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Personalisation of Therapies in COVID-19 Associated Acute Respiratory Distress Syndrome, Using Electrical Impedance Tomography

Atsuko Shono1, Toru Kotani1, Inéz Frerichs2

1 Department of Intensive Care Medicine, Showa University School of Medicine, Shinagawa, Tokyo Japan
2 Department of Anesthesiology and Intensive Care Medicine, University Medical Center, Schleswig-Holstein, Campus Kiel, Germany

DOI: 10.2478/jccm-2020-0045

Introduction: Each patient suffering from severe coronavirus COVID-19-associated acute respiratory distress syndrome (ARDS), requiring mechanical ventilation, shows different lung mechanics and disease evolution. Therefore, lung protective strategies should be personalised for the individual patient.
Case presentation: A 64-year-old male patient was intubated ten days after the symptoms of COVID-19 infection presented. He was placed in the prone position for sixteen hours, resulting in a marked improvement in oxygenation. However, after being returned to the supine position, his SpO2 rapidly dropped from 98% to 91%, and electrical impedance tomography showed less ventilation at the dorsal region and a ventral shift of ventilation distribution. An incremental and decremental PEEP trial under electrical impedance tomography monitoring was carried out, confirming that the dependent lung regions were recruited with increased pressures and homogenous ventilation distribution could be provided with 14 cmH2O of PEEP. The optimal settings were reassessed next day after returning from the second session of the prone position. After four prone position-sessions in five days, oxygenation was stabilised and eventually the patient was discharged.
Conclusions: Patients with COVID-19 associated ARDS require individualised ventilation support depending on the stage of their disease. Daily PEEP trial monitored by electrical impedance tomography can provide important information to tailor the respiratory therapies.

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The Susceptibility of MDR-K. Pneumoniae to Polymyxin B Plus its Nebulised Form Versus Polymyxin B Alone in Critically Ill South Asian Patients

Md. Jahidul Hasan1, Raihan Rabbani2, Ahmad Mursel Anam3, Ario Santini4, Shihan Mahmud Redwanul Huq2

1 Clinical Pharmacy Services, Square Hospitals Ltd., Dhaka, Bangladesh
2 ICU and Internal Medicine, Square Hospitals Ltd., Dhaka, Bangladesh
3 High Dependency Unit (HDU), Square Hospitals Ltd., Dhaka, Bangladesh
4 University of Medicine, Pharmacy, Science and Technology of Targu Mures, Romania

DOI: 10.2478/jccm-2020-0044

Introduction: Critically ill patients in intensive care units are at high risk of dying not only from the severity of their illness but also from secondary causes such as hospital-acquired infections. USA national medical record-data show that approximately 10% of patients on mechanical ventilation in an intensive care unit developed ventilator-associated pneumonia. Polymyxin B has been used intravenously in the treatment of multi-drug resistant gram-negative infections, either as a monotherapy or with other potentially effective antibiotics, and the recent international guidelines have emphasised the use of nebulised polymyxin B together with intravenous polymyxin B to gain the optimum clinical outcome in ventilator-associated pneumonia cases caused by multi-drug resistant gram-negative infections.
Methods: One hundred and seventy-eight patients with ventilator-associated pneumonia due to multi-drug resistant K. pneumoniae were identified during the study period. Following the inclusion and exclusion criteria, 121 patients were enrolled in the study and randomly allocated to two study groups. Group 1 patients were treated with intravenous Polymyxin B plus nebulised polymyxin B (n=64) and Group 2 patients with intravenous Polymyxin B alone (n=57). The study aimed to compare the use of Polymyxin B plus its nebulised form to polymyxin B alone, in the treatment of MDR-K. pneumoniae associated ventilator-associated pneumonia in critically ill patients.
Results: In Group 1, a complete clearance of K. pneumoniae was found in fifty-nine patients (92.1%; n=64) compared to forty patients (70.1%, n=57) in the Group 2 (P<0.003). The average time till extubation was significantly higher in Group 2 compared to Group 1 (P<0.05). The total length-of-stay in the ICU was significantly higher in Group 2 compared to Group 1. (P<0.05). These results support the view that the Polymyxin B dual-route regime may be considered as an appropriate antibiotic therapy, in critically ill South Asian patients with ventilator-associated pneumonia.

