Association between early viral lower respiratory tract infections and subsequent asthma development

BACKGROUND

The association between hospitalization for human respiratory syncytial virus (HRSV) bronchiolitis in early childhood and subsequent asthma is well established. The long-term prognosis for non-bronchiolitis lower respiratory tract infections (LRTI) caused by viruses different from HRSV and rhinovirus, on the other hand, has received less interest.

AIM

To investigate the relationship between infant LRTI and later asthma and examine the influence of confounding factors.

METHODS

The PubMed and Global Index Medicus bibliographic databases were used to search for articles published up to October 2021 for this systematic review. We included cohort studies comparing the incidence of asthma between patients with and without LRTI at ≤ 2 years regardless of the virus responsible. The meta-analysis was performed using the random effects model. Sources of heterogeneity were assessed by stratified analyses.

RESULTS

This review included 15 articles (18 unique studies) that met the inclusion criteria. LRTIs at ≤ 2 years were associated with an increased risk of subsequent asthma up to 20 years [odds ratio (OR) = 5.0, 95%CI: 3.3-7.5], with doctor-diagnosed asthma (OR = 5.3, 95%CI: 3.3-8.6), current asthma (OR = 5.4, 95%CI: 2.7-10.6), and current medication for asthma (OR = 1.2, 95%CI: 0.7-3.9). Our overall estimates were not affected by publication bias (P = 0.671), but there was significant heterogeneity [I² = 58.8% (30.6-75.5)]. Compared to studies with hospitalized controls without LRTI, those with ambulatory controls had a significantly higher strength of association between LRTIs and subsequent asthma. The strength of the association between LRTIs and later asthma varied significantly by country and age at the time of the interview. The sensitivity analyses including only studies with similar proportions of confounding factors (gender, age at LRTI development, age at interview, gestational age, birth weight, weight, height, smoking exposure, crowding, family history of atopy, and family history of asthma) between cases and controls did not alter the overall estimates.

CONCLUSION

Regardless of the causative virus and confounding factors, viral LRTIs in children < 2 years are associated with an increased risk of developing a subsequent asthma. Parents and pediatricians should be informed of this risk.

Ideal scoring system for acute pancreatitis: Quest for the Holy Grail

Clinical scoring systems are required to predict complications, severity, need for intensive care unit admission, and mortality in patients with acute pancreatitis. Over the years, many scores have been developed, tested, and compared for their efficacy and accuracy. An ideal score should be rapid, reliable, and validated in different patient populations and geographical areas and should not lose relevance over time. A combination of scores or serial monitoring of a single score may increase their efficacy.

Diuretic combinations in critically ill patients with respiratory failure: A systematic review and meta-analysis

BACKGROUND

In patients with respiratory failure, loop diuretics remain the cornerstone of the treatment to maintain fluid balance, but resistance is common.

AIM

To determine the efficacy and safety of common diuretic combinations in critically ill patients with respiratory failure.

METHODS

We searched MEDLINE, Embase, Cochrane Library and PROSPERO for studies reporting the effects of a combination of a loop diuretic with another class of diuretic. A meta-analysis using mean differences (MD) with 95% confidence interval (CI) was performed for the 24-h fluid balance (primary outcome) and the 24-h urine output, while descriptive statistics were used for safety events.

RESULTS

Nine studies totalling 440 patients from a total of 6510 citations were included. When compared to loop diuretics alone, the addition of a second diuretic is associated with an improved negative fluid balance at 24 h [MD: -1.06 L (95%CI: -1.46; -0.65)], driven by the combination of a thiazide plus furosemide [MD: -1.25 L (95%CI: -1.68; -0.82)], while no difference was observed with the combination of a loop-diuretic plus acetazolamide [MD: -0.40 L (95%CI: -0.96; 0.16)] or spironolactone [MD: -0.65 L (95%CI: -1.66; 0.36)]. Heterogeneity was high and the report of clinical and safety endpoints varied across studies.

CONCLUSION

Based on limited evidence, the addition of a second diuretic to a loop diuretic may promote diuresis and negative fluid balance in patients with respiratory failure, but only when using a thiazide. Further larger trials to evaluate the safety and efficacy of such interventions in patients with respiratory failure are required.

Ball-shaped right atrial mass in renal cell carcinoma: A case report

BACKGROUND

Renal cell carcinoma (RCC) is an aggressive tumor, with an incidental discovery in most patients. Classic presentation is rare, and it has a high frequency of local and distant metastasis at the time of detection.

CASE SUMMARY

We present a rare case of a 58-year-old man with a ball-shaped thrombus in the right atrium at the time of first incidental identification of RCC in the emergency department. Cardiac metastasis, especially thrombus in the right atrium, is rare. It could either be a bland thrombus or a tumor thrombus, and physicians should consider this potentially fatal complication of RCC early at the time of initial presentation.

CONCLUSION

Ball-shaped lesions in the right atrium are rare, and bland thrombus should be differentiated from tumor thrombus secondary to intracardiac metastasis.

Stress cardiomyopathy in critical care: A case series of 109 patients

BACKGROUND

Critically ill patients are at risk of developing stress cardiomyopathy (SC) but can be under-recognized.

AIM

To describe a case series of patients with SC admitted to critical care units.

METHODS

We conducted a retrospective observational study at a tertiary care teaching hospital. All adult (≥ 18 years old) patients admitted to the critical care units with stress cardiomyopathy over 5 years were included.

RESULTS

Of 24279 admissions to the critical care units [19139 to medical-surgical intensive care units (MSICUs) and 5140 in coronary care units (CCUs)], 109 patients with SC were identified. Sixty (55%) were admitted to the coronary care units (CCUs) and forty-nine (45%) to the medical-surgical units (MSICUs). The overall incidence of SC was 0.44%, incidence in CCU and MSICU was 1.16% and 0.25% respectively. Sixty-two (57%) had confirmed SC and underwent cardiac catheterization whereas 47 (43%) had clinical SC, and did not undergo cardiac catheterization. Forty-three (72%) patients in the CCUs were diagnosed with primary SC, whereas all (100%) patients in MSICUs developed secondary SC. Acute respiratory failure that required invasive mechanical ventilation and shock developed in twenty-nine (59%) MSICU patients. There were no statistically significant differences in intensive care unit (ICU) mortality, in-hospital mortality, use of inotropic or mechanical circulatory support based on type of unit or anatomical variant.

CONCLUSION

Stress cardiomyopathy can be under-recognized in the critical care setting. Intensivists should have a high index of suspicion for SC in patients who develop sudden or worsening unexplained hemodynamic instability, arrhythmias or respiratory failure in ICU.

Plasma D-dimer level in early and late-onset neonatal sepsis

BACKGROUND

Neonatal sepsis is a life-threatening disease. Early diagnosis is essential, but no single marker of infection has been identified. Sepsis activates a coagulation cascade with simultaneous production of the D-dimers due to lysis of fibrin. D-dimer test reflects the activation of the coagulation system.

AIM

To assess the D-dimer plasma level, elaborating its clinicopathological value in neonates with early-onset and late-onset neonatal sepsis.

METHODS

The study was a prospective cross-sectional study that included ninety neonates; divided into three groups: Group I: Early-onset sepsis (EOS); Group II: Late-onset sepsis (LOS); and Group III: Control group. We diagnosed neonatal sepsis according to our protocol. C-reactive protein (CRP) and D-dimer assays were compared between EOS and LOS and correlated to the causative microbiological agents.

RESULTS

D-dimer was significantly higher in septic groups with a considerably higher number of cases with positive D-dimer. Neonates with LOS had substantially higher levels of D-dimer than EOS, with no significant differences in CRP. Neonates with LOS had a significantly longer hospitalization duration and higher gram-negative bacteriemia and mortality rates than EOS (P < 0.01). Gram-negative bacteria have the highest D-dimer levels (Acinetobacter, Klebsiella, and Pseudomonas) and CRP (Serratia, Klebsiella, and Pseudomonas); while gram-positive sepsis was associated with relatively lower levels. D-dimer had a significant negative correlation with hemoglobin level and platelet count; and a significant positive correlation with CRP, hospitalization duration, and mortality rates. The best-suggested cut-off point for D-dimer in neonatal sepsis was 0.75 mg/L, giving a sensitivity of 72.7% and specificity of 86.7%. The D-dimer assay has specificity and sensitivity comparable to CRP in the current study.

CONCLUSION

The current study revealed a significant diagnostic value for D-dimer in neonatal sepsis. D-dimer can be used as an adjunct to other sepsis markers to increase the sensitivity and specificity of diagnosing neonatal sepsis.

Presentation and outcome of myocardial infarction with non-obstructive coronary arteries in coronavirus disease 2019

Among the cardiac complications of coronavirus disease 2019 (COVID-19), one increasingly reported in the literature is myocardial infarction with non-obstructive coronaries (MINOCA). We reviewed all reported cases of MINOCA in COVID-19 patients to summarize its clinical features, evaluation, and treatment. We performed a literature search in Pubmed using the search terms ‘COVID-19’ and ‘MINOCA’ or ‘non-obstructive coronaries’. Among the reported cases, the mean age was 61.5 years (SD ± 13.4), and 50% were men. Chest pain was the presenting symptom in five patients (62.5%), and hypertension was the most common comorbidity (62.5%). ST-elevation was seen in most patients (87.5%), and the overall mortality rate was 37.5%. MINOCA in COVID-19 is an entity with a broad differential diagnosis. Therefore, a uniform algorithm is needed in its evaluation to ensure timely diagnosis and management.

