index or markers of hypoxemia. Beta-Oxy was well tolerated and did not worsen next-day sleepiness/alertness.ConclusionRather than stabilize breathing during sleep, Beta-Oxy increases loop gain, which is likely to be deleterious for most people with OSA. However, in certain conditions characterized by blunted respiratory control (eg, obesity hypoventilation syndrome), interventions to increase loop gain may be beneficial.

Pronation in acute respiratory distress syndrome (ARDS) secondary to COVID-19

: In March 2020, the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was declared a pandemic by the World Health Organization. Patients with SARS-CoV-2 infection can develop coronavirus disease 2019 (COVID-19), the most concerning complication of which is acute hypoxaemic respiratory failure requiring mechanical ventilation and intensive care unit (ICU) admission. In this context prone position ventilation is an established method to improve oxygenation in severe acute respiratory distress syndrome (ARDS), and its application was able to reduce mortality rate. Prone position has been used since the 1970s to treat severe hypoxemia in patients with ARDS because of its effectiveness at improving gas exchange. Compared with the supine position, placing patients in prone position effects a more even tidal volume distribution, in part, by reversing the vertical pleural pressure gradient, which becomes more negative in the dorsal regions. Prone position also improves resting lung volume in the dorsocaudal regions by reducing the superimposed pressure of both the heart and the abdomen. In contrast, pulmonary perfusion remains preferentially distributed to the dorsal lung regions, thus improving overall alveolar ventilation/perfusion relationships. Moreover, the larger tissue mass suspended from a wider dorsal chest wall effects a more homogeneous distribution of pleural pressures throughout the lung that reduces abnormal strain and stress development. This is believed to ameliorate the severity or development of ventilator-induced lung injury and may partly explain why prone position reduces mortality in severe ARDS. In this review we investigate the physiological aspects of the pronation.

STUDY OF INFLAMMATORY MARKERS IN HYPOXIC COVID 19 PATIENTS AND CORRELATION WITH DISEASE SEVERITY

Background: COVID-19 is global pandemic affecting mainly a respiratory system and causing hypoxemia in the majority of those been infected. In our study, we aimed to correlate the inflammatory markers with severity of hypoxemia and predicting the significant markers of disease severity. Aims and Objectives:To correlate the inflammatory markers with degree of hypoxemia and To determine the inflammatory markers useful in predicting the disease severity. Materials and Methods:A cross-sectional observational study was conducted in the month of may 2021 in tertiary care hospital chinnaoutpalli near Vijayawada in Andhra Pradesh. The 296 patients diagnosed as COVID-19 positive by real-time Polymerase chain reaction and admitted in our hospital requiring oxygen (hypoxemic) were included. These patients were divided into supplemental oxygen group (SuO2 Group) and non invasive ventilation group (NIV group) and inflammatory markers among these groups were compared. Results: Out of 296 hypoxemic patients, 148 were in ward, requiring SuO2,148 were in ICU requiring NIV. There was significant differences in mean D-dimer (p=0.001), and neutrophil-to-lymphocyte ratio (p=0.012),among NIV and SuO2 group .There was no significant difference in CRP, ferritin. Conclusion: The inflammatory markers are a good guide for predicting the hypoxemia and disease severity. The results concluded Neutrophil-to-Lymphocyte ratio, D-Dimer were effective biomarkers in predicting a severity and prognosis of COVID- 19 patients, but could not establish significant association of serum Ferritin, CRP with disease severity.

Incidence of Severe Hypoxemia in Anesthetized Horses Undergoing Emergency Exploratory Laparotomy

