The Role and Impact of Extracorporeal Membrane Oxygenation in Critical Care

Use of extracorporeal membrane oxygenation (ECMO) has been exponentially increasing over the last decade and is now considered a mainstream lifesaving treatment modality in critical care medicine. However, the need for physician education, training, and experience remains imperative. Although ECMO has traditionally been used in end-stage lung disease and circulatory collapse, it is being adopted for use in right heart failure, as a bridge to heart and lung transplantation, and as rescue therapy for both sepsis and post-organ transplantation. The following article discusses indications, management, complications, and challenges of ECMO as well as our experience at the Houston Methodist DeBakey Heart & Vascular Center.

Structural and functional analysis of beta2 microglobulin abnormalities in human lung and breast cancer

The escape of tumor cells from immune recognition is a central problem in tumor immunology. Here, we examined the functional role of somatic beta 2-microglobulin (beta2m) gene mutations in human lung and breast cancers. Using single-strand conformational polymorphism (SSCP) analysis and DNA sequencing, we found mutations in the beta2m gene in 2 of 110 tested lung, colon and breast tumors and tumor cell lines. No mutations were identified in 63 breast cancer tumors, in B-lymphoblastoid cell lines or normal tissues from these or other patients. In these cell lines, beta2m protein was undetectable by Western blot analysis and there was no MHC class I on their cell surface even after treatment with interferon-gamma. Transfection of these tumor cell lines with the beta2m gene, but not addition of purified beta2m protein restored MHC expression without addition of exogenous pepticles, indicating that endogenous beta2m expression is necessary for proper intracellular MHC assembly and stabilization by endogeneous pepticles. Mutation in beta2m caused cell line H2009 to be resistant to specific lysis by influenza virus-specific CTL from HLA matched donors, and transfection of the beta2m gene restored this killing. A small cell lung cancer cell line with low class I expression and with a normal beta2m genomic sequence nonetheless also demonstrated increased class I expression after transfection of the beta2m expression vector alone, indicating that the availability of beta2m may be rate limiting for MHC assembly in this line. Our results indicate that somatic mutations or selective loss of expression of the beta2m gene in human lung cancer is rare, but can cause defective MHC class I expression and function allowing these cells to escape recognition by cytotoxic T cells.

Topical application of platelet-rich plasma for diabetic foot ulcers: A systematic review

AIM

To determine if topical application of platelet-rich plasma (PRP) to diabetic foot ulcers (DFUs) results in superior healing rates.

METHODS

A systematic review was registered with PROSPERO and performed using PRISMA guidelines. Level I-IV investigations of topical PRP application in DFUs were sought in multiple databases including: MEDLINE, Web of Science, and Cochrane Central Register of Controlled Trials. The search terms used were "platelet rich plasma", "diabetes", "ulcers", and "wound". The Modified Coleman Methodology Score (MCMS) was used to analyze study methodological quality. Study heterogeneity and a mostly non-comparative nature of evidence precluded meta-analysis. Only the outcome measurements used by more than 50% of the studies were included in the data synthesis to increase power of the measurement over that of individual studies. A weighted mean of healing rate per week between PRP group vs controls were compared using two-sample z-tests using P-value of less than 0.05 for significance.

RESULTS

One thousand two hundred and seventeen articles were screened. Eleven articles (322 PRP subjects, 126 controls, PRP subject mean age 58.4 ± 7.2 years, control mean age 58.7 ± 5.9 years) were analyzed. Six articles were level II evidence, four were level III, and one article was level IV. The mean MCMS was 61.8 ± 7.3. Healing rate was significantly faster with PRP application compared to controls (0.68 ± 0.56 cm2/wk vs 0.39 ± 0.09 cm2/wk; P < 0.001). Mean heal time to > 90% of the original ulcer area was 7.8 ± 2.7 wk and 8.3 ± 3.7 wk for patients in the PRP group and control groups, respectively (P = 0.115). There were significantly lower adverse effects reported with PRP application compared to controls (7 wound infections, 1 contact dermatitis vs 14 wound infections, 1 maceration; P < 0.001).