Need for oxygen therapy and ventilatory support in premature infants in a hospital in Southern Brazil

BACKGROUND

Prematurity in newborns is a condition that is associated with worse hospital outcomes when compared to birth to term. A preterm infant (PI) is classified when gestational age (GA) < 37 wk.

AIM

To analyze prognostic indicators related to the use of oxygen therapy, non-invasive ventilation (continuous positive airway pressure) and mechanical ventilation (MV) in PI.

METHODS

This is a retrospective cohort. The sample was composed of PIs from a private hospital in southern Brazil. We included neonates with GA < 37 wk of gestation in the period of January 1, 2018 to December 31, 2018. For data collection, electronic records were used in the Tasy Philips^TM system, identifying the variables: maternal age, type of birth, prenatal information, GA, Apgar score, birth weight, neonatal morbidities, vital signs in the 1st hour at birth, need for oxygen therapy, continuous positive airway pressure and MV, hospitalization in the neonatal intensive care unit, length of stay and discharge or death.

RESULTS

In total, 90 PI records were analyzed. The median (p25-p75) of GA was 34.0 (31.9-35.4) wk, and there were 45 (50%) males. The most common morbidity among PIs was the acute respiratory discomfort syndrome, requiring hospitalization in the neonatal intensive care unit in 76 (84.4%) cases. The utilization rate of oxygen therapy, continuous positive airway pressure and MV was 12 (13.3%), 37 (41.1%) and 13 (14.4%), respectively. The median (p25-p75) length of stay was 12.0 (5.0-22.2) d, with 10 (11.1%) deaths. A statistical association was observed with the use of MV and GA < 28 wk, lower maternal age, low birth weight, Apgar < 8 and neonatal deaths.

CONCLUSION

The identification of factors related to the need for MV in prematurity may help in the indication of a qualified team and technologies to promptly meet the unforeseen events that may occur after birth.

Cough as a neurological sign: What a clinician should know

Cough is a common respiratory complaint driving patients to seek medical advice. Besides being a fundamental respiratory sign, it is also a crucial neurological sign. There are three main types of coughs: Reflex cough (type I), voluntary cough (type II), and evoked cough (type III). Cough is a reflex predominantly mediated by control centers in the respiratory areas of the brainstem, modulated by the cerebral cortex. Cough reflex sensitivity could be increased in many neurological disorders such as brainstem space-occupying lesions, medullary lesions secondary to Chiari type I malformations, tics disorders such as Tourette's syndrome, somatic cough, cerebellar neurodegenerative diseases, and chronic vagal neuropathy due to allergic and non-allergic conditions. Meanwhile, cough sensitivity decreases in multiple sclerosis, brain hypoxia, cerebral hemispheric stroke with a brainstem shock, Parkinson's disease, dementia due to Lewy body disease, amyotrophic lateral sclerosis, and peripheral neuropathy as diabetic neuropathy, hereditary sensory and autonomic neuropathy type IV, vitamin B12, and folate deficiency. Arnold's nerve ear-cough reflex, syncopal cough, cough headache, opioids-associated cough, and cough-anal reflex are signs that could help diagnose underlying neurological conditions. Cough reflex testing is a quick, easy, and cheap test performed during the cranial nerve examination. In this article, we reviewed the role of cough in various neurological disorders that increase or decrease cough sensitivity.

Critical care practices in the world: Results of the global intensive care unit need assessment survey 2020

BACKGROUND

There is variability in intensive care unit (ICU) resources and staffing worldwide. This may reflect variation in practice and outcomes across all health systems.

AIM

To improve research and quality improvement measures administrative leaders can create long-term strategies by understanding the nature of ICU practices on a global scale.

METHODS

The Global ICU Needs Assessment Research Group was formed on the basis of diversified skill sets. We aimed to survey sites regarding ICU type, availability of staffing, and adherence to critical care protocols. An international survey ‘Global ICU Needs Assessment’ was created using Google Forms, and this was distributed from February 17^th, 2020 till September 23^rd, 2020. The survey was shared with ICU providers in 34 countries. Various approaches to motivating healthcare providers were implemented in securing submissions, including use of emails, phone calls, social media applications, and WhatsApp™. By completing this survey, providers gave their consent for research purposes. This study was deemed eligible for category-2 Institutional Review Board exempt status.

RESULTS

There were a total 121 adult/adult-pediatrics ICU responses from 34 countries in 76 cities. A majority of the ICUs were mixed medical-surgical [92 (76%)]. 108 (89%) were adult-only ICUs. Total 36 respondents (29.8%) were 31-40 years of age, with 79 (65%) male and 41 (35%) female participants. 89 were consultants (74%). A total of 71 (59%) respondents reported having a 24-h in-house intensivist. A total of 87 (72%) ICUs were reported to have either a 2:1 or ≥ 2:1 patient/nurse ratio. About 44% of the ICUs were open and 76% were mixed type (medical-surgical). Protocols followed regularly by the ICUs included sepsis care (82%), ventilator-associated pneumonia (79%); nutrition (76%), deep vein thrombosis prophylaxis (84%), stress ulcer prophylaxis (84%), and glycemic control (89%).

CONCLUSION

Based on the findings of this international, multi-dimensional, needs-assessment survey, there is a need for increased recruitment and staffing in critical care facilities, along with improved patient-to-nurse ratios. Future research is warranted in this field with focus on implementing appropriate health standards, protocols and resources for optimal efficiency in critical care worldwide.

Retrospective analysis of aspirin's role in the severity of COVID-19 pneumonia

BACKGROUND

Since December 2019, an outbreak of pneumonia caused by severe acute respiratory syndrome - coronavirus-2 (SARS-CoV-2) has led to a life-threatening ongoing pandemic worldwide. A retrospective study by Chow et al showed aspirin use was associated with decreased intensive care unit (ICU) admissions in hospitalized coronavirus disease 2019 (COVID-19) patients. Recently, the RECOVERY TRIAL showed no associated reductions in the 28-d mortality or the progression to mechanical ventilation of such patients. With these conflicting findings, our study was aimed at evaluating the impact of daily aspirin intake on the outcome of COVID-19 patients.

AIM

To study was aimed at evaluating the impact of daily aspirin intake on the outcome of COVID-19 patients.

METHODS

This retrospective cohort study was conducted on 125 COVID-19 positive patients. Subgroup analysis to evaluate the association of demographics and comorbidities was undertaken. The impact of chronic aspirin use was assessed on the survival outcomes, need for mechanical ventilation, and progression to ICU. Variables were evaluated using the chi-square test and multinomial logistic regression analysis.

RESULTS

125 patients were studied, 30.40% were on daily aspirin, and 69.60% were not. Cross-tabulation of the clinical parameters showed that hypertension (P = 0.004), hyperlipidemia (0.016), and diabetes mellitus (P = 0.022) were significantly associated with aspirin intake. Regression analysis for progression to the ICU, need for mechanical ventilation and survival outcomes against daily aspirin intake showed no statistical significance.

CONCLUSION

Our study suggests that daily aspirin intake has no protective impact on COVID-19 illness-associated survival outcomes, mechanical ventilation, or progression to ICU level of care.

Treatment with neurohormonal inhibitors and prognostic outcome in pulmonary arterial hypertension with risk factors for left heart disease

BACKGROUND

Despite major advances in pharmacologic treatment, patients with pulmonary arterial hypertension (PAH) still have a considerably reduced life expectancy. In this context, chronic hyperactivity of the neurohormonal axis has been shown to be detrimental in PAH, thus providing novel insights on the role of neurohormonal blockade as a potential therapeutic target.

AIM

To evaluate the application and prognostic effect of neurohormonal inhibitors (NEUi) in a single-center sample of patients with idiopathic PAH and risk factors for left heart disease.

METHODS

We analyzed data retrospectively collected from our register of right heart catheterizations performed consecutively from January 1, 2005 to October 31, 2018. Patients on beta-blocker, angiotensin-converting enzyme inhibitor, angiotensin receptor blocker or mineralocorticoid receptor antagonist at the time of right heart catheterization were classified as NEUi users and compared to NEUi non-recipients.

RESULTS

Complete data were available for 57 PAH subjects: 27 of those (47.4%) were taking at least one NEUi at the time of right heart catheterization and were compared with the remaining 36 NEUi non-recipients. NEUi users were older and had a higher cardiovascular risk profile compared to non-recipients. Additionally, NEUi non-users had a higher probability of dying during the course of follow-up than NEUi recipients (56.7% vs 25.9%, log-rank P = 0.020).

CONCLUSION

The above data highlighted a subgroup of patients with PAH and comorbidities for left heart disease in which NEUi use has shown to be associated with improved survival. Future prospective studies are needed to identify the most appropriate therapeutic strategies in this subset population.

Association of latitude and altitude with adverse outcomes in patients with COVID-19: The VIRUS registry

BACKGROUND

The coronavirus disease 2019 (COVID-19) course may be affected by environmental factors. Ecological studies previously suggested a link between climatological factors and COVID-19 fatality rates. However, individual-level impact of these factors has not been thoroughly evaluated yet.