Prevalence and risk factors of severe hypoxemia in anesthetized horses undergoing emergency exploratory laparotomy are sparsely documented. The aim of this study was to report incidence of severe hypoxemia ( PaO2 < 60 mmHg) in horses undergoing emergency exploratory laparotomy and identify potential risk factors for this complication. A single center retrospective cross sectional designed was used. Clinical data of 714 horses undergoing general anesthesia for emergency explorative laparotomy were reviewed. A backward stepwise elimination procedure was used to determine the final multivariable logistic regression model; all covariables with univariable P-values <.25 were incorporated, with retention of covariables with Wald P-values <.05 at each step, in order to determine which explanatory variables would be included in the final model. The overall incidence of severe hypoxemia in our population was 15.3%. Multivariable logistic regression analysis showed that increasing body weight (odds ratio [OR] 1.01, 95% confidence interval [CI] 1.0–1.01, P = .002), colon torsion (OR 3.0, 95% CI 1.3–6.8, P = .006), increased dead space ventilation (OR 1.06, 95% CI 1.04–1.09, P ≤ .001), shorter time between induction of anesthesia and collection of arterial blood gas samples (OR 0.98, 95% CI 0.98–0.99, P ≤ .001) and intratracheal aerosolized salbutamol (OR 13.5, 95% CI 7.6–24, P ≤ .001) were associated with the outcome. The incidence of hypoxemia found in our study was in line with previous literature. Increasing body weight, colon torsion and shorter time between the time of induction of anesthesia and collection of arterial blood gas samples represented risk factors for hypoxemia.

Design of Personal Health Monitoring Devices for Early Detection of Silent Hypoxia

Silent hypoxia in Covid-19 patients and symptoms of severe hypoxemia require appropriate treatment. These cases often appear asymptomatic but risk fatal to life-threatening. One of the recommended devices is pulse oximetry. Embedded systems technologies and the Internet of Things (IoT) can develop low-cost personal health monitoring devices. This study developed a pulse oximetry prototype integrated with a digital temperature sensor and equipped with the interpretation results of both "normal" and "hypoxic" conditions. It is called OxyTemp. IoT technologies monitor user conditions remotely using the Blynk application via mobile phones. This study used Research &amp; Development with the Reverse engineering method. The OxyTemp has Different types of prototype testing are physical and functional inspection, electrical safety testing, and performance testing of each parameter using an appropriate calibrator. The working method refers to SK Direktur Jenderal Pelayanan Kesehatan Tahun 2018 No. 041-18 on Pulse Oximeter Testing Working Methods.

Hourly Analysis of Mechanical Ventilation Parameters in Critically Ill Adult Covid-19 Patients: Association with Mortality

Objective: There exists controversy about the pathophysiology and lung mechanics of COVID-19 associated acute respiratory distress syndrome (ARDS), because some report severe hypoxemia with preserved respiratory system mechanics, contrasting with “classic” ARDS. We performed a detailed hourly analysis of the characteristics and time course of lung mechanics and biochemical analysis of patients requiring invasive mechanical ventilation (IMV) for COVID-19-associated ARDS, comparing survivors and non-survivors. Methods: Retrospective analysis of the data stored in the ICU information system of patients admitted in our hospital ICU that required IMV due to confirmed SARS-CoV-2 pneumonia between March 5th and April 30th, 2020. We compare respiratory system mechanics and gas exchange during the first ten days of IMV, discriminating volume and pressure controlled modes, between ICU survivors and non-survivors. Results: 140 patients were included, analyzing 11 138 respiratory mechanics recordings. Global mortality was 38.6%. Multivariate analysis showed that age (OR 1.092, 95% (CI 1.014-1.176)) and need of renal replacement therapies (OR 10.15, (95% CI 1.58-65.11)) were associated with higher mortality. Previous use of Angiotensin Converting Enzyme inhibitor (ACEI)/angiotensin-receptor blockers (ARBs) also seemed to show an increased mortality (OR 4.612, (95% CI 1.19-17.84)) although this significance was lost when stratifying by age. Respiratory variables start to diverge significantly between survivors and non-survivors after the 96 to 120 hours (hs) from mechanical ventilation initiation, particularly respiratory system compliance. In non survivors, mechanical power at 24 and 96 hs was higher regardless ventilatory mode. Conclusions: In patients admitted for SARS-CoV-2 pneumonia and requiring mechanical ventilation, non survivors have different respiratory system mechanics than survivors in the first 10 days of ICU admission. We propose a checkpoint at 96–120 hs to assess patients improvement or worsening in order to consider escalating to extracorporeal therapies.