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Post-Traumatic Stress Disorder and Burnout in Healthcare Professionals During the SARS-CoV-2 Pandemic: A Cross-Sectional Study

Ioannis Ilias1, Vassiliki Mantziou2, Efstratios Vamvakas2, Efstathia Kampisiouli2, Maria Theodorakopoulou2, Chariklia Vrettou2, Evangelia Douka2, Alice G. Vassiliou2, Stylianos Orfanos2, Anastasia Kotanidou2, Ioanna Dimopoulou2

1 Elena Venizelou Hospital, Athens, Greece
2 National and Kapodistrian University of Athens

DOI: 10.2478/jccm-2020-0042

Introduction: Healthcare professionals who are directly involved in the diagnosis, treatment, and general care of patients with SARS-CoV-2 are at risk of developing adverse psychological reactions. A cross-sectional study of healthcare professionals aimed to determine the impact of the SARS-CoV-2 pandemic on the mental health of healthcare professionals in two of the largest referral hospitals in Athens, Greece.
Methods: The study was conducted in the two largest SARS-CoV-2 referral hospitals in Athens, Greece. An assessment and the interrelationship of post-traumatic stress disorder, using the Impact of Event Scale-Revised [IES-R]) and burnout, using the Maslach Burnout Inventory [MBI]) was carried out.
Results: A total of 162 subjects were enrolled in the study. Fifty-six (35%) had an IES-R score > 33, suggesting post-traumatic stress disorder. Forty-nine (30%) had an MBI score > 27. Seventy-five (46%) had a personal accomplishment score of < 33 and 46 (28%) had a depersonalization score >10. Stepwise backward logistic regression revealed that the only independent variable that was retained regarding the presence of post-traumatic stress disorder was the emotional exhaustion score of the MBI (at a cut-off of 24 in this scale, the 95% CI of the odds ratio for the presence of post-traumatic stress disorder was 1.077-1.173).
Conclusions: In this sample of first-line Greek healthcare professionals against SARS-CoV-2, most of them were proven to be quite resilient to this challenge. One-third of them had post-traumatic stress disorder, which depended on their degree of emotional exhaustion. Healthcare professionals, as represented by this study, performed their duties without feeling helpless and developing adverse psychological reactions.

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Atypical Variant of Guillain Barre Syndrome in a Patient with COVID-19

Megan M. Lowery1, Muhammad Taimur Malik2, Joseph Seemiller2, Cynthia S. Tsai1

1 Pulmonary/Critical Care Medicine, Geisinger Medical Center, Danville PA, USA
2 Geisinger Neuroscience Institute, Geisinger Medical Center, Danville, PA, USA

DOI: 10.2478/jccm-2020-0038

Objective: A rare variant Miller Fisher Syndrome overlap with Guillain Barre Syndrome is described in an adult patient with SARS-COV-2 infection.
Case Presentation: The clinical course of a 45-year-old immunosuppressed man is summarized as a patient who developed ataxia, ophthalmoplegia, and areflexia after upper respiratory infection symptoms began. A nasopharyngeal swab was positive for COVID-19 polymerase chain reaction. He progressed to acute hypoxemic and hypercapnic respiratory failure requiring intubation and rapidly developed tetraparesis. Magnetic resonance imaging of the spine was consistent with Guillain Barre Syndrome. However, the clinical symptoms, along with positive anti-GQ1B antibodies, were consistent with Miller Fisher Syndrome and Guillain Barre Syndrome overlap. The patient required tracheostomy and had limited improvement in his significant neurological symptoms after several months.
Conclusions: The case demonstrates the severe neurological implications, prolonged recovery and implications in the concomitant respiratory failure of COVID-19 patients with neurological symptoms on the spectrum of disorders of Guillain Barre Syndrome.

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Right Heart Thrombus in an Adult COVID-19 Patient: A Case Report

Enrico Merlo, Giuseppe Grutta, Ivo Tiberio, Gabriele Martelli

Intensive Care Unit “U.O.C. Anestesia e Rianimazione” Department of Medicine (DIMED) Padua University Hospital, Padua, Italy

DOI: 10.2478/jccm-2020-0039

Introduction: Right heart thrombus (RiHTh) can be considered a rare and severe condition associated with thromboembolic phenomena. A case is described of a COVID-19 patient presenting with an isolated thrombus in the right ventricle.
Case presentation: An 80-years-old Caucasian male was admitted in an intensive care unit (ICU) for COVID-19 related acute respiratory distress syndrome. The patient showed signs of hemodynamic instability, elevated cardiac troponin I and altered coagulation. On further assessment, a thrombotic mass near the apex of the right ventricle was detected. Moreover, the apex and the anteroseptal wall of the right ventricle appeared akinetic. Following the administration of a therapeutic dose of unfractionated heparin over a forty-eight hour period, re-evaluation of the right chambers showed that the thrombotic mass had resolved entirely.
Conclusion: COVID-19 patients could constitute a population at risk of RiHTh. Routine use of echocardiography and a multidisciplinary approach can improve the management of this condition.