CONCLUSION

The topical application of PRP for DFUs results in statistically superior healing rates and lower complication rates compared to controls.

Correlation between metabolic syndrome and sleep apnea

The so-called “metabolic syndrome” (MS), constitutes a cluster of metabolic and cardiovascular abnormalities, including fasting glucose, blood pressure, triglycerides, high density lipoprotein cholesterol (HDL-C), and waist circumference that arise from insulin resistance. Obstructive sleep apnea (OSA) syndrome is characterized by recurrent episodes of partial or complete obstruction of the upper airway, involving cessation or significant decreased airflow, with intermittent hypoxemia, frequent arousals from sleep and recurrent oxyhemoglobin desaturations that interfere with normal sleep patterns generating difficulty falling asleep, unrefreshing sleep and loud snoring. The relation between these two entities is known as “Syndrome Z”, and there is no question about the impact of these risk factors on health and disease. This clinical condition presents a growing epidemic Worldwide, affecting approximately 60% of the general population with both MS and OSA due to the constant increase of body mass index in humans. This article presents evidence-based data that focuses on the direct relationship between MS and OSA.

Radiological Findings in Patients with COVID-19

After its origin in Wuhan, China, coronavirus related respiratory illness spread across the globe, being declared as a pandemic by WHO on March 13, 2020. Because it is acquired via respiratory droplets, community spread is responsible for the recent global crisis. The current diagnostic options include real-time polymerase chain reaction (RT-PCR) and a few serology tests, including but not limited to the recently approved five minutes serology tests. The disease presents as a lower respiratory tract illness. Anecdotal experiences have shown that imaging characteristics are crucial to diagnosis as radiological evidence of disease appears prior to clinical manifestations and tends to evolve over time, which can be useful in predicting the stage of the disease. CT scan is more sensitive than a chest X-ray in highlighting these changes.

Severe insulin resistance treatment with intravenous chromium in septic shock patient

Insulin resistance has been well documented in critically ill patients. Adequate blood sugar control has been associated with better wound healing, and better outcomes in selected patient populations. Chromium is an essential component of human diet. It is believed to affect changes in glucose uptake. Several studies have shown beneficial effects of oral chromium in diabetic patients with insulin resistance, but role of intravenous chromium infusion has not been completely evaluated. We present a case of extreme insulin resistance in a 62-year-old woman with history of diabetes who suffered a cardiac arrest and respiratory failure, leading to aspiration pneumonia and septic shock requiring greater than 7000 units of insulin over a period of 12 h which was successfully treated with intravenous chromium replacement.

Impact of Conservative Versus Conventional Oxygenation on Outcomes of Patients in Intensive Care Units: A Systematic Review and Meta-analysis

BACKGROUND

There is mixed evidence in the superiority of conservative versus conventional approach to oxygen therapy among patients admitted into the intensive care unit (ICU). The purpose of this study was to determine if conservative versus conventional oxygenation results in a statistically significant difference in outcomes in ICU patients.

METHODS

A systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) and performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria consisted of Level I-IV investigations of conservative versus conventional oxygenation among ICU patients. ICU mortality, 28-day mortality, in-hospital mortality, ICU length-of-stay, hospital length-of-stay, rate of new infections, and rate of new non-respiratory organ failure were compared using two-sample Z-tests using p-value less than 0.05.

