Derrick Anthony Cleland1, Clarence H. H. Tsai2, Joslyn Vo1, Dafne Moretta1
1 Loma Linda University Medical Center Loma Linda, CA, USA 2 Loma Linda University School of Medicine, Loma Linda, CA, USA
Introduction: Silicone (polydimethylsiloxane) injections are used for cosmetic augmentation. Their use is associated with life-threatening complications such as acute pneumonitis, alveolar hemorrhage, and acute respiratory distress among others [1,2]. We report a case of a Hispanic woman who developed severe respiratory distress syndrome after gluteal silicone injections. Case Presentation: A 44-year-old Hispanic female presented to the Emergency Department complaining of progressive dyspnea on exertion for two weeks. Chest imaging revealed patchy bibasilar airspace opacities of peripheral distribution. Labs were significant for leukocytosis, elevated PT, D-dimer, lactate dehydrogenase, and fibrinogen, concerning for COVID-19, however SARS-CoV-2 testing was negative multiple times. The patient later became encephalopathic, hypoxemic, and eventually required intubation. Further history uncovered that the patient had received illicit gluteal silicone injections a few days prior to her onset of symptoms. The patient was diagnosed with silicone embolism syndrome (SES) and initiated on high dose intravenous methylprednisolone . Case Discussion: Patients from lower socioeconomic backgrounds utilize illicit services to receive silicone injections at minimal costs. This leads to dangerous outcomes. The serology and imaging findings observed in our case have similarities to the typical presentation of COVID-19 pneumonia making the initial diagnosis difficult. This case serves as a cautionary tale of the importance of thorough history taking in patients with concern for COVID-19.
Department of Anesthesiology and Intensive Care, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
Pain is one of the major concerns in Intensive Care Units (ICU). The majority of the patients admitted in ICU experience a certain degree of pain during their stay. Opioid analgesia constitutes the main analgesic option for ICU patients . Opioids are known to have serious side effects, some of them such as ileus, respiratory depression, which leads to prolonged mechanical ventilation, can interfere with the patient’s outcome can lengthen the stay in ICU and leads to iatrogenic withdrawal syndrome (IWS) [1, 2]. In the last few years, a new concept of pain management in ICU patients was introduced: opioid free analgesia (OFA). This concept implies achieving good quality analgesia without using any type of opioids, in any manner . [More]
Sarah A. Bachman, Ryan S. Peterson, Peter S. Burrage, Leigh C Hickerson
Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
Perioperative management of pheochromocytoma in the setting of catecholamine-induced heart failure requires careful consideration of hemodynamic optimization and possible mechanical circulatory support. A Jehovah’s Witness patient with catecholamine-induced acutely decompensated heart failure required dependable afterload reduction for a cardio-protective strategy. This was emphasized due to the relative contraindication to perioperative anticoagulation required for mechanical circulatory support. A phenylephrine challenge clearly demonstrated adequate alpha blockade after only 24 hours of phenoxybenzamine treatment. This resulted in advancement of the surgery date. This case also highlights management of beta blockade, volume and salt loading, autologous blood transfusion, and profound post-operative vasoplegia in the setting of cardiogenic shock. Careful attention to hemodynamic optimization and cardio-protective strategies ultimately resulted in positive outcome for this challenging clinical scenario.
Judit Gutierrez-Gutierrez, Reyes Muñoz-Calahorro, Laura Bermejo-Guerrero, Zaira Molina-Collado, Ignacio Saez de la Fuente, Jose Angel Sánchez-Izquierdo
Hospital Universitario 12 de Octubre, Madrid, Spain
A case of myoclonic status treated with plasmapheresis in a patient of 63 years of age who was admitted to a Spanish intensive care unit is reported. The patient showed clinical and radiological evidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection; molecular tests did not verify this.
1 Department of Intensive Care Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan 2 Department of Public Health, Sapporo Medical University School of Medicine, Sapporo, Japan
Introduction: The medical emergency team enables the limitation of patients’ progression to critical illness in the general ward. The early warning scoring system (EWS) is one of the criteria for medical emergency team activation; however, it is not a valid criterion to predict the prognosis of patients with MET activation. Aim: In this study, the National Early Warning Score (NEWS) and Rapid Emergency Medicine Score (REMS) was compared with that of the Acute Physiology and Chronic Health Evaluation II (APACHE II) score in predicting the prognosis of patients who had been treated a medical emergency team. Material and Methods: In this single-centre retrospective cohort study, patients treated by a medical emergency team between April 2013 and March 2019 and the 28-day prognosis of MET-activated patients were assessed using APACHE II, NEWS, and REMS. Results: Of the 196 patients enrolled, 152 (77.5%) were men, and 44 (22.5%) were women. Their median age was 68 years (interquartile range: 57-76 years). The most common cause of medical emergency team activation was respiratory failure (43.4%). Univariate analysis showed that APACHE II score, NEWS, and REMS were associated with 28-day prognostic mortality. There was no significant difference in the area under the receiver operating characteristic curve of APACHE II (0.76), NEWS (0.67), and REMS (0.70); however, the sensitivity of NEWS (0.70) was superior to that of REMS (0.47). Conclusion: NEWS is a more sensitive screening tool like APACHE II than REMS for predicting the prognosis of patients with medical emergency team activation. However, because the accuracy of NEWS was not sufficient compared with that of APACHE II score, it is necessary to develop a screening tool with higher sensitivity and accuracy that can be easily calculated at the bedside in the general ward.