0535 Prevalence of various forms of sleep disordered breathing in infants with Down syndrome

Abstract Introduction Children with Down Syndrome (DS) are at high risk of sleep disordered breathing (SDB). Undiagnosed SDB in younger children may confer further risks of cardiovascular and neurocognitive complications associated with DS. However, there is paucity of studies examining SDB in infants with DS. The purpose of the study was to examine the prevalence of obstructive sleep apnea (OSA), sleep hypoventilation (SH) and hypoxemia in infants with DS. Methods Infants (≤12 months old) with DS who underwent first polysomnography (PSG) at Seattle Children’s hospital over a 6-year period were included. Data collected included obstructive apnea hypopnea index (oAHI), central apnea hypopnea index (CAHI), time spent with CO2 levels &amp;gt; 50 mmHg, time (minutes) spent with saturations &amp;lt;88% (T88), and saturation nadir (minO2sat). Exclusion criteria: follow up studies, and studies post procedures. Data presented by descriptive statistics and comparison by unpaired t-test. Results A total of 526 children with DS underwent PSG during the collection time. Forty two fit criteria (Mean age 6.6 months, male 66%). Diagnostic (n=13), split to oxygen (n=29, 69%). Split studies were more severe when compared with full diagnostic AHI (Mean 44.7 vs. 14.8, p=0.0007), T88 (Mean 12.5 vs. 0.2 p=0.03) and minO2sat (77.6 vs. 85.8%, p=0.01). Overall mean oAHI was 33.7 (S.D. 30) CAI was 3.4 (S.D. 3.1). 5/31 with reliable capnography had SH (16.1%) with no difference in age vs. the non-SH group (6.0 [3.2] vs. 6.6 [3.1], p&amp;gt;0.05). Overall, oAHI was more severe in infants with hypoventilation (58.9 [23.6] vs. 29.3 [63],p&amp;gt;0.05). Ten infants spent &amp;gt;5 min with saturations &amp;lt;88% (21.4%). All infants with hypoxemia had OSA (oAHI Mean 66.5 SD 40). Infants with OSA and hypoxemia had worse oAHI than those without hypoxemia (p&amp;lt;0.05). Conclusion Our data shows that a large percent of infants with DS (69%) required a split study due to severe OSA (mean oAHI 66.5) or hypoxemia (21.4%). The overall mean AHI for this age group was 33.7. Hypoventilation was present in 16.1%. This study highlights the high prevalence of SDB in infants with DS and supports early PSG assessment in this patient population. Support (If Any)

Nocturnal hypoxemia and central apneas increase mortality, but not recurrent ischemic events after ischemic stroke

BackgroundThe aim of the study was to investigate whether findings in cardiorespiratory polygraphy had an association with stroke mortality or ischemic event recurrence after ischemic stroke. MethodsWe prospectively studied 204 ischemic stroke patients who underwent cardiorespiratory polygraphy within the first 48 h after the symptom onset. We followed all these patients for a median of 6.2 years. We evaluated mortality, time of survival, causes of death and new ischemic events. ResultsOf 204 ischemic stroke patients, 43 died and 48 had a new ischemic event during the follow-up. The lowest arterial oxyhemoglobin saturation (min SaO₂) (P = 0.007) was lower, the percentage of time spent below arterial oxyhemoglobin saturation less than 90% (T90) (P = 0.005) was higher, and central apnea index per hour (CAI/h) (P = 0.04) was higher among the deceased. Male gender, older age, diabetes mellitus, elevated modified Rankin scale (mRS) score, lower Glasgow Coma Scale (GCS) score and CAI/h independently predicted higher mortality. Peripheral arterial disease (PAD) and higher National Institutes of Health Stroke Scale (NIHSS) score were independent predictors for a recurrent ischemic event. Among those having respiratory event index (REI) at least 30, older age and lower GCS score independently predicted higher mortality. Only 21 stroke patients initiated continuous positive airway pressure (CPAP) treatment; of those, only one had a new ischemic event. ConclusionsThe non-survivors had more severe nocturnal hypoxemia and more central apneas than survivors. Among patients with REI at least 30/h, increased CAI predicted higher mortality, but not independently. Clinical trial registrationURL:http://www.clinicaltrials.gov. Unique identifier: NCT01861275