RESULTS

Three thousand four hundred thirty-three articles were screened. Four articles were included in the analysis. Three hundred seventy-two patients under the conservative oxygenation arm (Minimum target SpO2: 88-94%) and 370 patients under the conventional oxygenation arm (Minimum target SpO2: 96-97%) were analyzed. ICU mortality (16.7 ± 9.5% vs. 22.7 ± 6.0%; P<0.01), 28-day mortality (34.6 ± 26.4% vs. 41.6 ± 14.6%; P=0.02), and in-hospital mortality (30.2 ± 22.5% vs. 37.7 ± 14.2%; P<0.01) were all significantly lower in the conservative oxygenation arm versus the conventional oxygenation arm, respectively. Rate of new non-respiratory organ failure was also significantly lower in the conservative oxygenation arm (20.0 ± 8.5% vs. 29.7 ± 11.7%; P<0.01).

CONCLUSION

The authors conclude that conservative oxygenation therapy could result in significantly lower rates of ICU mortality, 28-day mortality, in-hospital mortality, and new-onset non-respiratory organ failure. Further randomized controlled studies that show clinical outcome improvement in multiple parameters may be worthwhile to assess the true efficacy of this practice.

Weaning from Mechanical Ventilator in a Long-term Acute Care Hospital: A Retrospective Analysis

BACKGROUND

Prolonged Mechanical Ventilation (PMV) is associated with a higher cost of care and increased morbidity and mortality. Patients requiring PMV are referred mostly to Long-Term Acute Care (LTAC) facilities.

OBJECTIVE

To determine if protocol-driven weaning from mechanical ventilator by Respiratory Therapist (RT) would result in quicker weaning from mechanical ventilation, cost-effectiveness, and decreased mortality.

METHODS

A retrospective case-control study was conducted that utilized protocol-driven ventilator weaning by respiratory therapist (RT) as a part of the Respiratory Disease Certification Program (RDCP).

RESULTS

51 patients on mechanical ventilation before initiation of protocol-based ventilator weaning formed the control group. 111 patients on mechanical ventilation after implementation of the protocol formed the study group. Time to wean from the mechanical ventilation before the implementation of protocol-driven weaning by RT was 16.76 +/- 18.91 days, while that after the implementation of protocol was 7.67 +/- 6.58 days (p < 0.0001). Mortality proportion in patients after implementation of protocol-based ventilator weaning was 0.21 as compared to 0.37 in the control group (p=0.0153). The daily cost of patient care for the LTAC while on mechanical ventilation was $2200/day per patient while it was $ 1400/day per patient while not on mechanical ventilation leading to significant cost savings.

CONCLUSION

Protocol-driven liberation from mechanical ventilation in LTAC by RT can significantly decrease the duration of a mechanical ventilator, leading to decreased mortality and cost savings.

Posterior Alien Hand Syndrome from Acute Ischemic Left Parietal Lobe Infarction

Alien hand syndrome (AHS) is defined as an involuntary goal-directed movement of the hand as if acting on its own will, or as being under the control of someone else. Moreover, the affected hand typically does not show any signs of weakness or convulsive movement. The cause of AHS is associated with an insult to the brain from various conditions such as stroke, trauma, tumor, aneurysm, neurosurgical intervention, infection, and degenerative brain diseases. We hereby illustrate a case of a patient with chronic atrial dysrhythmia whose oral anticoagulation therapy was placed on hold by his gastroenterologist for a scheduled colonoscopy. The patient presented to the hospital with symptoms of right-hand paresthesia with uncontrolled movement. These symptoms were seen along ST-segment elevation in the inferior leads on a 12 lead electrocardiogram. The case report acknowledges an unusual presentation of acute ischemic stroke, which may be frightening and bewildering to patients, their families, and any healthcare providers, including neurologists, who may have encountered it for the first time. Also, our patient had posterior AHS, likely from infarction involving the left inferior parietal lobe, which is reported to have a low prevalence.

Urinary Incontinence in Older Adults Takes Collaborative Nursing Efforts to Improve

There is a misconception that urinary incontinence (UI) in older adults, usually above the age of 65 is a part of aging. More than 50% of residents in long-term care (LTC) settings are affected by UI and it is associated in many cases with markedly reduced quality of life. It has become evident that incontinence can be cured or successfully managed. However, many nurses lack sufficient knowledge to intervene appropriately. The purpose of this review is to share how the collaborative efforts of nurses at all levels may lead to increased assessment and interventions of UI in this population.