AIM

To study the association of climatological factors related to patient location with unfavorable outcomes in patients.

METHODS

In this observational analysis of the Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study: COVID-19 Registry cohort, the latitudes and altitudes of hospitals were examined as a covariate for mortality within 28 d of admission and the length of hospital stay. Adjusting for baseline parameters and admission date, multivariable regression modeling was utilized. Generalized estimating equations were used to fit the models.

RESULTS

Twenty-two thousand one hundred eight patients from over 20 countries were evaluated. The median age was 62 (interquartile range: 49-74) years, and 54% of the included patients were males. The median age increased with increasing latitude as well as the frequency of comorbidities. Contrarily, the percentage of comorbidities was lower in elevated altitudes. Mortality within 28 d of hospital admission was found to be 25%. The median hospital-free days among all included patients was 20 d. Despite the significant linear relationship between mortality and hospital-free days (adjusted odds ratio (aOR) = 1.39 (1.04, 1.86), P = 0.025 for mortality within 28 d of admission; aOR = -1.47 (-2.60, -0.33), P = 0.011 for hospital-free days), suggesting that adverse patient outcomes were more common in locations further away from the Equator; the results were no longer significant when adjusted for baseline differences (aOR = 1.32 (1.00, 1.74), P = 0.051 for 28-day mortality; aOR = -1.07 (-2.13, -0.01), P = 0.050 for hospital-free days). When we looked at the altitude’s effect, we discovered that it demonstrated a non-linear association with mortality within 28 d of hospital admission (aOR = 0.96 (0.62, 1.47), 1.04 (0.92, 1.19), 0.49 (0.22, 0.90), and 0.51 (0.27, 0.98), for the altitude points of 75 MASL, 125 MASL, 400 MASL, and 600 MASL, in comparison to the reference altitude of 148 m.a.s.l, respectively. P = 0.001). We detected an association between latitude and 28-day mortality as well as hospital-free days in this worldwide study. When the baseline features were taken into account, however, this did not stay significant.

CONCLUSION

Our findings suggest that differences observed in previous epidemiological studies may be due to ecological fallacy rather than implying a causal relationship at the patient level.

Potential role of vitamin D in patients with diabetes, dyslipidaemia, and COVID-19

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus-2 has become a worldwide public health crisis. Studies have demonstrated that diabetes and dyslipidaemia are common comorbidities and could be high-risk factors for severe COVID-19. Vitamin D, a group of fat-soluble compounds responsible for intestinal absorption of calcium, magnesium, and phosphate, has been widely used as a dietary supplement for the prevention and treatment of numerous diseases, including infectious and non-infectious diseases, due to its high cost-effectiveness; safety; tolerability; and anti-thrombotic, anti-inflammatory, antiviral, and immunomodulatory properties. In this letter to the editor, we mainly discuss the potential role of vitamin D in patients with diabetes, dyslipidaemia, and COVID-19.

Point-of-care ultrasound for critically-ill patients: A mini-review of key diagnostic features and protocols

Point-of-care ultrasonography (POCUS) for managing critically ill patients is increasingly performed by intensivists or emergency physicians. Results of needs surveys among intensivists reveal emphasis on basic cardiac, lung and abdominal ultrasound, which are the commonest POCUS modalities in the intensive care unit. We therefore aim to describe the key diagnostic features of basic cardiac, lung and abdominal ultrasound as practised by intensivists or emergency physicians in terms of accuracy (sensitivity, specificity), clinical utility and limitations. We also aim to explore POCUS protocols that integrate basic cardiac, lung and abdominal ultrasound, and highlight areas for future research.

Precision medicine in sepsis and septic shock: From omics to clinical tools

Sepsis is a heterogeneous disease with variable clinical course and several clinical phenotypes. As it is associated with an increased risk of death, patients with this condition are candidates for receipt of a very well-structured and protocolized treatment. All patients should receive the fundamental pillars of sepsis management, which are infection control, initial resuscitation, and multiorgan support. However, specific subgroups of patients may benefit from a personalized approach with interventions targeted towards specific pathophysiological mechanisms. Herein, we will review the framework for identifying subpopulations of patients with sepsis, septic shock, and multiorgan dysfunction who may benefit from specific therapies. Some of these approaches are still in the early stages of research, while others are already in routine use in clinical practice, but together will help in the effective generation and safe implementation of precision medicine in sepsis.

Endotracheal intubation sedation in the intensive care unit

Endotracheal intubation is one of the most common, yet most dangerous procedure performed in the intensive care unit (ICU). Complications of ICU intubations include severe hypotension, hypoxemia, and cardiac arrest. Multiple observational studies have evaluated risk factors associated with these complications. Among the risk factors identified, the choice of sedative agents administered, a modifiable risk factor, has been reported to affect these complications (hypotension). Propofol, etomidate, and ketamine or in combination with benzodiazepines and opioids are commonly used sedative agents administered for endotracheal intubation. Propofol demonstrates rapid onset and offset, however, has drawbacks of profound vasodilation and associated cardiac depression. Etomidate is commonly used in the critically ill population. However, it is known to cause reversible inhibition of 11 β-hydroxylase which suppresses the adrenal production of cortisol for at least 24 h. This added organ impairment with the use of etomidate has been a potential contributing factor for the associated increased morbidity and mortality observed with its use. Ketamine is known to provide analgesia with sedation and has minimal respiratory and cardiovascular effects. However, its use can lead to tachycardia and hypertension which may be deleterious in a patient with heart disease or cause unpleasant hallucinations. Moreover, unlike propofol or etomidate, ketamine requires organ dependent elimination by the liver and kidney which may be problematic in the critically ill. Lately, a combination of ketamine and propofol, “Ketofol”, has been increasingly used as it provides a balancing effect on hemodynamics without any of the side effects known to be associated with the parent drugs. Furthermore, the doses of both drugs are reduced. In situations where a difficult airway is anticipated, awake intubation with the help of a fiberoptic scope or video laryngoscope is considered. Dexmedetomidine is a commonly used sedative agent for these procedures.

Epidemiology of electrical burns and its impact on quality of life - the developing world scenario

BACKGROUND

Electrical burns are devastating injuries and can cause deep burns with significant morbidity and delayed sequelae. Epidemiological data regarding the etiology, socioeconomic differences and geographic variation are necessary to assess the disease burden and plan an effective preventive strategy. These severe injuries often lead to amputations and thus hamper quality of life in the long term

AIM

To identify the population at maximum risk of sustaining electrical burns. We also studied the impact of electrical burns on these patients in terms of quality of life as well as return to work.

METHODS

The study was conducted at a tertiary referral teaching hospital over a period of eighteen months. All patients with a history of sustaining electrical burns and satisfying the inclusion criteria were included in the study. All relevant epidemiological parameters and treatment details were recorded. The patients were subsequently followed up at 3 mo, 6 mo and 9 mo. The standardized Brief Version of the Burn Specific Health Scale (BSHS-B) was adopted to assess quality of life. Statistical analysis was conducted using IBM SPSS statistics (version 22.0). A P value of < 0.05 was considered statistically significant.

RESULTS

A total of 103 patients were included in the study. The mean age of the patients was 31.83 years (range 18-75 years). A significant majority (91.3%) of patients were male. The mean total body surface area (TBSA) in these patients was 21.1%. In most of the patients (67%), the injury was occupation-related. High voltage injuries were implicated in 72.8% of patients. Among the 75 high voltage burn patients, 31 (41%) required amputation. The mean number of surgeries the patients underwent in hospital was 2.03 (range 1 to 4). The quality of life parameters amongst the patients sustaining high voltage electrical burns were poorer when compared to low voltage injuries at all follow-up intervals across nine domains. In eight of these domains, the difference was statistically significant. Similarly, the scores among the amputees were poorer when compared to non-amputees. The difference was statistically significant in six domains.

CONCLUSION

Electrical burns remain a problem in the developing world. Most injuries are occupation-related. The quality of life in patients with high voltage burns and amputees remains poor. Work resumption was almost impossible for amputees. These patients could not regain pre-injury status. Steps should be taken to create awareness and to implement an effective preventive strategy to safeguard against electrical injuries.

Efficacy of remdesivir for hospitalized COVID-19 patients with end stage renal disease

BACKGROUND

Since the beginning of corona virus disease 2019 (COVID-19) pandemic, there has been a widespread use of remdesivir in adults and children. There is little known information about its outcomes in patients with end stage renal disease who are on dialysis.

AIM

To assess the clinical outcomes with use of remdesivir in adult patients with end stage kidney failure on hemodialysis.

METHODS

A retrospective, multicenter study was conducted on patients with end stage renal disease on hemodialysis that were discharged after treatment for COVID-19 between April 1, 2020 and December 31, 2020. Primary endpoints were oxygen requirements, time to mortality and escalation of care needing mechanical ventilation.

RESULTS

A total of 45 patients were included in the study. Twenty patients received remdesivir, and 25 patients did not receive remdesivir. Most patients were caucasian, females with diabetes mellitus and hypertension being the commonest comorbidities. There was a trend towards reduced oxygen requirement (beta = -25.93, X² (1) = 6.65, P = 0.0099, probability of requiring mechanical ventilation (beta = -28.52, X² (1) = 22.98, P < 0.0001) and mortality (beta = -5.03, X² (1) = 7.41, P = 0.0065) in patients that received remdesivir compared to the control group.

