Angiotensin II Use in Treatment of Refractory Shock Due to Benazepril and Amlodipine Toxic Ingestion

Introduction: Calcium channel blockers (CCB) are a leading cause of ingestion-associated fatality. Angiotensin-converting enzyme inhibitor (ACEi) overdose as part of co-ingestion is common and associated with refractory shock. Treatment options to manage this profound vasoplegia are limited. We describe the first case of use of newly formulated Angiotensin II for treatment of severe ACEi and CCB poisoning. Case Report: A 57-year-old man presented after suicide attempt by ingesting 20 tablets each of amlodipine 10 mg and benazepril 20 mg. His hypotension was initially managed with 35 mL/kg of crystalloid, norepinephrine, and hyperinsulinemic euglycemic therapy (HIET). His hemodynamics further deteriorated, and he developed lactic acidosis, electrolyte derangements, and renal dysfunction. Further complications of his ingestion included cardiac arrest, subsequent requirement for emergency cricothyrotomy, and renal replacement therapy. Maximal hemodynamic support with HIET therapy insulin drip 4.4 units/kg/hour, norepinephrine 2 mcg/kg/min, epinephrine 1 mcg/kg/min, vasopressin .06 units/hour, and intravenous lipid emulsion was unsuccessful. Ang II was started and titrated to maximal doses with dramatic improvement in hemodynamics. Within hours of starting Ang II, epinephrine was stopped and norepinephrine decreased by 50%. He was downgraded from the intensive care unit without any ongoing end-organ dysfunction. Discussion: Isolated CCB overdoses have high complication rates and well-established treatments. Therefore, management of CCB and ACEi co-ingestion is typically driven by CCB poisoning algorithm. There are multiple reports of CCB and ACEi co-ingestions causing treatment-refractory shock. Therapeutic options are limited by toxicities and availability of salvage therapies. Ang II is a safe and highly effective option to manage these patients.

Comparison of four handheld point-of-care ultrasound devices by expert users

Background

Point-of-care ultrasound (POCUS) is rapidly becoming ubiquitous across healthcare specialties. This is due to several factors including its portability, immediacy of results to guide clinical decision-making, and lack of radiation exposure to patients. The recent growth of handheld ultrasound devices has improved access to ultrasound for many clinicians. Few studies have directly compared different handheld ultrasound devices among themselves or to cart-based ultrasound machines. We conducted a prospective observational study comparing four common handheld ultrasound devices for ease of use, image quality, and overall satisfaction. Twenty-four POCUS experts utilized four handheld devices (Butterfly iQ+™ by Butterfly Network Inc., Kosmos™ by EchoNous, Vscan Air™ by General Electric, and Lumify™ by Philips Healthcare) to obtain three ultrasound views on the same standardized patients using high- and low-frequency probes.

Results

Data were collected from 24 POCUS experts using all 4 handheld devices. No single ultrasound device was superior in all categories. For overall ease of use, the Vscan Air™ was rated highest, followed by the Lumify™. For overall image quality, Lumify™ was rated highest, followed by Kosmos™. The Lumify™ device was rated highest for overall satisfaction, while the Vscan Air™ was rated as the most likely to be purchased personally and carried in one’s coat pocket. The top 5 characteristics of handheld ultrasound devices rated as being “very important” were image quality, ease of use, portability, total costs, and availability of different probes.

Conclusions

In a comparison of four common handheld ultrasound devices in the United States, no single handheld ultrasound device was perceived to have all desired characteristics. POCUS experts rated the Lumify™ highest for image quality and Vscan Air™ highest for ease of use. Overall satisfaction was highest with the Lumify™ device, while the most likely to be purchased as a pocket device was the Vscan Air™. Image quality was felt to be the most important characteristic in evaluating handheld ultrasound devices.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13089-022-00274-6.