TPA or not tPA? Lysis therapy in the setting of COVID‐19 and ECMO

We read with interest the recent article entitled, “Using lysis therapy to treat five critically ill COVID-19 patients who show echocardiographic criteria of right ventricular strain” by Mahdy et al., which described five patients who underwent lysis therapy for COVID-19-associated critical illness with respiratory failure and right heart strain. We find this topic especially relevant in the context of the global COVID-19 pandemic, which has now claimed over 800,000 American lives and over 1.5 million worldwide. Critical illness secondary to COVID-19 is associated with an inflammatory state and coagulopathy; the mechanisms underlying this state are still under investigation [1-4]. There are multiple case reports describing adverse thrombotic events in this population [1-4] and we are particularly interested in the authors’ report of Patient 5, who was receiving extracorporeal membranous oxygenation (ECMO) at the time of lysis therapy. ECMO generally requires systemic anticoagulation due to a hypercoagulable state induced by contact of the patient's blood with the cannulas, but the choice of medication and the intensity of therapy vary in different settings and in patients with different medical conditions. The increased volume of distribution caused by the circuit also calls the standard dosing of alteplase into question. The balance between thrombotic events and bleeding complications is a delicate one without even accounting for the coagulopathy associated with COVID-19. Recently, we provided veno-venous ECMO for a 47-year-old man with severe hypoxemia secondary to acute respiratory distress syndrome (ARDS) associated with COVID-19 pneumonia. His hypoxemia was refractory to mechanical ventilation, neuromuscular blockade, and prone positioning. In addition, the patient had completed a course of dexamethasone and remdesivir as targeted therapy for COVID-19. His medical history was significant for obesity, congenital solitary kidney, hypothyroidism, and hyperlipidemia. While on ECMO, he received therapeutic anticoagulation with unfractionated heparin. On hospital day 17 (ICU day 13 and day 21 since symptom onset), our patient developed a massive pulmonary embolism with acute right ventricle (RV) failure (Figure 1). The patient's coagulation parameters on this day were as follows: PTT 102.3 s, INR 2, d-dimer 85,940 FEU. He was too hemodynamically unstable to transfer for thrombectomy. After a multidisciplinary discussion, we gave intravenous alteplase (10 mg bolus over 1 min followed by 90 mg infusion over 2 h). Within minutes, he stabilized and there were no associated bleeding complications. Anticoagulation decreases mortality in COVID-19-associated critical illness and is recommended while patients are on ECMO [2-4], but studies reporting thrombotic complications despite therapeutic heparin are common [5]. The ideal anticoagulation strategy for these patients is still unclear. Prior to the pandemic, there were scant reports on the use of thrombolytics while on ECMO, leaving little guidance for clinicians at the bedside. We are curious if the authors of this case series are able to report more on Patient 5's coagulation studies, how they chose their alteplase dose, their consideration of bleeding risks, and if they have other recommendations for clinicians considering lytic therapy for patients with COVID-19 disease requiring veno-venous ECMO. We are grateful to the patient described here, and to the patient's family who consented to the publication of this report. The authors declare no conflict of interest. The authors received no specific funding for this work.