CONCLUSION

Larger studies are justified to study the effects of remdesivir in this high-risk population with end stage kidney disease on dialysis.

Medico-legal risks associated to hand and wrist trauma

BACKGROUND

Acute hand and wrist injuries are common and may lead to long-term disability if not managed adequately. Claims for negligence have been increasing in medical practice over the past few decades, with hand and wrist injuries and their treatment representing a significant percentage of orthopedic surgery lawsuits. There is no available literature regarding medical malpractice claims in hand and wrist injuries and surgery in Greece.

AIM

To identify claims related to hand and wrist trauma and surgery and to define the reasons of successful litigations.

METHODS

We performed a retrospective study of all legal claims of negligence for hand and upper extremity surgery that went to a trial, attributed to all surgical specialties, in Greece for a 20-year period. Data was further analyzed to identify claims related to hand and wrist trauma and surgery.

RESULTS

There were six malpractice claims related to hand and wrist trauma that ended in a trial. A missed diagnosis, which resulted in failure of initial management of the injury, was the main reason for a claim. Three of the six cases resulted in complete or partial loss of a finger. Two cases are still open, requiring an expert witness’s report, two cases were closed in favor of the defendant, and two cases were closed in favor of the plaintiff with a mean compensation of €2000 (€1000-€3000).

CONCLUSION

Missed diagnosis was the main reason for a malpractice claim. Better understanding of factors leading to successful claims will help surgeons improve their practice to minimize legal implications and litigation.

Acute exacerbation of interstitial lung disease in the intensive care unit

Acute exacerbations of interstitial lung disease (AE-ILD) represent an acute, frequent and often highly morbid event in the disease course of ILD patients. Admission in the intensive care unit (ICU) is very common and the need for mechanical ventilation arises early. While non-invasive ventilation has shown promise in staving off intubation in selected patients, it is unclear whether mechanical ventilation can alter the exacerbation course unless it is a bridge to lung transplantation. Risk stratification using clinical and radiographic findings, and early palliative care involvement, are important in ICU care. In this review, we discuss many of the pathophysiological aspects of AE-ILD and raise the hypothesis that ventilation strategies used in acute respiratory distress syndrome might be implemented in AE-ILD. We present possible decision-making and management algorithms that can be used by the intensivist when caring for these patients.

Intensive care unit hospitalizations and outcomes in patients with severe COVID-19 during summer and fall surges in Georgia

BACKGROUND

There is limited data on the difference in the clinical characteristics and outcomes of patients with severe coronavirus disease 2019 (COVID-19) infection in the summer compared to the fall surge.

AIM

To compare the sociodemographic, clinical characteristics, and outcomes among mechanically ventilated patients with severe COVID-19 infection admitted to the intensive care unit (ICU) during the summer and fall surges in the year 2020.

METHODS

We included patients admitted to the ICU and treated with invasive mechanical ventilation for COVID-19 associated respiratory failure between April 1 and December 31, 2020. Patients were categorized into summer surge for ICU admissions between June 15, 2020, and August 15, 2020, and fall surge between October 15, 2020, and December 31, 2020. We compared patients' characteristics and outcomes using descriptive and inferential statistics.

RESULTS

A total of 220 patients were admitted to the Grady Memorial Hospital ICU and mechanically ventilated for COVID-19 associated hypoxemic respiratory failure during the period considered (125 during the summer surge and 95 during the fall surge). More women were admitted in the fall compared to summer (41.1% vs 36.8%, difference, 4.3%; 95%CI: 1.2, 7.5). Patients admitted in the fall had fewer comorbidities (chronic obstructive pulmonary disease, stroke, diabetes mellitus, obstructive sleep apnea and body mass index ≥ 35 kg/m²). Overall, patients in the fall had a lower ICU mortality rate (27.4% vs 38.4%, difference, -11.0; 95%CI: -6.4, -18.2), shorter length of stay on the mechanical ventilator (7 d vs 11 d, difference, 4 d; 95%CI: 2.1, 6.6) and shorter ICU length of stay (9 d vs 14 d, difference, 5 d; 95%CI: 2.7, 9.4).

CONCLUSION

Patients admitted with severe COVID-19 infection requiring mechanical ventilation had better outcomes in the fall than summer. This difference observed is likely attributable to a better understanding of the condition and advances in treatment strategies.

Point of care venous Doppler ultrasound: Exploring the missing piece of bedside hemodynamic assessment

Accurate assessment of the hemodynamic status is vital for appropriate management of patients with critical illness. As such, there has been a constant quest for reliable and non-invasive bedside tools to assess and monitor circulatory status in order to ensure end-organ perfusion. In the recent past, point of care ultrasonography (POCUS) has emerged as a valuable adjunct to physical examination in various specialties, which basically is a clinician-performed bedside ultrasound to answer focused questions. POCUS allows visualization of the internal anatomy and flow dynamics in real time, guiding apt interventions. While both arterial (forward flow) and venous (organ outflow or afterload) limbs of hemodynamic circuit are important for tissue perfusion, the venous side remains relatively under-explored. With recent data underscoring the deleterious consequences of iatrogenic volume overload, objective evaluation of venous congestion is gaining attention. Bedside Doppler ultrasound serves this purpose and aids in diagnosing and monitoring the congestion/venous blood flow pattern. In this article, we summarize the rationale for integrating this technology into routine care of patients with volume-related disorders, discuss the normal and abnormal waveforms, limitations, and future directions.

Management of genitourinary trauma – current evaluation from the Sub-Saharan region: A systematic review

BACKGROUND

Trauma is a major cause of morbidity globally and the sixth leading cause of death, accounting for 10% of all mortalities. The genitourinary trauma is estimated for approximately 10% of all patients presenting with trauma, and the kidney is the most injured genitourinary organ globally. However, there is a paucity of data on genitourinary injury from the Sub-Saharan, and there may be variations from common genitourinary organs injured in developed nations.

AIM

To provide insight on the epidemiology and management of genitourinary trauma in Sub-Saharan Africa with recommendations based on international guidelines.

METHODS

A thorough literature search of genitourinary trauma was conducted using PubMed, Google Scholar and African Journal Online.

RESULTS

A total of 30 studies from the Sub-Saharan region were eligible for the study and reviewed for epidemiology, biodata, types of injury, mechanisms of injury, treatment and follow-up. After evaluating 21904 patients presenting with urological emergencies, approximately 6.6% of cases were due to genitourinary trauma. The commonest injury was urethral 42.9% (22.2-62.2%) followed by injury to the external genitalia (penis, scrotum, testes) 25.1% (8.8-67.7%).

CONCLUSION

Genitourinary injury in Sub-Saharan Africa is underreported, and the presence of more trauma registries, trained urologists and trauma facilities could improve the overall standard of care as well as providing data for research and development in the field.

Recovery after acute kidney injury requiring kidney replacement therapy in patients with left ventricular assist device: A meta-analysis

BACKGROUND

Acute kidney injury (AKI) is a common and severe complication after left ventricular assist device (LVAD) implantation with an incidence of 37%; 13% of which require kidney replacement therapy (KRT). Severe AKI requiring KRT (AKI-KRT) in LVAD patients is associated with high short and long-term mortality compared with AKI without KRT. While kidney function recovery is associated with better outcomes, its incidence is unclear among LVAD patients with severe AKI requiring KRT.

AIM

To identify studies evaluating the recovery rates from severe AKI-KRT after LVAD placement, which is defined by regained kidney function resulting in the discontinuation of KRT. Random-effects and generic inverse variance method of DerSimonian-Laird were used to combine the effect estimates obtained from individual studies.

METHODS

A total of 268 patients from 14 cohort studies that reported severe AKI-KRT after LVAD were included. Follow-up time ranged anywhere from two weeks of LVAD implantation to 12 mo. Kidney recovery occurred in 78% of enrollees at the time of hospital discharge or within 30 d. Overall, the pooled estimated AKI recovery rate among patients with severe AKI-KRT was 50.5% (95%CI: 34.0%-67.0%) at 12 mo follow up. Majority (85%) of patients used continuous-flow LVAD. While the data on pulsatile-flow LVAD was limited, subgroup analysis of continuous-flow LVAD demonstrated that pooled estimated AKI recovery rate among patients with severe AKI-KRT was 52.1% (95%CI: 36.8%-67.0%). Meta-regression analysis did not show a significant association between study year and AKI recovery rate (P = 0.08). There was no publication bias as assessed by the funnel plot and Egger's regression asymmetry test in all analyses.

RESULTS

A total of 268 patients from 14 cohort studies that reported severe AKI-KRT after LVAD were included. Follow-up time ranged anywhere from two weeks of LVAD implantation to 12 mo. Kidney recovery occurred in 78% of enrollees at the time of hospital discharge or within 30 d. Overall, the pooled estimated AKI recovery rate among patients with severe AKI-KRT was 50.5% (95%CI: 34.0%-67.0%) at 12 mo follow up. Majority (85%) of patients used continuous-flow LVAD. While the data on pulsatile-flow LVAD was limited, subgroup analysis of continuous-flow LVAD demonstrated that pooled estimated AKI recovery rate among patients with severe AKI-KRT was 52.1% (95%CI: 36.8%-67.0%). Meta-regression analysis did not show a significant association between study year and AKI recovery rate (P = 0.08). There was no publication bias as assessed by the funnel plot and Egger's regression asymmetry test in all analyses.