Developing and Testing a Protocol for Managing Cardiopulmonary Resuscitation of Patients with Suspected or Confirmed COVID-19: An In-Situ Simulation Study (Preprint)

Background

Resuscitating patients with suspected or confirmed COVID-19 imposes unique challenges to organizations and code blue teams. Studies that applied the American Heart Association (AHA) COVID-19–related Interim Resuscitation Guideline and similar European guidelines are scarce.

Objective

This study aimed to develop and test a cardiopulmonary resuscitation protocol based on the AHA COVID-19–related Interim Resuscitation Guideline.

Methods

The study was conducted as an in situ simulation in a medical intensive care unit. The COVID-19 cardiopulmonary resuscitation protocol was created and validated by 11 health care team members and tested using 4 simulation sessions where 46 code blue team members participated. During the simulation, we observed role clarity, the effectiveness of communication, team dynamics, infection control measures, and the availability of essential supplies and equipment.

Results

The main issues identified in each simulation session were debriefed to the code blue teams and used to further revise the protocol. These include the assignment of tasks, availability of equipment and supplies, and failure of communication between the in-room and out-of-room teams. Solutions included changes in the placement of team members and roles and responsibilities; the creation of an isolation code medication package, a respiratory therapy kit, and an isolation code blue bag; and the use of two-way radios and N-95 masks with eye goggles to enhance communication between the teams.

Conclusions

This study shed light on the challenges to implement the AHA COVID-19–related Interim Resuscitation Guideline. The in situ simulation was an effective approach for rapid training, identifying unreliable equipment and ineffective and inefficient workflow, and managing the complexity of the physical environment.

Staged Implementation of Awakening and Breathing, Coordination, Delirium Monitoring and Management, and Early Mobilization Bundle Improves Patient Outcomes and Reduces Hospital Costs

OBJECTIVES

To measure the impact of staged implementation of full versus partial ABCDE bundle on mechanical ventilation duration, ICU and hospital lengths of stay, and cost.

DESIGN

Prospective cohort study.

SETTING

Two medical ICUs within Montefiore Healthcare Center (Bronx, NY).

PATIENTS

One thousand eight hundred fifty-five mechanically ventilated patients admitted to ICUs between July 2011 and July 2014.

INTERVENTIONS

At baseline, spontaneous (B)reathing trials (B) were ongoing in both ICUs; in period 1, (A)wakening and (D)elirium (AD) were implemented in both full and partial bundle ICUs; in period 2, (E)arly mobilization and structured bundle (C)oordination (EC) were implemented in the full bundle (B-AD-EC) but not the partial bundle ICU (B-AD).

MEASUREMENTS AND MAIN RESULTS

In the full bundle ICU, 95% patient days were spent in bed before EC (period 1). After EC was implemented (period 2), 65% of patients stood, 54% walked at least once during their ICU stay, and ICU-acquired pressure ulcers and physical restraint use decreased (period 1 vs 2: 39% vs 23% of patients; 30% vs 26% patient days, respectively; p < 0.001 for both). After adjustment for patient-level covariates, implementation of the full (B-AD-EC) versus partial (B-AD) bundle was associated with reduced mechanical ventilation duration (-22.3%; 95% CI, -22.5% to -22.0%; p < 0.001), ICU length of stay (-10.3%; 95% CI, -15.6% to -4.7%; p = 0.028), and hospital length of stay (-7.8%; 95% CI, -8.7% to -6.9%; p = 0.006). Total ICU and hospital cost were also reduced by 24.2% (95% CI, -41.4% to -2.0%; p = 0.03) and 30.2% (95% CI, -46.1% to -9.5%; p = 0.007), respectively.

CONCLUSIONS

In a clinical practice setting, the addition of (E)arly mobilization and structured (C)oordination of ABCDE bundle components to a spontaneous (B)reathing, (A)wakening, and (D) elirium management background led to substantial reductions in the duration of mechanical ventilation, length of stay, and cost.