P65 THE USE OF CPAP IN A HEMODYNAMICS ROOM ON A PATIENT UNDERGOING CORONARY PROCEDURE – SAFETY AND FEASIBILITY

Abstract Context of the Study It’s not uncommon that patients who suffer from Acute Coronary Syndrome (ACS) also show respiratory failure from acute pulmonary edema. The need to treat these patients preemptively with an invasive approach is made harder by the difficulty of managing them in a hemodynamics room in a supine decubitus position. Therefore, the risk is that the procedure is delayed, or that it becomes necessary to proceed with an orotracheal intubation. Not much data is available on the use of non–invasive assisted ventilation with cPAP during revascularization in a hemodynamics room. In general, there is quite some distrust over both the hemodynamic effects of positive pressure and the managerial difficulties for the nursing staff. Goal of the Study To evaluate the safety and feasibility of the use of cPAP in patients with ACS and severe acute respiratory failure, radiological framework of acute pulmonary edema and severe hypoxemia, decubits semiortopnoic cumpolsory. Materials and methods Patients who suffer from ACS and acute pulmonary edema, undergoing urgent coronary catheterization with the use of cPAP in a hemodynamics room, with a “total face” mask. Description of the management by the nursing staff. Results 27 patients were analyzed. For all patients, cPAP was positioned before the procedure and maintained at all times during the coronary interventional procedure. Never was necessary the intervention of a rianimator, nor was orotracheal intubation. Conclusions The use of cPAP, in a hemodynamics room, by the nursing staff, has been proven to be feasible and safe, and it might reduce the need for orotracheal intubation in patients suffering from ACS and acute pulmonary edema. Proposal for a multicentre study.

Correlation between Lactate Dehydrogenase Levels and Severity by Pulmonary Tomography in Patients with Sars-Cov-2

Serum lactate dehydrogenase (LHD) concentration has been described as a biomarker to predict severe lung injury and severe hypoxemia in patients with ARDS. The aim of the study was to correlate lactate dehydrogenase concentrations with the tomographic severity index in SARS-CoV-2 pneumonia cases, considering lung CT as the gold standard for severity diagnosis in this population based on the presence of ground glass pattern and the score given in the segmental assessment. A total of 110 patients were included in the study, in the period from April to September 2020. From the results, a moderate correlation was obtained between serum LHD levels and severity score by pulmonary tomography, with an r=0.474 and p &lt;0.0001; with a severity-associated serum LHD cut-off point of 396 mg /dl (p &lt; 0.001, sensitivity 86.02%, specificity 75%, AUC 0.806). Serum DHL levels may be useful for predicting severity in patients with COVID pneumonia 19t

A randomized clinical trial to compare ketamine-butorphanol-azaperone-medetomidine and detomidine-etorphine-acepromazine for anesthesia of captive Przewalski horses (Equus przewalskii).

To compare ketamine-butorphanol-azaperone-medetomidine (KBAM) to detomidine-etorphine-acepromazine (DEA) for field anesthesia in captive Przewalski horses (Equus przewalskii). 10 adult Przewalski horses. A prospective randomized crossover trial was conducted. Each horse was immobilized once with KBAM (200 mg ketamine, 109.2 mg butorphanol, 36.4 mg azaperone, and 43.6 mg medetomidine) and once with DEA (40 mg detomidine premedication, followed 20 minutes later by 3.9 to 4.4 mg etorphine and 16 to 18 mg acepromazine). Both protocols were administered by IM remote dart injection with a washout period of 6 months between treatments. Selected cardiorespiratory variables and quality of anesthesia were recorded. Antagonists were administered IM (KBAM, 215 mg atipamezole and 50 mg naltrexone; DEA, 4 mg RX821002 and 100 mg naltrexone). All horses were anesthetized and recovered uneventfully. Inductions (DEA, 6.8 min; KBAM, 11.6 min; P = 0.04) and recoveries (DEA, 3.2 min; KBAM, 19.6 min; P < 0.01) were faster with DEA compared with KBAM. Quality scores for induction and recovery did not differ between protocols, but maintenance quality was poorer for DEA (P < 0.01). Clinical concerns during DEA immobilizations included apnea, severe hypoxemia (arterial partial pressure of oxygen < 60 mm Hg), muscle rigidity, and tremors. Horses treated with KBAM were moderately hypoxemic, but arterial partial pressures of oxygen were higher compared with DEA (P < 0.01). Captive Przewalski horses are effectively immobilized with KBAM, and this protocol results in superior muscle relaxation and less marked hypoxemia during the maintenance phase, but slower inductions and recoveries, compared with DEA.

Early intubation and decreased in-hospital mortality in patients with coronavirus disease 2019.