CONCLUSION

Recovery from severe AKI-KRT after LVAD occurs approximately 50.5%, and it has not significantly changed over the years despite advances in medicine.

Sequential organ failure assessment score is superior to other prognostic indices in acute pancreatitis

BACKGROUND

Acute pancreatitis (AP) is a common surgical condition, with severe AP (SAP) potentially lethal. Many prognostic indices, including; acute physiology and chronic health evaluation II score (APACHE II), bedside index of severity in acute pancreatitis (BISAP), Glasgow score, harmless acute pancreatitis score (HAPS), Ranson’s score, and sequential organ failure assessment (SOFA) evaluate AP severity and predict mortality.

AIM

To evaluate these indices' utility in predicting severity, intensive care unit (ICU) admission, and mortality.

METHODS

A retrospective analysis of 653 patients with AP from July 2009 to September 2016 was performed. The demographic, clinical profile, and patient outcomes were collected. SAP was defined as per the revised Atlanta classification. Values for APACHE II score, BISAP, HAPS, and SOFA within 24 h of admission were retrospectively obtained based on laboratory results and patient evaluation recorded on a secure hospital-based online electronic platform. Data with < 10% missing data was imputed via mean substitution. Other patient information such as demographics, disease etiology, and patient outcomes were also derived from electronic medical records.

RESULTS

The mean age was 58.7 ± 17.5 years, with 58.7% males. Gallstones (n = 404, 61.9%), alcohol (n = 38, 5.8%), and hypertriglyceridemia (n = 19, 2.9%) were more common aetiologies. 81 (12.4%) patients developed SAP, 20 (3.1%) required ICU admission, and 12 (1.8%) deaths were attributed to SAP. Ranson’s score and APACHE-II demonstrated the highest sensitivity in predicting SAP (92.6%, 80.2% respectively), ICU admission (100%), and mortality (100%). While SOFA and BISAP demonstrated lowest sensitivity in predicting SAP (13.6%, 24.7% respectively), ICU admission (40.0%, 25.0% respectively) and mortality (50.0%, 25.5% respectively). However, SOFA demonstrated the highest specificity in predicting SAP (99.7%), ICU admission (99.2%), and mortality (98.9%). SOFA demonstrated the highest positive predictive value, positive likelihood ratio, diagnostic odds ratio, and overall accuracy in predicting SAP, ICU admission, and mortality. SOFA and Ranson’s score demonstrated the highest area under receiver-operator curves at 48 h in predicting SAP (0.966, 0.857 respectively), ICU admission (0.943, 0.946 respectively), and mortality (0.968, 0.917 respectively).

CONCLUSION

The SOFA and 48-h Ranson’s scores accurately predict severity, ICU admission, and mortality in AP, with more favorable statistics for the SOFA score.

Extracorporeal membrane oxygenation and inhaled sedation in coronavirus disease 2019-related acute respiratory distress syndrome

Coronavirus disease 2019 (COVID-19) related acute respiratory distress syndrome (ARDS) is a severe complication of infection with severe acute respiratory syndrome coronavirus 2, and the primary cause of death in the current pandemic. Critically ill patients often undergo extracorporeal membrane oxygenation (ECMO) therapy as the last resort over an extended period. ECMO therapy requires sedation of the patient, which is usually achieved by intravenous administration of sedatives. The shortage of intravenous sedative drugs due to the ongoing pandemic, and attempts to improve treatment outcome for COVID-19 patients, drove the application of inhaled sedation as a promising alternative for sedation during ECMO therapy. Administration of volatile anesthetics requires an appropriate delivery. Commercially available ones are the anesthetic gas reflection systems AnaConDa^® and MIRUS^TM, and each should be combined with a gas scavenging system. In this review, we describe respiratory management in COVID-19 patients and the procedures for inhaled sedation during ECMO therapy of COVID-19 related ARDS. We focus particularly on the technical details of administration of volatile anesthetics. Furthermore, we describe the advantages of inhaled sedation and volatile anesthetics, and we discuss the limitations as well as the requirements for safe application in the clinical setting.

Timing of tracheostomy in mechanically ventilated COVID-19 patients

According to the World Health Organization as of September 16, 2021, there have been over 226 million documented cases of coronavirus disease 2019 (COVID-19), which has resulted in more than 4.6 million deaths and approximately 14% develop a more severe disease that requires respiratory assistance such as intubation. Early tracheostomy is recommended for patients that are expected to be on prolonged mechanical ventilation; however, supporting data has not yet been provided for early tracheostomies in COVID-19 patients. The aim of this study was to explore established guidelines for performing tracheostomies in patients diagnosed with COVID-19. Factors considered were patient outcomes such as mortality, ventilator-associated pneumonia, intensive care unit length of stay, complications associated with procedures, and risks to healthcare providers that performed tracheostomies. Various observational studies, meta-analyses, and systematic reviews were collected through a PubMed Database search. Additional sources were found through Google. The search was refined to publications in English and between the years of 2003 and 2021. The keywords used were “Coronavirus” and/or “guidelines'' and/or “tracheostomy” and/or “intensive care”. Twenty-three studies were retained. Due to the complex presentation of the respiratory virus COVID-19, previously established guidelines for tracheostomies had to be reevaluated to determine if these guidelines were still applicable to these critically ill ventilated patients. More specifically, medical guidelines state benefits to early tracheostomies in critically ill ventilated non-COVID-19 patients. However, after having conducted this review, the assumptions about the benefits of early tracheostomies in critically ill ventilated patients may not be appropriate for COVID-19 patients.

Role of bronchoscopy in critically ill patients managed in intermediate care units - indications and complications: A narrative review

Flexible bronchoscopy (FB) has become a standard of care for the triad of inspection, sampling, and treatment in critical care patients. It is an invaluable tool for diagnostic and therapeutic purposes in critically ill patients in intensive care unit (ICU). Less is known about its role outside the ICU, particularly in the intermediate care unit (IMCU), a specialized environment, where an intermediate grade of intensive care and monitoring between standard care unit and ICU is provided. In the IMCU, the leading indications for a diagnostic work-up are: To visualize airway system/obstructions, perform investigations to detect respiratory infections, and identify potential sources of hemoptysis. The main procedures for therapeutic purposes are secretion aspiration, mucus plug removal to solve atelectasis (total or lobar), and blood aspiration during hemoptysis. The decision to perform FB might depend on the balance between potential benefits and risks due to frailty of critically ill patients. Serious adverse events related to FB are relatively uncommon, but they may be due to lack of expertise or appropriate precautions. Finally, nowadays, during dramatic recent coronavirus disease 2019 (COVID-19) pandemic, the exact role of FB in COVID-19 patients admitted to IMCU has yet to be clearly defined. Hence, we provide a concise review on the role of FB in an IMCU setting, focusing on its indications, technical aspects and complications.

Orosomucoid-like protein 3, rhinovirus and asthma

The genetic variants of orosomucoid-like protein 3 (ORMDL3) gene are associated with highly significant increases in the number of human rhinovirus (HRV)-induced wheezing episodes in children. Recent investigations have been focused on the mechanisms of ORMDL3 in rhinovirus infection for asthma and asthma exacerbations. ORMDL3 not only regulates major human rhinovirus receptor intercellular adhesion molecule 1 expression, but also plays pivotal roles in viral infection through metabolisms of ceramide and sphingosine-1-phosphate, endoplasmic reticulum (ER) stress, ER-Golgi interface and glycolysis. Research on the roles of ORMDL3 in HRV infection will lead us to identify new biomarkers and novel therapeutic targets in childhood asthma and viral induced asthma exacerbations.

Elderly adults with COVID-19 admitted to intensive care unit: A narrative review

BACKGROUND

In the context of the Coronavirus disease 2019 (COVID-19) pandemic, it has been reported that elderly patients are particularly at risk of developing severe illness and exhibiting increased mortality. While many studies on hospitalized elderly patients with COVID-19 have been published, limited information is available on the characteristics and clinical outcomes of those elderly patients admitted to intensive care unit (ICU).

AIM

To review the available evidence of the clinical data of elderly patients admitted to the ICU due to COVID-19.

METHODS

We searched for published articles available in English literature to identify those studies conducted in critically ill patients admitted to the ICU due to COVID-19, either exclusively designed for the elderly or for the whole ICU population with COVID-19, provided that analyses according to the patients’ age had been conducted.

RESULTS

Only one study exclusively focusing on critically ill elderly patients admitted to the ICU due to COVID-19 was found. Eighteen additional studies involving 17011 ICU patients and providing information for elderly patients as a subset of the whole study population have also been included in the present review article. Among the whole patient population, included in these studies, 8310 patients were older than 65 years of age and 2630 patients were older than 70 years. Clinical manifestations were similar for all patients; however, compared to younger ones, they suffered from more comorbidities and showed a varied, albeit high mortality.