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Acute Eosinophilic Pneumonia Due to Vaping-Associated Lung Injury

Molly Wolf, Jeremy Richards

Beth Israel Deaconess Medical Center, Boston, MA, USA

DOI: 10.2478/jccm-2020-0037

A case is described of a 29-year-old female who presented with acute hypoxic respiratory failure due to acute eosinophilic pneumonia, associated with the use of electronic cigarettes to vape tetrahydrocannabinol (THC), together with the contemporary clinical understanding of the syndrome of electronic-cigarette associated lung injury (EVALI). Attention is drawn to acute eosinophilic pneumonia as a potential consequence of vaping-associated lung injury to understand the diagnostic evaluations and therapeutic interventions for acute eosinophilic pneumonia associated with vaping THC.

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Cardiopulmonary Arrest Following a Single 25 mg Dose of Quetiapine: A Case Report

Pamela Chia1, Lim Chuan Poh2, John Ong3,4, Sharon Ong5,6

1 Division of Anaesthesiology and Perioperative Sciences, Singapore General Hospital, Singapore
2 Department of Pharmacy, Singapore General Hospital, Singapore
3 Department of Medicine, National University of Singapore, Singapore
4 Department of Engineering, University of Cambridge, Cambridge, United Kingdom
5 Department of Surgical Intensive Care, Singapore General Hospital, Singapore
6 Department of Surgical Intensive Care, Sengkang General Hospital, Singapore

DOI: 10.2478/jccm-2020-0035

Introduction: Quetiapine is commonly used in intensive care units (ICU) to treat delirium. Cardiopulmonary arrest caused by low dose quetiapine is unreported. Only two cases in the literature have reported acute respiratory failure after single doses of 50mg and 100mg respectively. We report a case of cardiopulmonary arrest in a patient after the administration of a single 25mg dose of quetiapine.
Case presentation: A 72-year-old Chinese female with multiple cardiovascular co-morbidities was admitted to the ICU intubated, following complications from an elective endovascular repair of an infrarenal abdominal aortic aneurysm. She was alert and extubated the following day. She subsequently showed signs of delirium and was administered a single 25mg dose of oral quetiapine. Seven hours after ingestion, she developed type 2 respiratory failure and eventually cardiopulmonary arrest. She was successfully resuscitated and other causes for cardiopulmonary arrest were excluded. Twenty-four hours following her cardiopulmonary arrest, her respiratory failure had completely reversed and she was extubated uneventfully.
Conclusion: This case report demonstrates that a single dose of oral quetiapine 25mg is sufficient to cause respiratory failure and cardiopulmonary arrest. Caution is advised when prescribing quetiapine in the elderly, especially in those with impaired drug clearance.

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Hemoadsorption in Critical Care – It Is a Useful or a Harmful Technique?

Judit Kovacs

Department of Anesthesiology and Intensive Care, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478/jccm-2020-0036

Since ancient times it has been known that elimination of toxins from the body helps to relieve symptoms, heal patients; for that hot baths, sweating techniques, enemas, and phlebotomy were used in the treatment of severe diseases.
Blood purification is still practiced today, but using modern techniques. The theoretical basis for the elimination of toxins by osmosis and dialysis through a semipermeable membrane was laid by Thomas Graham in the 19th century, but the first “artificial kidney”, was built and used successfully by Kolff only in 1943, in patients with acute renal failure.
Since then, blood purification has developed a lot, today it is possible to eliminate endo- and exotoxins in acute and chronic renal failure, liver failure, intoxications with various substances, but also the elimination of mediators formed in excess in sepsis and systemic inflammatory syndrome of other etiologies, and elimination of immune complexes in autoimmune and graft versus host diseases.

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The Prolonged Use of VV ECMO Support in COVID-19: A Case Report

Amelia Lucy Fitzgerald1, Hemal Hitesh Vachharajani1, Benjamin Paul Davidson1, Natalie Joanne Kruit1, Adam Trevor Eslick1,2

1 Westmead Hospital, Westmead, Sydney, New South Wales, Australia
2 Faculty of Medicine, University of Sydney, New South Wales, Australia

DOI: 10.2478/jccm-2020-0034

COVID-19 has resulted in unprecedented global health and economic challenges. The reported mortality in patients with COVID-19 requiring mechanical ventilation is high. VV ECMO may serve as a lifesaving rescue therapy for a minority of patients with COVID-19; however, its impact on overall survival of these patients is unknown. To date, few reports describe successful discharge from ECMO in COVID-19 after a prolonged ECMO run. The only Australian case of a COVID-19 patient, supported by prolonged VV ECMO in conjunction with prone ventilation, complicated by significant airway bleeding, and successfully decannulated after forty-two days, is described. VV ECMO is a resource-intense form of respiratory support. Providing complex therapies such as VV ECMO during a pandemic has its unique challenges. This case report provides a unique insight into the potential clinical sequelae of COVID-19, supported in an intensive care environment which was not resource-limited at the time, and adds to the evolving experience of prolonged VV ECMO support for ARDS with a goal to lung recovery.

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