1 McGaw Medical Center of Northwestern University, Chicago, IL, USA 2 Beth Israel Deaconess Medical Center, Boston, MA, USA
Introduction: The COVID-19 pandemic has put increased stress on medical systems, infrastructure, and the public in expected and unexpected ways. This case report summarises an unexpected case of methanol poisoning from hand sanitiser ingestion due to changes in industry regulations, increased demand for cleaning products and severe psychosocial stressors brought on by the pandemic. Severe methanol toxicity results in profound metabolic disturbances, damage to the retina and optic nerves, and potentially death. Case Presentation: The patient was a 26-year-old male with alcohol use disorder who presented with one day of nausea, vomiting, and abdominal pain after consuming hand sanitiser. Within a few hours, the patient had suffered multiple seizures, cardiac arrests and required admission to the ICU for emergent management of methanol poisoning. EEG and brain perfusion imaging were performed to confirm brain death, given concerns about the cranial nerve exam after methanol poisoning. Conclusions: While rare, methanol toxicity remains a potentially fatal poisoning in the United States and worldwide. When healthcare and public resources are strained, healthcare professionals must consider particularly abnormal presentations. In patients suspected of brain death from methanol toxicity, cranial nerve examination may be unreliable. Therefore, additional testing is necessary to confirm brain death.
Komal Imtiaz1, Wade Jodeh2, Dave Sudekum2, Bruno DiGiovine2, Jason Hecht2
1 University of Texas at Houston, Houston, TX, USA 2 St Joseph Mercy Ann Arbor. Ann Arbor, MI, USA
Introduction: Inhaled epoprostenol (iEpo) is a pulmonary vasodilator used to treat refractory respiratory failure, including that caused by Coronavirus 2019 (COVID-19) pneumonia. Aim of Study: To describe the experience at three teaching hospitals using iEpo for severe respiratory failure due to COVID-19 and evaluate its efficacy in improving oxygenation. Methods: Fifteen patients were included who received iEpo, had confirmed COVID-19 and had an arterial blood gas measurement in the 12 hours before and 24 hours after iEpo initiation. Results: Eleven patients received prone ventilation before iEpo (73.3%), and six (40%) were paralyzed. The partial pressure of arterial oxygen to fraction of inspired oxygen (P/F ratio) improved from 95.7 mmHg to 118.9 mmHg (p=0.279) following iEpo initiation. In the nine patients with severe ARDS, the mean P/F ratio improved from 66.1 mmHg to 95.7 mmHg (p=0.317). Ultimately, four patients (26.7%) were extubated after an average of 9.9 days post-initiation. Conclusions: The findings demonstrated a trend towards improvement in oxygenation in critically ill COVID-19 patients. Although limited by the small sample size, the results of this case series portend further investigation into the role of iEpo for severe respiratory failure associated with COVID-19.
Sylvère Störmann, John Hoppe, Daniela Steinert, Matthias W. Angstwurm
Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Germany
This report concerns a young man who attempted suicide by ingesting a cocktail with a lethal dose of chloroquine phosphate and large amounts of diazepam. On presentation, the patient was drowsy, unresponsive and in cardiogenic shock with severely impaired left ventricular function. Active charcoal and vasopressors were administered, and despite his intoxication with diazepam, a high-dose diazepam treatment was initiated in the hospital. It is concluded that diazepam in the cocktail played a vital role in the survival of this patient. With a rise in numbers, every emergency and intensive care physician should be familiar with chloroquine poisoning.
Samuel Windham, Kellen Hirsch, Ryan Peterson, David Douin, Lakshmi Chauhan, Lauren Heery, Connor Fling, Nemanja Vukovic, Fernando Holguin, Shanta Zimmer, Kristine Erlandson
University of Colorado Anschutz Medical Campus, Denver, CO, USA
Introduction: The predictive potential of demographics, clinical characteristics, and inflammatory markers at admission to determine future intubation needs of hospitalised CoVID-19 patients is unknown. The study aimed to determine the predictive potential of elevated serum inflammatory markers in determining the need for intubation in CoVID-19 Patients. Methods: In a retrospective cohort study of hospitalised SARS-CoV2 positive patients, single and multivariable regression analyses were used to determine covariate effects on intubation odds, and a minimax concave penalty regularised logistic regression was used to build a predictive model. A second prospective independent cohort tested the model. Results: Systemic inflammatory markers obtained at admission were higher in patients that required subsequent intubation, and adjusted odds of intubation increased for every standard deviation above the mean for c-reactive protein (CRP) OR:2.8 (95% CI 1.8-4.5, p<0.001) and lactate dehydrogenase OR:2.1 (95% CI 1.3-3.3, p=0.002). A predictive model incorporating C-reactive protein, lactate dehydrogenase, and diabetes status at the time of admission predicted intubation status with an area under the curve (AUC) of 0.78 with corresponding sensitivity of 86%, specificity of 63%. This predictive model achieved an AUC of 0.83, 91% sensitivity, and 41% specificity on the validation cohort. Conclusion: In patients hospitalised with CoVID-19, elevated serum inflammatory markers measured within the first twenty-four hours of admission are associated with an increased need for intubation. Additionally, a model of C-reactive protein, lactate dehydrogenase, and the presence of diabetes may play a predictive role in determining the future need for intubation.
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