CONCLUSION

In summary, at present, although elderly patients constitute a considerable proportion of critically ill patients admitted to the ICU due to severe COVID-19, studies providing specific information are limited. The evidence so far suggests that advanced age and comorbidities are associated with worse clinical outcome. Future studies exclusively designed for this vulnerable group are needed.

Retrospective analysis of anti-inflammatory therapies during the first wave of COVID-19 at a community hospital

BACKGROUND

Our understanding of the severe acute respiratory syndrome coronavirus 2 has evolved since the first reported cases in December 2019, and a greater emphasis has been placed on the hyper-inflammatory response in severely ill patients. The purpose of this study was to determine risk factors for mortality and the impact of anti-inflammatory therapies on survival.

AIM

To determine the impact of various therapies on outcomes in severe coronavirus disease 2019 patients with a focus on anti-inflammatory and immune-modulating agents.

METHODS

A retrospective analysis was conducted on 261 patients admitted or transferred to the intensive care unit in two community hospitals between March 12, 2020 and June 17, 2020. Totally 167 patients received glucocorticoid (GC) therapy. Seventy-three patients received GC alone, 94 received GC and tocilizumab, 28 received tocilizumab monotherapy, and 66 received no anti-inflammatory therapy.

RESULTS

Patient survival was associated with GC use, either alone or with tocilizumab, and decreased vasopressor requirements. Delayed administration of GC was found to decrease the survival benefit of GC therapy. No difference in survival was found with varying anticoagulant doses, convalescent plasma, tocilizumab monotherapy; prone ventilation, hydroxychloroquine, azithromycin, or intravenous ascorbic acid use.

CONCLUSION

This analysis demonstrated the survival benefit associated with anti-inflammatory therapy of GC, with or without tocilizumab, with the combination providing the most benefit. More studies are needed to assess the optimal timing of anti-inflammatory therapy initiation.

Incremental value of compression ultrasound sonography in the emergency department

The quick evaluation of venous thromboembolism is a key point of modern medicine since the delayed diagnosis is associated with a worse prognosis. Venous ultrasound (VU) is a sensitive and rapidly performed test in cases of suspected deep venous thrombosis. Various protocols have been proposed for its execution, such as the study of the whole deep venous circulation of the lower limb or the analysis of the femoral-popliteal area. The aim is to detect a vessel thrombus and the most sensitive element is the non-compressibility with the probe. Initially, the thrombus is hypoechogenic and adherent to the vessel; later, it tends to organize and recanalize. Usually, in the early stages, the risk of embolism is higher. The role of studying the iliac axis and calf veins is still uncertain. VU is not useful for assessing response to anticoagulation therapy and it is unclear whether the persistence of thrombotic abnormalities can guide on a possible prolongation of therapy.

Neutrophil kinetics and function after major trauma: A systematic review

BACKGROUND

Immune dysfunction following major traumatic injury is complex and strongly associated with significant morbidity and mortality through the development of multiple organ dysfunction syndrome (MODS), persistent inflammation, immunosuppression, and catabolism syndrome and sepsis. Neutrophils are thought to be a pivotal mediator in the development of immune dysfunction.

AIM

To provide a review with a systematic approach of the recent literature describing neutrophil kinetics and functional changes after major trauma in humans and discuss hypotheses as to the mechanisms of the observed neutrophil dysfunction in this setting.

METHODS

Medline, Embase and PubMed were searched on January 15, 2021. Papers were screened by two reviewers and those included had their reference list hand searched for additional papers of interest. Inclusion criteria were adults > 18 years old, with an injury severity score > 12 requiring admission to an intensive care unit. Papers that analysed major trauma patients as a subgroup were included.

RESULTS

Of 107 papers screened, 48 were included in the review. Data were heterogeneous and most studies had a moderate to significant risk of bias owing to their observational nature and small sample sizes. Key findings included a persistently elevated neutrophil count, stereotyped alterations in cell-surface markers of activation, and the elaboration of heterogeneous and immunosuppressive populations of cells in the circulation. Some of these changes correlate with clinical outcomes such as MODS and secondary infection. Neutrophil phenotype remains a promising avenue for the development of predictive markers for immune dysfunction.

CONCLUSION

Understanding of neutrophil phenotypes after traumatic injury is expanding. A greater emphasis on incorporating functional and clinically significant markers, greater uniformity in study design and assessment of extravasated neutrophils may facilitate risk stratification in patients affected by major trauma.

Near-fatal Panton-Valentine leukocidin-positive Staphylococcus aureus pneumonia, shock and complicated extracorporeal membrane oxygenation cannulation: A case report

BACKGROUND

Panton-Valentine leukocidin (PVL) is an exotoxin secreted by Staphylococcus aureus (S. aureus), responsible for skin and soft tissue infections. As a cause of severe necrotising pneumonia, it is associated with a high mortality rate. A rare entity, the epidemiology of PVL S. aureus (PVL-SA) pneumonia as a complication of influenza coinfection, particularly in young adults, is incompletely understood.

CASE SUMMARY

An adolescent girl presented with haemoptysis and respiratory distress, deteriorated rapidly, with acute respiratory distress syndrome (ARDS) and profound shock requiring extensive, prolonged resuscitation, emergency critical care and venovenous extracorporeal membrane oxygenation (ECMO). Cardiac arrest and a rare complication of ECMO cannulation necessitated intra-procedure extracorporeal cardiopulmonary resuscitation, i.e., venoarterial ECMO. Coordinated infectious disease, microbiology and Public Health England engagement identified causative agents as PVL-SA and influenza A/H3N2 from bronchial aspirates within hours. Despite further complications of critical illness, the patient made an excellent recovery with normal cognitive function. The coordinated approach of numerous multidisciplinary specialists, nursing staff, infection control, specialist cardiorespiratory support, hospital services, both adult and paediatric and Public Health are testimony to what can be achieved to save life against expectation, against the odds. The case serves as a reminder of the deadly nature of PVL-SA when associated with influenza and describes a rare complication of ECMO cannulation.

CONCLUSION

PVL-SA can cause severe ARDS and profound shock, with influenza infection. A timely coordinated multispecialty approach can be lifesaving.

Medical students as disaster volunteers: A strategy for improving emergency department surge response in times of crisis

Disasters resulting in mass casualty incidents can rapidly overwhelm the Emergency Department (ED). To address critical manpower needs in the ED’s disaster response, medical student involvement has been advocated. Duke-National University of Singapore Medical School is in proximity to Singapore General Hospital and represents an untapped manpower resource. With appropriate training and integration into ED disaster workflows, medical students can be leveraged upon as qualified manpower. This review provides a snapshot of the conceptualization and setting up of the Disaster Volunteer Corps – a programme where medical students were recruited to receive regular training and assessment from emergency physicians on disaster response principles to fulfil specific roles during a crisis, while working as part of a team under supervision. We discuss overall strategy and benefits to stakeholders, emphasizing the close symbiotic relationship between academia and healthcare services.

Reduced exercise capacity and self-perceived health status in high-risk patients undergoing lung resection

BACKGROUND

Lung resection represents the main curative treatment modality of non-small cell lung cancer. Patients with high-risk to develop postoperative pulmonary complications have been classified as “high-risk patients.” Characterizing this population could be important to improve their approach and rehabilitation.

AIM

To identify the differences between high and low-risk patients in exercise capacity and self-perceived health status after hospitalization.

METHODS

A longitudinal observational prospective cohort study was carried out. Patients undergoing lung resection were recruited from the “Hospital Virgen de las Nieves” (Granada) and divided into two groups according to the risk profile criteria (age ≥ 70 years, forced expiratory volume in 1 s ≤ 70% predicted, carbon monoxide diffusion capacity ≤ 70% predicted or scheduled pneumonectomy). Outcomes included were exercise capacity (Fatigue Severity Scale, Unsupported Upper-Limb Exercise, handgrip dynamometry, Five Sit-to-stand test, and quadriceps hand-held dynamometry) and patient-reported outcome (Euroqol-5 dimensions 5 Levels Visual Analogue Scale).

RESULTS

In total, 115 participants were included in the study and divided into three groups: high-risk, low-risk and control group. At discharge high-risk patients presented a poorer exercise capacity and a worse self-perceived health status (P < 0.05). One month after discharge patients in the high-risk group maintained these differences compared to the other groups.

CONCLUSION

Our results show a poorer recovery in high-risk patients at discharge and 1 mo after surgery, with lower self-perceived health status and a poorer upper and lower limb exercise capacity. These results are important in the rehabilitation field.

Clinical benefits of corticosteroid administration during adult cardiopulmonary resuscitation: A systemic review and meta-analysis

BACKGROUND

The clinical benefits of steroid administration during cardiac arrest remain unclear. Several studies reported that patients who received steroids after achieving a return of spontaneous circulation (ROSC) had better outcomes, but few studies have investigated the benefits of steroid administration during resuscitation. We hypothesized that administration of steroid during cardiac arrest would be associated with better clinical outcomes in adults with cardiac arrest.

AIM

To investigate the effect of steroid administration during cardiac arrest and the outcomes of resuscitation.

