Department of Anesthesiology and Intensive Care, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu-Mures, Romania
Target Controlled Infusion (TCI) represents a technique of intravenous anaesthetic drug administration where we aim a predictable concentration of the drug in a specific body compartment. The technique uses a computer-controlled infusion pump which delivers the anaesthetic drugs based on patient’s parameters (height, weight, age, gender and others) in order to achieve a predicted plasmatic level (TCIp) or a specific site (brain) (TCIe) . The main advantage of the system consists in theoretical calculations and application of precise doses. TCI is designed upon the three-compartmental pharmacokinetic model, maintaining the same level of sedation, and avoiding drugs accumulation. This delivery method could also reduce the intra-operative awareness, emphasising on patient safety. However, the practice showed that those theoretical facts may not be easily applied into clinical practice .[More]
The Aga Khan University Hospital, Karachi, Pakistan
Background: Covid-19 related acute respiratory distress syndrome (ARDS) requires intensive care, which is highly expensive in lower-income countries. Outcomes of COVID-19 patients requiring invasive mechanical ventilation in Pakistan have not been widely reported. Identifying factors forecasting outcomes will help decide optimal care levels and prioritise resources. Methods: A single-centre, retrospective study on COVID-19 patients requiring invasive mechanical ventilation was conducted from 1st March to 31st May 2020. Demographic variables, physical signs, laboratory values, ventilator parameters, complications, length of stay, and mortality were recorded. Data were analysed in SPSS ver.23. Results: Among 71 study patients, 87.3% (62) were males, and 12.7% (9) were females with a mean (SD) age of 55.5(13.4) years. Diabetes mellitus and hypertension were the most common comorbidities in 54.9% (39) patients. Median(IQR) SOFA score on ICU admission and at 48 hours was 7(5-9) and 6(4-10), and median (IQR) APACHE-II score was 15 (11-24) and 13(9-23), respectively. Overall, in-hospital mortality was 57.7%; 25% (1/4), 55.6% (20/36) and 64.5% (20/31) in mild, moderate, and severe ARDS, respectively. On univariate analysis; PEEP at admission, APACHE II and SOFA score at admission and 48 hours; Acute kidney injury; D-Dimer>1.5 mg/L and higher LDH levels at 48 hours were significantly associated with mortality. Only APACHE II scores at admission and D-Dimer levels> 1.5 mg/L were independent predictors of mortality on multivariable regression (p-value 0.012 & 0.037 respectively). Admission APACHE II scores, Area under the ROC curve for mortality was 0.80 (95%CI 0.69-0.90); sensitivity was 77.5% and specificity 70% (cut-off ≥13.5). Conclusion: There was a high mortality rate in severe ARDS. The APACHE II score can be utilised in mortality prediction in COVID-19 ARDS patients. However, larger-scale studies in Pakistan are required to assess predictors of mortality.
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.
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.
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.
Azza Sarfraz1,2, Zouina Sarfraz1,3, Aman Siddiqui1,4, Ali Totonchian4, Syed Hashim Abbas Ali Bokhari5, Hafiza Hussain3, Muzna Sarfraz1, Gaurav Patel1, Muhammad Hassaan Amjad6, Sameer Saleem Tebha1, Ivan Cherrez-Ojeda7,8, Patrick Dreyer1, Harshad Amin1, Jack Michel1
1 Larkin Health System, South Miami, FL, USA 2 Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan 3 Research and Publications, Fatima Jinnah Medical University, Lahore, Pakistan 4 Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan 5 School of Medicine, The Aga Khan University, Karachi, Pakistan 6 Neurosurgery, Sir Ganga Ram Hospital, Lahore, Pakistan 7 Allergy and Pulmonology, Universidad de Especialidades Espíritu Santo, Ecuador 8 Respiralab Research Center, Guayaquil, Ecuador
A case series is presented of five overweight or obese patients with confirmed coronavirus disease 2019 (COVID-19) in South Miami, Florida, United States. A multitude of coagulation parameters was suggestive of a hypercoagulable state among the hospitalized COVID-19 patients. This article reports various manifestations of hypercoagulable states in overweight and obese patients, such as overt bleeding consistent with disseminated intravascular coagulation, venous thromboembolism, gastrointestinal bleeding as well as retroperitoneal hematoma. All of the required admission to the intensive care unit and subsequently patients died. The characteristics of COVID-19-associated coagulopathy are atypical and warrant a further understanding of the pathophysiology to improve clinical outcomes, specifically in overweight or obese patients.
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