[When the Brain Dictates the Rhythm]

INTRODUCTION

In rare cases, an HSV-Encephalitis can lead to sinus node dysfunction, as was the case in this 70-year old woman who suffered from recurrent syncopes. Diagnostic work-up showed sinus bradycardias and short-lasting sinus arrests, primarily consider-ed to be of cardiac etiology. After development of fever and neurological alteration, an HSV1 encephalitis was diagnosed. As our research of the current literature showed, the connection between the two is not completely clear. The HSVtypical infestation of the insular cortex, which influences the autonomic nervous system, should be discussed by all means. However, due to cessation of arrhythmia after seizure-suppressing therapy, we suspected an epileptic cause in this case. This shows the importance of a thorough differential diagnostic evaluation.

[Shock and Coma after Ingestion of Morels]

Shock and Coma after Ingestion of Morels Abstract. We present the case report of a previously healthy, 42-year-old woman who suffered from a hypovolemic shock, hypoglycemic coma, NSTEMI and temporary dependency on dialysis following the ingestion of morels. Alas there is little public knowledge about the toxicity of morels and the importance of their appropriate preparation so that intoxications can be prevented.

Dynamics of disease characteristics and clinical management of critically ill COVID-19 patients over the time course of the pandemic: an analysis of the prospective, international, multicentre RISC-19-ICU registry

Background

It remains elusive how the characteristics, the course of disease, the clinical management and the outcomes of critically ill COVID-19 patients admitted to intensive care units (ICU) worldwide have changed over the course of the pandemic.

Methods

Prospective, observational registry constituted by 90 ICUs across 22 countries worldwide including patients with a laboratory-confirmed, critical presentation of COVID-19 requiring advanced organ support. Hierarchical, generalized linear mixed-effect models accounting for hospital and country variability were employed to analyse the continuous evolution of the studied variables over the pandemic.

Results

Four thousand forty-one patients were included from March 2020 to September 2021. Over this period, the age of the admitted patients (62 [95% CI 60–63] years vs 64 [62–66] years, p < 0.001) and the severity of organ dysfunction at ICU admission decreased (Sequential Organ Failure Assessment 8.2 [7.6–9.0] vs 5.8 [5.3–6.4], p < 0.001) and increased, while more female patients (26 [23–29]% vs 41 [35–48]%, p < 0.001) were admitted. The time span between symptom onset and hospitalization as well as ICU admission became longer later in the pandemic (6.7 [6.2–7.2| days vs 9.7 [8.9–10.5] days, p < 0.001). The PaO₂/FiO₂ at admission was lower (132 [123–141] mmHg vs 101 [91–113] mmHg, p < 0.001) but showed faster improvements over the initial 5 days of ICU stay in late 2021 compared to early 2020 (34 [20–48] mmHg vs 70 [41–100] mmHg, p = 0.05). The number of patients treated with steroids and tocilizumab increased, while the use of therapeutic anticoagulation presented an inverse U-shaped behaviour over the course of the pandemic. The proportion of patients treated with high-flow oxygen (5 [4–7]% vs 20 [14–29], p < 0.001) and non-invasive mechanical ventilation (14 [11–18]% vs 24 [17–33]%, p < 0.001) throughout the pandemic increased concomitant to a decrease in invasive mechanical ventilation (82 [76–86]% vs 74 [64–82]%, p < 0.001). The ICU mortality (23 [19–26]% vs 17 [12–25]%, p < 0.001) and length of stay (14 [13–16] days vs 11 [10–13] days, p < 0.001) decreased over 19 months of the pandemic.

Conclusion

Characteristics and disease course of critically ill COVID-19 patients have continuously evolved, concomitant to the clinical management, throughout the pandemic leading to a younger, less severely ill ICU population with distinctly different clinical, pulmonary and inflammatory presentations than at the onset of the pandemic.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04065-2.