METHODS

We included studies of participants older than 18 years of age who experienced cardiac arrest and included at least one arm that received corticosteroids during cardiac arrest. A literature search of PubMed and Embase on 31 January 2021 retrieved placebo-controlled studies without limitation for type, location, and initial presenting rhythm of cardiac arrest. The study outcomes were reported by odds ratios (ORs) compared with placebo. The primary outcome was survival rate at hospital discharge. Secondary outcomes included a sustained ROSC, survival rate at hospital admission, and neurological outcome at hospital discharge.

RESULTS

Six studies including 146262 participants were selected for analysis. The risk of bias ranged from low to high for randomized-controlled trials (RCTs) and low (for non-RCTs). Steroid administration was associated with increased survival at hospital discharge [OR: 3.51, 95% confidence interval (CI): 1.98-6.20, P < 0.001], and steroid administration during cardiac arrest was associated with both an increased rate of sustained ROSC (OR: 1.81, 95%CI: 1.91-4.02, P < 0.001) and a favorable neurological outcome at hospital discharge (OR: 3.02, 95%CI: 1.26-7.24, P = 0.01).

CONCLUSION

Steroid administration during cardiac arrest was associated with better outcomes of resuscitation. Further study of the use of steroid in the selected circumstances are warranted.

Point-of-care ultrasound in a pandemic: Practical guidance in COVID-19 units

The coronavirus disease 2019 (COVID-19) pandemic has stretched our healthcare system to the brink, highlighting the importance of efficient resource utilization without compromising healthcare provider safety. While advanced imaging is a great resource for diagnostic purposes, the risk of contamination and infection transmission is high and requires extensive logistical planning for intrahospital patient transport, healthcare provider safety, and post-imaging decontamination. This dilemma has necessitated the transition to more bedside imaging. More so than ever, during the current pandemic, the clinical utility and importance of point-of-care ultrasound (POCUS) cannot be overstressed. It allows for safe and efficient beside procedural guidance and provides front line providers with valuable diagnostic information that can be acted upon in real-time for immediate clinical decision-making. The authors have been routinely using POCUS for the management of COVID-19 patients both in the emergency department and in intensive care units turned into “COVID-units.” In this article, we review the nuances of using POCUS in a pandemic situation and maximizing diagnostic output from this bedside technology. Additionally, we review various methods and diagnostic uses of POCUS which can replace conventional imaging and bridge current literature and common clinical practices in critically ill patients. We discuss practical guidance and pertinent review of the literature for the most relevant procedural and diagnostic guidance of respiratory illness, hemodynamic decompensation, renal failure, and gastrointestinal disorders experienced by many patients admitted to COVID-units.

Trends of central line-associated bloodstream infections in the intensive care unit in the Kingdom of Bahrain: Four years’ experience

BACKGROUND

The central venous line is an essential component in monitoring and managing critically ill patients. However, it poses patients with increased risks of severe infections with a higher probability of morbidity and mortality.

AIM

To define the trends of the rates of central line-associated bloodstream infections (CLABSI) over four years, its predicted risk factors, aetiology, and the antimicrobial susceptibility of the isolated pathogens.

METHODS

The study was a prospective case-control study, performed according to the guidelines of the Center for Disease Control surveillance methodology for CLABSI in patients admitted to the adult intensive care unit (ICU) and auditing the implementation of its prevention bundle.

RESULTS

Thirty-four CLABSI identified over the study period, giving an average CLABSI rate of 3.2/1000 central line days. The infection's time trend displayed significant reductions over time concomitantly with the CLABSI prevention bundle's reinforcement from 4.7/1000 central line days at the beginning of 2016 to 1.4/1000 central line days by 2018. The most frequently identified pathogens causing CLABSI in our ICU were gram-negative organisms (59%). The most common offending organisms were Acinetobacter, Enterococcus, and Staphylococcus epidermidis, each of them accounted for 5 cases (15%). Multidrug-resistant organisms contributed to 56% of CLABSI. Its rate was higher when using femoral access and longer hospitalisation duration, especially in the ICU. Insertion of the central line in the non-ICU setting was another identified risk factor.

CONCLUSION

Implementing the prevention bundles reduced CLABSI significantly in our ICU. Implementing the CLABSI prevention bundle is crucial to maintain a substantial reduction in the CLABSI rate in the ICU setting.

Role of proning and positive end-expiratory pressure in COVID-19

The novel coronavirus, which was declared a pandemic by the World Health Organization in early 2020 has brought with itself major morbidity and mortality. It has increased hospital occupancy, heralded economic turmoil, and the rapid transmission and community spread have added to the burden of the virus. Most of the patients are admitted to the intensive care unit (ICU) for acute hypoxic respiratory failure often secondary to acute respiratory distress syndrome (ARDS). Based on the limited data available, there have been different opinions about the respiratory mechanics of the ARDS caused by coronavirus disease 2019 (COVID-19). Our article provides an insight into COVID-19 pathophysiology and how it differs from typical ARDS. Based on these differences, our article explains the different approach to ventilation in COVID-19 ARDS compared to typical ARDS. We critically analyze the role of positive end-expiratory pressure (PEEP) and proning in the ICU patients. Through the limited data and clinical experience are available, we believe that early proning in COVID-19 patients improves oxygenation and optimal PEEP should be titrated based on individual lung compliance.

New Year's greeting and overview of World Journal of Critical Care Medicine in 2021

As editors of World Journal of Critical Care Medicine (WJCCM), it is our great pleasure to take this opportunity to wish all our authors, subscribers, readers, Editorial Board members, independent expert referees, and staff of the Editorial Office a Very Happy New Year. On behalf of the Editorial Team, we would like to express our gratitude to all authors who have contributed their valuable manuscripts and to the independent referees and our subscribers and readers for their continuous support, dedication, and encouragement. The excellent team effort by our editorial board members and staff of the Editorial Office allowed WJCCM to advance remarkably in 2020. In the future, the Baishideng Publishing Group and WJCCM’s editorial board will continue to increase their communication and collaboration, both internally and involving our external contributors, in order to promote our collective impact on the field of Critical Care Medicine even further.

Sepsis: Evidence-based pathogenesis and treatment

Sepsis can develop during the body’s response to a critical illness leading to multiple organ failure, irreversible shock, and death. Sepsis has been vexing health care providers for centuries due to its insidious onset, generalized metabolic dysfunction, and lack of specific therapy. A common factor underlying sepsis is the characteristic hypermetabolic response as the body ramps up every physiological system in its fight against the underlying critical illness. A hypermetabolic response requires supraphysiological amounts of energy, which is mostly supplied via oxidative phosphorylation generated ATP. A by-product of oxidative phosphorylation is hydrogen peroxide (H₂O₂), a toxic, membrane-permeable oxidizing agent that is produced in far greater amounts during a hypermetabolic state. Continued production of mitochondrial H₂O₂ can overwhelm cellular reductive (antioxidant) capacity leading to a build-up within cells and eventual diffusion into the bloodstream. H₂O₂ is a metabolic poison that can inhibit enzyme systems leading to organ failure, microangiopathic dysfunction, and irreversible septic shock. The toxic effects of H₂O₂ mirror the clinical and laboratory abnormalities observed in sepsis, and toxic levels of blood H₂O₂ have been reported in patients with septic shock. This review provides evidence to support a causal role for H₂O₂ in the pathogenesis of sepsis, and an evidence-based therapeutic intervention to reduce H₂O₂ levels in the body and restore redox homeostasis, which is necessary for normal organ function and vascular responsiveness.

COVID-19 and resuscitation: La tournée of traditional Chinese medicine?

BACKGROUND

As it has been established in previous publications of the author, the current extra-hospital statistics referring to cardiopulmonary resuscitation (CPR) are far from being minimally satisfactory (14%-17% success). Since the appearance of acquired immune deficiency syndrome, its application has been increasingly undermined as other subsequent pandemics (H1N1, Ebola, coronavirus disease 2019) seriously infringing lay rescuers intervention during classical CPR steps (mouth-to-mouth ventilation), forcing to modify vital support protocols. Both KI-1 Yong quan and PC-9 Zhong chong alternative rescue maneuvers could come to aid those victims of impending death situation due to both cardiac arrest or stroke, upgrading current survival rates of said unfortunate patients.

AIM

To validate a complementary resuscitation maneuver originated in Chinese Medicine knowledge, carefully integrated into international CPR protocols [World Journal of Critical Care Medicine (WJCCM), August 2013].

METHODS

The model to verify its statistical validity of quoted research was the Retrospective Cohort Study, which redeems the "semiotic paradigm" that gave rise to medical semiotics. Its value strives in the differential detail if the deceased patients are considered the control group instead of the patients that may be deceased. Thus, combining the semiotic paradigm with the Retrospective Cohort Study allows us to manage the collateral potential lethal effects of the random process in cases of extreme emergencies.

RESULTS

The statistic results provided by the methodological analysis of this work were previously published in WJCCM August 2013, ISSN 2220-3141). In a total of 89 patients in which the Yong quan maneuver was tested, 75 survived and 14 died. In order to compare this data with the percentages of survivors in the other maneuvers, we stipulate the assumption that if 89 patients are the 100% of the sample, how many patients would survive if the survival rate is 6.4% in CPR, 30% in defibrillation and 48% in CPR + defibrillation. By this way we obtained the approximate values of patients that would survive when applying these classical resuscitation maneuvers. Then we obtained the format of the tables to perform the exact Fisher test with the help of a statistical processor; the consequent result in a valuation of P < 0.0001 was considered "extremely statistically significant".