Patient Engagement and Patient Safety: Are We Missing the Patient in the Center?

The global healthcare delivery paradigm shift calls for enhanced strategies to engage patients in delivering safer and high-quality healthcare. There still exists a gap area in a globally accepted measure for the person-centered care. Recent tri-institutional global quality reports from National Academies of Sciences, Engineering, and Medicine (NAESM), World Bank Group, and Lancet Global Health Commission attempted to report the patient engagement measures used globally. We aim to understand the variation in these globally reported patient-centered care measures and highlight the recent proactive strategies to enhance patient engagement to improve patient safety. I.

Updates on critical care management of cardiovascular patients

Cardiology and cardiovascular surgery patients have historically been one of the sickest populations that physicians encounter. With the inherent compromise of the cardiac and/or respiratory system and the added complexity of a major surgical procedure, this patient group requires a demanding level of care. As innovations in the treatment of cardiac patients have prolonged life, we have encountered patients who require redo-redo-redo procedures. There has been a tremendous increase in the use of a wide variety of mechanical assist devices, transplantation procedures, robotic surgery, and hybrid approaches in which cardiac surgeons and cardiologists work in the same room on the same patient. Against this background, there have been quite a few changes taking place in the field of critical care. This report discusses the transformations being made in blood pressure management, blood product transfusion, prevention of healthcareassociated infections, physical therapy in cardiothoracic intensive care units (ICUs), ventilatory management, and the role of intensivists in cardiothoracic ICUs.

Vasoplegia: A Review

Vasoplegia is a condition characterized by persistent low systemic vascular resistance despite a normal or high cardiac index, resulting in profound and uncontrolled vasodilation. Vasoplegia may occur due to various conditions, including cardiac failure, sepsis, and post-cardiac surgery. In the cardiac cohort, multiple risk factors for vasoplegia have been identified. Several factors contribute to the pathophysiology of this condition, and various mechanisms have been proposed, including nitric oxide, adenosine, prostanoids, endothelins, the renin-angiotensin-aldosterone system, and hydrogen sulfide. Early identification and prompt management of vasoplegia is crucial to prevent development of shock. This review expands upon the different vasopressors used in management of vasoplegia, including catecholamines such as norepinephrine, dopamine, epinephrine, phenylephrine, and other agents including vasopressin, methylene blue, angiotensin II, hydroxocobalamin, vitamin C, thiamine, and corticosteroids (ie, hydrocortisone). It also emphasizes the importance of conducting further research and making advancements in treatment regimens for vasoplegia.

Changing Paradigms of Bedside Clinical Teaching

Education has continued to evolve since the existence of mankind. We have now become more well-equipped and refined our teaching methodology over time. Despite all the progress made, we still continue to rely on bedside huddle for teaching. Globalization has facilitated learning in culturally diverse environment. Grand rounds, noon lectures and conferences help the millennial house-staff to effectively translate their concepts to hands-on clinical experience. Useful teaching strategies like story-telling, connecting, simplifying, playing hierarchy make learning more fun and engaging. Multidisciplinary collaborative learning has eased conceptualization and retention of practical knowledge. Our education system now focuses more on patient-centered, case-based learning system.

Patient and Family Engagement During Challenging Times: What Works and What Does Not?

A paradigm shift towards enhanced strategies to effectively engage patients and families in delivering safe and high-quality healthcare services was observed during recent times, particularly in the last decade. Immediately prior to the coronavirus disease 2019 (Covid-19) pandemic, the tri-institutional global healthcare quality reports from the National Academies of Sciences, Engineering, and Medicine, World Bank Group, and Lancet Global Health Commission reported the patient and family engagement measures used globally, highlighting the variations across the regions of the world. Through a pandemic for more than a year now, we aim to present the key lessons learned from practices and strategies to proactively engage patients and families. These strategies may continue to be implemented in the post-Covid-19 pandemic era to improve patient and family-centered care.