[Record-Breaking Acidosis]

Record-Breaking Acidosis Abstract. To maintain a stable cellular metabolism, tight regulation of blood pH within a normal range (pH 7,35-7,45) is essential. Even small aberrations can have detrimental effects, and pH values <6,8 or pH >7,8 are considered - based on current medical and physiological knowledge - incompatible with life [9-19].

Machine learning using the extreme gradient boosting (XGBoost) algorithm predicts 5-day delta of SOFA score at ICU admission in COVID-19 patients

Background

Accurate risk stratification of critically ill patients with coronavirus disease 2019 (COVID-19) is essential for optimizing resource allocation, delivering targeted interventions, and maximizing patient survival probability. Machine learning (ML) techniques are attracting increased interest for the development of prediction models as they excel in the analysis of complex signals in data-rich environments such as critical care.

Methods

We retrieved data on patients with COVID-19 admitted to an intensive care unit (ICU) between March and October 2020 from the RIsk Stratification in COVID-19 patients in the Intensive Care Unit (RISC-19-ICU) registry. We applied the Extreme Gradient Boosting (XGBoost) algorithm to the data to predict as a binary outcome the increase or decrease in patients' Sequential Organ Failure Assessment (SOFA) score on day 5 after ICU admission. The model was iteratively cross-validated in different subsets of the study cohort.

Results

The final study population consisted of 675 patients. The XGBoost model correctly predicted a decrease in SOFA score in 320/385 (83%) critically ill COVID-19 patients, and an increase in the score in 210/290 (72%) patients. The area under the mean receiver operating characteristic curve for XGBoost was significantly higher than that for the logistic regression model (0.86 vs. 0.69, P < 0.01 [paired t-test with 95% confidence interval]).

Conclusions

The XGBoost model predicted the change in SOFA score in critically ill COVID-19 patients admitted to the ICU and can guide clinical decision support systems (CDSSs) aimed at optimizing available resources.

[An Unusual Case of Rhabdomyolysis]

An Unusual Case of Rhabdomyolysis Abstract. We present the case of a 52-year-old patient with accidental liquorice intoxication after consumption of liquorice tea. In the Arabic cultures the consumption of liquorice tea is very popular during Ramadan and is used to suppress thirst. In the described case this led to a severe case of pseudohyperaldosteronism. Because of the classic presentation of a hypertensive crisis, hypokalaemia and rhabdomyolysis, the patient needed intensive care. Typically, the symptoms last for up to seven days after discontinuation of liquorice and completely subside with time. The treatment consists only of supportive care.

Implications of early respiratory support strategies on disease progression in critical COVID-19: a matched subanalysis of the prospective RISC-19-ICU cohort

BACKGROUND

Uncertainty about the optimal respiratory support strategies in critically ill COVID-19 patients is widespread. While the risks and benefits of noninvasive techniques versus early invasive mechanical ventilation (IMV) are intensely debated, actual evidence is lacking. We sought to assess the risks and benefits of different respiratory support strategies, employed in intensive care units during the first months of the COVID-19 pandemic on intubation and intensive care unit (ICU) mortality rates.

METHODS

Subanalysis of a prospective, multinational registry of critically ill COVID-19 patients. Patients were subclassified into standard oxygen therapy ≥10 L/min (SOT), high-flow oxygen therapy (HFNC), noninvasive positive-pressure ventilation (NIV), and early IMV, according to the respiratory support strategy employed at the day of admission to ICU. Propensity score matching was performed to ensure comparability between groups.

RESULTS

Initially, 1421 patients were assessed for possible study inclusion. Of these, 351 patients (85 SOT, 87 HFNC, 87 NIV, and 92 IMV) remained eligible for full analysis after propensity score matching. 55% of patients initially receiving noninvasive respiratory support required IMV. The intubation rate was lower in patients initially ventilated with HFNC and NIV compared to those who received SOT (SOT: 64%, HFNC: 52%, NIV: 49%, p = 0.025). Compared to the other respiratory support strategies, NIV was associated with a higher overall ICU mortality (SOT: 18%, HFNC: 20%, NIV: 37%, IMV: 25%, p = 0.016).