CONCLUSION

The author herein provides a methodological-statistical analysis of such contribution which does not imply any cost at all and could even help prevent the withdrawal of classical CPR practices.

What we learned in the past year in managing our COVID-19 patients in intensive care units?

Coronavirus disease 2019 is a pandemic, was first recognized at Wuhan province, China in December 2019. The disease spread quickly across the globe, spreading stealthily from human to human through both symptomatic and asymptomatic individuals. A multisystem disease which appears to primarily spread via bio aerosols, it has exhibited a wide clinical spectrum involving multiple organ systems with the respiratory system pathology being the prime cause of morbidity and mortality. Initially unleashing a huge destructive trail at Wuhan China, Lombardy Italy and New York City, it has now spread to all parts of the globe and has actively thrived and mutated into new forms. Health care systems and Governments responded initially with panic, with containment measures giving way to mitigation strategies. The global medical and scientific community has come together and responded to this huge challenge. Professional medical societies quickly laid out "expert" guidelines which were conservative in their approach. Many drugs were re formulated and tested quickly with the help of national and international collaborative groups, helping carve out effective treatment strategies and help build a good scientific foundation for evidence-based medicine. Out of the darkness of chaos, we now have an orderly approach to manage this disease both from a public health preventive and therapeutic standpoint. With preventive measures such as masking and social distancing to the development of highly effective and potent vaccines, the public health success of such measures has been tempered by behavioral responses and resource mobilization. From a therapy standpoint, we now have drugs that were promising but now proven ineffective, and those that are effective when given early during viral pathogenesis or later when immune dysregulation has established, and the goal is to help reign in the destructive cascade. It has been a fascinating journey for mankind and our work here recapitulates the evolution of various aspects of critical care and other inpatient practices which continue to evolve.

Emergency service results of central venous catheters: Single center, 1042 patients, 10-year experience

BACKGROUND

Central venous catheterization is currently an important procedure in critical care. Central catheterization has important advantages in many clinical situations. It can also lead to different complications such as infection, hemorrhage, and thrombosis. It is important to investigate critically ill patients undergoing catheterization.

AIM

To evaluate the characteristics, such as hospitalization, demographic characteristics, post-catheterization complications, and mortality relationships, of patients in whom a central venous catheter was placed in the emergency room.

METHODS

A total of 1042 patients over the age of 18 who presented to the emergency department between January 2005 and December 2015 were analyzed retrospectively. The patients were divided into three groups, jugular, subclavian, and femoral, according to the area where the catheter was inserted. Complications related to catheterization were determined as pneumothorax, guidewire problems, bleeding, catheter site infection, arterial intervention, and sepsis. Considering the treatment follow-up of the patients, three groups were formed as outpatient treatment, hospitalization, and death.

RESULTS

The mean age of the patients was 60.99 ± 19.85 years; 423 (40.6%) of them were women. Hospitalization time was 11.89 ± 16.38 d. There was a significant correlation between the inserted catheters with gender (P = 0.009) and hospitalization time (P = 0.040). Also, blood glucose, blood urea nitrogen, creatinine, and serum potassium values among the biochemical values of the patients who were catheterized were significant. A significant association was observed in the analysis of patients with complications that develop according to the catheter region (P = 0.001) and the outcome stage (P = 0.001). In receiver operating characteristic curve analysis of hospitalization time and mortality area under curve was 0.575, the 95% confidence interval was 0.496-0.653, the sensitivity was 71%, and the specificity was 89% (P = 0.040).

CONCLUSION

Catheter location and length of stay are important risk factors for catheter-borne infections. Because the risk of infection was lower than other catheters, jugular catheters should be preferred at entry points, and preventive measures should be taken by monitoring patients closely to reduce hospitalization infections.

Glucocorticoid and mineralocorticoid receptor expression in critical illness: A narrative review

The glucocorticoid receptor (GCR) and the mineralocorticoid receptor (MR) are members of the steroid receptor superfamily of hormone-dependent transcription factors. The receptors are structurally and functionally related. They are localized in the cytosol and translocate into the nucleus after ligand binding. GCRs and MRs can be co-expressed within the same cell, and it is believed that the balance in GCR and MR expression is crucial for homeostasis and plays a key role in normal adaptation. In critical illness, the hypothalamic-pituitary-adrenal axis is activated, and as a consequence, serum cortisol concentrations are high. However, a number of patients exhibit relatively low cortisol levels for the degree of illness severity. Glucocorticoid (GC) actions are facilitated by GCR, whose dysfunction leads to GC tissue resistance. The MR is unique in this family in that it binds to both aldosterone and cortisol. Endogenous GCs play a critical role in controlling inflammatory responses in critical illness. Intracellular GC concentrations can differ greatly from blood levels due to the action of the two 11β-hydroxysteroid dehydrogenase isozymes, type 1 and type 2. 11β-hydroxysteroid dehydrogenases interconvert endogenous active cortisol and intrinsically inert cortisone. The degree of expression of the two isozymes has the potential to dramatically influence local GC availability within cells and tissues. In this review, we will explore the clinical studies that aimed to elucidate the role of MR and GCR expression in the inflammatory response seen in critical illness.

SARS-CoV-2 (COVID-19), viral load and clinical outcomes; lessons learned one year into the pandemic: A systematic review

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections is diagnosed via real time reverse transcriptase polymerase chain reaction (RT-PCR) and reported as a binary assessment of the test being positive or negative. High SARS-CoV-2 viral load is an independent predictor of disease severity and mortality. Quantitative RT-PCR may be useful in predicting the clinical course and prognosis of patients diagnosed with coronavirus disease 2019 (COVID-19).

AIM

To identify whether quantitative SARS-CoV-2 viral load assay correlates with clinical outcome in COVID-19 infections.

METHODS

A systematic literature search was undertaken for a period between December 30, 2019 to December 31, 2020 in PubMed/MEDLINE using combination of terms "COVID-19, SARS-CoV-2, Ct values, Log10 copies, quantitative viral load, viral dynamics, kinetics, association with severity, sepsis, mortality and infectiousness''. After screening 990 manuscripts, a total of 60 manuscripts which met the inclusion criteria were identified. Data on age, number of patients, sample sites, RT-PCR targets, disease severity, intensive care unit admission, mortality and conclusions of the studies was extracted, organized and is analyzed.

RESULTS

At present there is no Food and Drug Administration Emergency Use Authorization for quantitative viral load assay in the current pandemic. The intent of this research is to identify whether quantitative SARS-CoV-2 viral load assay correlates with severity of infection and mortality? High SARS-CoV-2 viral load was found to be an independent predictor of disease severity and mortality in majority of studies, and may be useful in COVID-19 infection in susceptible individuals such as elderly, patients with co-existing medical illness such as diabetes, heart diseases and immunosuppressed. High viral load is also associated with elevated levels of TNF-α, IFN-γ, IL-2, IL-4, IL-6, IL-10 and C reactive protein contributing to a hyper-inflammatory state and severe infection. However there is a wide heterogeneity in fluid samples and different phases of the disease and these data should be interpreted with caution and considered only as trends.

CONCLUSION

Our observations support the hypothesis of reporting quantitative RT-PCR in SARS-CoV-2 infection. It may serve as a guiding principle for therapy and infection control policies for current and future pandemics.

Predictive modeling in neurocritical care using causal artificial intelligence

Artificial intelligence (AI) and digital twin models of various systems have long been used in industry to test products quickly and efficiently. Use of digital twins in clinical medicine caught attention with the development of Archimedes, an AI model of diabetes, in 2003. More recently, AI models have been applied to the fields of cardiology, endocrinology, and undergraduate medical education. The use of digital twins and AI thus far has focused mainly on chronic disease management, their application in the field of critical care medicine remains much less explored. In neurocritical care, current AI technology focuses on interpreting electroencephalography, monitoring intracranial pressure, and prognosticating outcomes. AI models have been developed to interpret electroencephalograms by helping to annotate the tracings, detecting seizures, and identifying brain activation in unresponsive patients. In this mini-review we describe the challenges and opportunities in building an actionable AI model pertinent to neurocritical care that can be used to educate the newer generation of clinicians and augment clinical decision making.

Inhaling muscle spray: A rising trend of abuse

Ethyl chloride was popular as an inhalant recreational drug in the 1980s. It is easily available in pharmacies as well as sold online as a topical anesthetic spray for pain relief. In recent times, its use is gaining popularity again among the youth as an inhalant drug due to its neuro-stimulatory effects. To avoid the risks associated with use of illegal drugs, and ease of availability of ethyl chloride without restrictions, there is a rising trend to use it as a “substitute” drug of abuse. In this paper, we try to highlight to the critical care and emergency physicians that majority of these cases present with predominant neurological symptoms, with occasional involvement of the cardiovascular system. The diagnosis of ethyl chloride poisoning is primarily clinical and supportive care is the mainstay of treatment, along with subsequent counseling. Ethyl chloride abuse should be considered as a differential diagnosis in young patients presenting with predominant neurological symptoms. Alongside raising public awareness, the manufacturers and retail distributors of these products have an important role to play in reducing the risk of abuse.