Enrichment of Antigen-Specific Class-Switched B Cells from Individuals Naturally Immunized by Infection with Group A Streptococcus

The low frequency of circulating antigen-specific memory B cells is a considerable obstacle in the discovery and development of human monoclonal antibodies for therapeutic application. Here, we evaluate two solid-phase isolation methods to enrich the number of antigen-specific B cells from individuals naturally immunized against streptolysin O (SLO), a key virulence factor and known immunogen of group A streptococcus (GAS). Class-switched B cells obtained from individuals with a history of GAS infection were separated from peripheral blood mononuclear cells (PBMCs) by immunomagnetic methods. SLO-specific B cells were further enriched directly by binding to SLO monomers and captured by streptavidin-coated magnetic microbeads or indirectly by binding a fluorescently labeled SLO-streptavidin tetramer and captured by anti-fluorophore immunomagnetic microbeads. SLO-bound B cells were quantitated by flow cytometry and/or expanded in batch culture to determine IgG specificity. From individuals who have suffered a GAS infection ≥2 years prior, only the direct method enriched SLO-specific B cells, as determined by flow cytometry. Likewise, in batch culture, B cells isolated by the direct method resulted in an average of 375-fold enrichment in anti-SLO IgG, while no enrichment was observed for B cells isolated by the indirect method. The direct method established here provides a simple approach to increase low-frequency antigen-specific B cell populations supporting many downstream applications, such as immortalization of B cells, cloning of immunoglobulin genes, or purification of antibodies from supernatant for future study. Overall, this process is efficient, is inexpensive, and can be applied to many naturally immunogenic antigens.IMPORTANCE Bacteria called group A streptococci can cause a variety of skin and soft tissue infections ranging from mild pharyngitis ("strep throat") to deadly necrotizing fasciitis (sometimes called "flesh-eating" disease). In each case, the development of disease and the degree of tissue damage are mediated by toxins released from the bacteria during infection. Consequently, novel therapies aimed at clearing bacterial toxins are greatly needed. One promising new treatment is the utilization of monoclonal antibodies delivered as an immunotherapeutic for toxin neutralization. However, current methods of antibody development are laborious and costly. Here, we report a method to enrich and increase the detection of highly desirable antigen-specific memory B cells from individuals previously exposed to GAS using a cost-effective and less-time-intensive strategy. We envision that this method will be incorporated into many applications supporting the development of immunotherapeutics.

Case Report: Fulminant Murine Typhus Presenting with Status Epilepticus and Multi-Organ Failure: an Autopsy Case and a Review of the Neurologic Presentations of Murine Typhus

Murine typhus (MT) is an important cause of febrile illness in endemic areas, and there is an epidemiologic resurgence of this infection currently transpiring in Texas and California. Fatal cases and severe neurological complications are rare. A fatal case of MT in a middle-aged man is reported with a course culminating in multi-organ failure and refractory status epilepticus. An autopsy revealed hemorrhagic pneumonia, acute tubular necrosis, and ischemic necrosis in the liver, adrenals, and brain. We have also reviewed the neurologic complications of MT.

Asthma patient education: current utilization in pulmonary training programs

The national guidelines for the diagnosis and management of asthma published in April of 1997 emphasized patient education in asthma management. It is unclear how often patient education is included in asthma management clinics. We sought to determine how often education programs are available by surveying teaching hospitals with training programs in pulmonary and critical care medicine. Using this survey, we also determined the reason programs are not offered and whether computer resources are routinely available to utilize computer-delivered patient educational materials. We sent mail questionnaires to 163 training programs in the United States. We had a response rate of 72% (117 of 163). Of the 117 programs responding, 75 (64%) reported having a formal asthma patient education program. Most (72%) were in university teaching hospitals. A majority of respondents (84%) believed that compensation for their efforts was inadequate, and those hospitals with no formal asthma education program reported that financial cost and time requirements were the primary reasons for not having such a program. Despite the fact that many programs did not have a patient education component, 96% (72 of 75) of respondents with an educational program viewed patient education as an effective patient self-management tool. Of all programs surveyed, 85% reported they would use a high-quality computer-based asthma education program if one was available. Implementation of such a program is feasible, with 69% of programs surveyed having a personal computer in their clinic and 60% having Internet access. We conclude that most training directors believe that patient asthma education is important and effective; however, cost and time issues remain barriers to its implementation. Computer-based educational programs delivered over the Internet are feasible, could address some of these limitations, and are acceptable to most programs.