CONCLUSION

In this cohort of critically ill patients with COVID-19, a trial of HFNC appeared to be the most balanced initial respiratory support strategy, given the reduced intubation rate and comparable ICU mortality rate. Nonetheless, considering the uncertainty and stress associated with the COVID-19 pandemic, SOT and early IMV represented safe initial respiratory support strategies. The presented findings, in agreement with classic ARDS literature, suggest that NIV should be avoided whenever possible due to the elevated ICU mortality risk.

[Lactic Acidosis and Other Misunderstandings]

Lactic Acidosis and Other Misunderstandings Abstract. Lactic acidosis is a frequently encountered clinical problem in intensive care medicine. Nevertheless, many of the underlying biochemical processes are insufficiently understood, which leads to various misconceptions. Physiologically, lactate is an important, continuously produced carrier of energy and by no means a metabolic 'waste product'. Lactate is the corresponding base to lactic acid and is produced directly from pyruvate. In this reaction H⁺ is consumed and therefore lactate production itself cannot be directly responsible for the simultaneously arising acidosis. An elevated lactate level allows no conclusions about the underlying pathophysiological process, and, more importantly, it is not an appropriate marker for tissue oxygenation.

[A Sweet Drink with Consequences]

A Sweet Drink with Consequences Abstract. Intoxications with ethylene glycol are rare, however, small quantities from the substance can be life-threatening. Regarding the treatment it is important to recognize the intoxication quickly and to immediately start the appropriate treatment. Intoxications with ethylene glycol or with methanol should always be considered as differential diagnosis in patients with severe metabolic acidosis. It is also very important to calculate the osmolal gap.

[Not Available]

Zusammenfassung. Wir präsentieren den Fall einer 23-jährigen Patientin, die in suizidaler Absicht Blätter des Roten Fingerhutes sammelte und einnahm. Trotz Einnahme einer relevanten Dosis hatte sie jedoch nur geringe Symptome. Intoxikationen mit Herzglykosiden sind selten, können aber relevante Herzrhythmusstörungen verursachen. Die einzige wirksame Behandlung stellt die frühzeitige und ggf. prophylaktische Gabe von digitalisspezifischen Fab-Antikörpern dar.

[Not Available]

Zusammenfassung. Zusammenfassung: Wir berichten über einen 69-jährigen Patienten, bei dem eine mikrochirurgische Dekompression und Diskektomie durchgeführt wurde. Im Verlauf entwickelte er stärkste Beinschmerzen ohne Ansprechen auf eine Schmerztherapie. Die durchgeführte Computertomografie zeigte grosse Lufteinschlüsse im retroperitonealen Raum von subdiaphragmal bis ins kleine Becken. Trotz sofortiger und radikaler chirurgischer Sanierung sowie antibiotischer Therapie starb der Patient noch im Operationssaal. Die vielzähligen intraoperativen Biopsien sowie alle Blutkulturen waren postmortem positiv für Clostridium perfringens.

[Not Available]

Zusammenfassung. Wir berichten über einen 72-jährigen Patienten mit progredienten Bauchschmerzen, Nausea und Dyspnoe seit Tagen bei vorbekannter Leberzirrhose und Diabetes mellitus. Trotz begonnener antibiotische Therapie bei spontan bakterieller Peritonitis verschlechterte sich der Zustand des Patienten weiter, sodass er in schwerstem Schockzustand auf die Intensivstation verlegt wurde. Bei schwerer Laktatazidose, Schock sowie Einnahme von Metformin wurde eine Metformin-assoziierte Laktatazidose diagnostiziert. Der Säure-Basen-Status liess sich unter kontinuierlicher Hämodiafiltration komplett korrigieren. Der Patient starb aber an einem Leberversagen bei vorbestehender Leberzirrhose.