BackgroundSome academic organizations recommended that physicians intubate patients with COVID-19 with a relatively lower threshold of oxygen usage particularly in the early phase of pandemic. We aimed to elucidate whether early intubation is associated with decreased in-hospital mortality among patients with novel coronavirus disease 2019 (COVID-19) who required intubation.MethodsA multicenter, retrospective, observational study was conducted at 66 hospitals in Japan where patients with moderate-to-severe COVID-19 were treated between January and September 2020. Patients who were diagnosed as COVID-19 with a positive reverse-transcription polymerase chain reaction test and intubated during admission were included. Early intubation was defined as intubation conducted in the setting of ≤ 6 L/min of oxygen usage. In-hospital mortality was compared between patients with early and non-early intubation. Inverse probability weighting analyses with propensity scores were performed to adjust patient demographics, comorbidities, hemodynamic status on admission and time at intubation, medications before intubation, severity of COVID-19, and institution characteristics. Subgroup analyses were conducted on the basis of age, severity of hypoxemia at intubation, and days from admission to intubation.ResultsAmong 412 patients eligible for the study, 110 underwent early intubation. In-hospital mortality was lower in patients with early intubation than those with non-early intubation (18 [16.4%] vs. 88 [29.1%]; odds ratio, 0.48 [95% confidence interval 0.27–0.84]; p = 0.009, and adjusted odds ratio, 0.28 [95% confidence interval 0.19–0.42]; p < 0.001). The beneficial effects of early intubation were observed regardless of age and severity of hypoxemia at time of intubation; however, early intubation was associated with lower in-hospital mortality only among patients who were intubated later than 2 days after admission.ConclusionsEarly intubation in the setting of ≤ 6 L/min of oxygen usage was associated with decreased in-hospital mortality among patients with COVID-19 who required intubation.Trial Registration None.Supplementary InformationThe online version contains supplementary material available at 10.1186/s13054-022-03995-1.

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

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

Impact of moderate-to-severe obstructive sleep apnea on aggressive clinicopathological features of papillary thyroid carcinoma

ObjectiveObstructive sleep apnea (OSA) may to be strongly associated with cancer mortality. The risk hazards of OSA regarding aggressive features of papillary thyroid carcinoma (PTC) remain unclear. The main objective of this study was to explore the relationship between OSA and aggressive features of PTC. MethodsWe prospectively studied 210 patients (54 men, 156 women; age 43 ± 13 years) with PTC. Indices of sleep respiratory disturbance and oxygen desaturation were determined by polysomnography with the apnea-hypopnea index (AHI) and lowest oxygen saturation (LSaO2), respectively. PTC aggressive features were assessed by postoperative histopathological analysis. Multivariant logistic regression models adjusting for demographic and OSA-related factors were generated to determine OSA risk hazards for aggressive PTC features. ResultsThe prevalence of moderate-to-severe OSA (defined as AHI of >15) was 20% in PTC patients. Those in the moderate-to-severe OSA group had higher BMI and more aggressive PTC features. Moderate-to-severe OSA was associated with increased odds of larger tumor size (OR, 4.31; 95% CI, 1.79–10.37; p = 0.001), capsular invasion (OR, 2.96; 95% CI, 1.42–6.16; p = 0.004), multifocality (OR, 3.11; 95% CI, 1.52–6.39; p = 0.002), central (OR, 4.7; 95% CI, 1.77–12.49; p = 0.003) and lateral (OR, 5.94; 95% CI, 2.27–15.54; p < 0.001) cervical lymph node metastasis, and BRAF mutation (OR, 2.88; 95% CI, 1.31–6.31; p = 0.008). Moderate to severe hypoxemia did not correlated with aggressive PTC behaviors. ConclusionsOSA is a common respiratory disturbance in PTC. Aggressive PTC features in patients with moderate-to-severe OSA implicate OSA as a cause of cancer progression. Respiratory disturbance events have a greater impact on PTC aggressiveness than hypoxia.

Venovenous extracorporeal membrane oxygenation in patients with acute covid-19 associated respiratory failure: comparative effectiveness study

ObjectiveTo estimate the effect of extracorporeal membrane oxygenation (ECMO) compared with conventional mechanical ventilation on outcomes of patients with covid-19 associated respiratory failure.DesignObservational study.Setting30 countries across five continents, 3 January...