A model intervention for elder abuse and dementia

This article describes a 2-year collaborative project in Cleveland, OH, that improved the reporting and management of potential and suspected elder abuse situations involving persons with dementia. Educational curricula for cross-training, screening tools, and referral protocols were developed and tested for staff and volunteers in adult protective services and dementia care. A handbook for caregivers of persons with dementia was produced that enables caregivers to self-identify elder abuse risk and seek appropriate interventions to prevent abuse. Project organization, implementation, and evaluation are discussed along with strategies for replication in other communities.

Realizing the promise: delivering pulmonary continuing medical education over the Internet

STUDY OBJECTIVES

Continuing medical education (CME) is meant to bridge the gap between new scientific observations and clinical practice. However, traditional CME has not been effective at altering the behaviors of physicians. One reason for this failure of traditional CME programs may be their inflexibility. In traditional CME, the clinician does not choose the topic, the pace of the program, or the place of learning, and the CME material cannot be easily delivered to the point of care where the clinician needs the information. Computers and computer networks have the potential to accomplish these goals. CME has begun to appear on the Internet; however, there have been few evaluations of its usefulness, acceptance, and effectiveness. Over the last 18 months, we have developed three on-line pulmonary CME programs, and we have delivered them on the Virtual Hospital, the University of Iowa's digital health sciences library on the Internet. We report our initial experience with this CME material.

DESIGN

We measured the frequency with which the Internet-delivered CME is accessed by monitoring page accessions and by using a log file analysis program (Analog 1.2.3; University of Cambridge Statistical Laboratory; Cambridge, UK). In addition, we collected all completed CME examinations and evaluation forms submitted by registered users.

MEASUREMENTS AND RESULTS

We have found that the frequency with which the Internet-delivered CME is accessed has continued to increase with time (2.3-fold increase over 18 months), that evaluations of technical and content issues are strongly favorable, and that some clinicians have been willing to pay to receive CME through the medium of the Internet.

CONCLUSIONS

We feel that with adequate peer review and quality control, physicians will use the Internet-delivered CME. However, several obstacles to wide use remain. These obstacles include issues regarding training in using the Internet for physicians, reluctance of physicians to participate in on-line commerce, and the current unavailability of CME to be delivered in small-grained quantities to the point of care. As these issues are addressed, we feel that on-line CME will represent an increasingly important CME medium for clinicians.

Outcome of the treatment for sarcoidosis

The clinical characteristics and pathology of sarcoidosis are well defined; however, the optimal therapy for this disorder remains unclear. Although patients respond, acutely, to corticosteroid therapy, it is not clear that these agents ultimately alter the natural history of this disease. These observations and that corticosteroids have significant side effects suggest that only patients who will clearly benefit from corticosteroid therapy should be treated. In a prospective study of patients' with sarcoidosis (n = 98), we limited our use of corticosteroids to those patients who had objective evidence of recent deterioration in lung function or serious extrapulmonary disease. All patients with sarcoidosis fulfilling these criteria were treated with corticosteroids. Patients were tapered off corticosteroids after they were treated for 1 yr. Of the 98 study subjects, 91 had not received therapy for the disease and 7 were on therapy before entry into the study. Of the 91 previously untreated patients, 55 were observed without therapy and 36 were treated with corticosteroids. Of those who were observed off therapy, only eight deteriorated. Of these latter patients, six responded and stabilized with the administration of corticosteroids for treatment of the underlying disease, to antibiotics for an associated bronchiectasis, or to diuretics for treatment for congestive heart failure; two were lost to follow-up. None of these six patients deteriorated while receiving corticosteroids. Of the 36 patients who deteriorated and were treated with corticosteroids, 20 remained stable and 16 improved clinically. Of the 37 patients who were eventually tapered off corticosteroids, five deteriorated and required reinitiation of corticosteroid therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Plasma fibronectin levels during cardiopulmonary bypass

Plasma fibronectin, also called cold-insoluble globulin, is a cryoprecipitable glycoprotein with both opsonic and adhesive activities. It binds to collagen, actin, and heparin and can form soluble as well as cryoprecipitable complexes in the cold. Fibronectin augments particulate phagocytosis by the reticuloendothelial system and can influence lung vascular permeability. Plasma fibronectin deficiency is temporally associated with respiratory failure in septic surgical, trauma, and burn patients. We measured plasma fibronectin and albumin levels in nine adults undergoing elective cardiopulmonary bypass to determine whether dilution alone could account for the changes in plasma fibronectin. Plasma fibronectin concentration decreased 17% with the surgical trauma of opening of the chest and placement of the vascular cannulas. On heparinization and initiation of cardiopulmonary bypass, plasma fibronectin fell an additional 48% (P less than 0.001), whereas albumin concentration (corrected for albumin in the pump prime) fell only 25% (P less than 0.001), emphasizing that dilution was not the only mechanism contributing to the decline in plasma fibronectin. Fibronectin levels began to increase after discontinuation of cardiopulmonary bypass and in association with diuresis, but unexpectedly they remained subnormal until 4 days postoperation. Thus the decline in fibronectin concentration with cardiopulmonary bypass may be due to dilution as well as opsonic consumption and possible complexing with heparin in the cold.

Reversal of opsonic deficiency in surgical, trauma, and burn patients by infusion of purified human plasma fibronectin. Correlation with experimental observations

Plasma fibronectin deficiency has been documented in critically ill surgical, trauma, and burn patients. Human plasma fibronectin was isolated by gelatin-Sepharose affinity chromatography and evaluated with respect to its opsonic activity following pasteurization, its in vivo clearance kinetics, and its short-term influence on cardiovascular hemodynamics in postoperative septic sheep. Six patients with low plasma fibronectin levels were also evaluated with respect to temporal changes of immunoreactive fibronectin and opsonic activity following infusion of fibronectin at a dose calculated to elevate the plasma fibronectin level to 400 micrograms/ml. With utilization of three different in vitro radioisotopic phagocytic assays, i.e., liver slice assay, peritoneal macrophage monolayer assay, and Kupffer cell monolayer assay, retention of opsonic activity by fibronectin following pasteurization was documented. The normal biphasic kinetics associated with plasma clearance of fibronectin were also not altered by pasteurization. In postoperative septic sheep with hemodynamic instability, intravenous infusion of 500 mg of purified human fibronectin initiated no abnormal hemodynamic response. Indeed, as compared with placebo, the infusion of fibronectin into the postoperative septic sheep resulted in a more stable systemic vascular resistance and pulmonary vascular resistance with a higher arterial pressure. It also elevated immunoreactive fibronectin levels (p less than 0.05) and increased opsonic activity (p less than 0.05). Surgical, trauma, and burn patients (ages 18 to 80 years) with low plasma fibronectin levels (160 to 236 micrograms/ml) manifested no disturbance in cardiovascular, respiratory, or hematologic parameters following fibronectin infusion (590 to 988 mg per patient), but did display an early increase of opsonic activity. This standardized, pasteurized, and opsonically active preparation of purified human plasma fibronectin (5.0 mg/ml after reconstitution) has utility for future randomized clinical trials in injured patients with sepsis.