An Intriguing Case of Pneumoperitoneum In a Patient With COVID-19: Do All Pneumoperitoneum Cases Need Surgery?

Pneumoperitoneum is pneumatosis in the potential space of the abdominal cavity. It is generally considered a surgical emergency and is mostly due to perforated hollow viscus. Rarely, pneumoperitoneum might occur even in the absence of bowel perforation. We hereby present a case of pneumoperitoneum in a patient with COVID-19 pneumonia and pneumomediastinum, which was managed non-surgically.

Evidence-Based Medicine: History, Review, Criticisms, and Pitfalls

Evidence-based medicine (EBM) is the use of high-quality clinical research in making decisions about the care of patients. Its formal origin dates back to the mid-nineteenth century, and since then, it has continued to evolve. The best research evidence, clinical expertise, and patient values are described as the foundations of EBM. However, several tools and skills have been developed and added over time. EBM has faced a lot of criticism, and the pitfalls are widely discussed and published in the medical literature. The biggest challenge is the changing paradigm of healthcare, cost-effectiveness, and changing evidence which has led to controversies and challenges in the rapid adaptation of the EBM. This review article discusses the history, conception, and evolution of modern-day EBM. In addition, we discuss why EBM has been criticized and highlight the pitfalls.

Evolving paradigm of thrombolysis in pulmonary embolism: Comprehensive review of clinical manifestations, indications, recent advances and guideline

Thrombolytic therapy has been the mainstay for patients with pulmonary embolism (PE). Despite being linked to a higher risk of significant bleeding, clinical trials demonstrate that thrombolytic therapy should be used in patients with moderate to high-risk PE, in addition to hemodynamic instability symptoms. This prevents the progression of right heart failure and impending hemodynamic collapse. Diagnosing PE can be challenging due to the variety of presentations; therefore, guidelines and scoring systems have been established to guide physicians to correctly identify and manage the condition. Traditionally, systemic thrombolysis has been utilized to lyse the emboli in PE. However, newer techniques for thrombolysis have been developed, such as endovascular ultrasound-assisted catheter-directed thrombolysis for massive and intermediate-high submassive risk groups. Additional newer techniques explored are the use of extracorporeal membrane oxygenation, direct aspiration, or fragmentation with aspiration. Because of the constantly changing therapeutic options and the scarcity of randomized controlled trials, choosing the best course of treatment for a given patient may be difficult. To help, the Pulmonary Embolism Reaction Team is a multidisciplinary, rapid response team that has been developed and is used at many institutions. Hence to bridge the knowledge gap, our review highlights various indications of thrombolysis in addition to the recent advances and management guidelines

Cardiogenic Shock in Perioperative and Intraoperative Settings: A Team Approach

Cardiogenic shock (CS) is a multifactorial disease process with high morbidity and mortality. When it occurs in a peri- or intraoperative setting, factors such as surgery, anesthesia, and post-surgical physiology can negatively affect patient outcomes. Since patient needs often escalate during CS-from medications to mechanical support to palliative care-this disease demands a multidisciplinary approach that encompasses all aspects of medical delivery. Preliminary studies have indicated that a multidisciplinary team approach to CS results in earlier diagnosis and treatment and improves patient outcomes. Here we discuss various management strategies for CS from an anesthesiology, surgery, and critical care perspective.

When a Dead Patient Is Not Really Dead: Lazarus Phenomenon

Lazarus phenomenon refers to autoresuscitation of a patient declared dead after cessation of cardiopulmonary resuscitation (CPR). The Lazarus phenomenon is rarely encountered and pathophysiology is not very well understood, but physicians need to be aware of this phenomenon. It is prudent that a physician leading a CPR effort waits for some time and monitors the patient further using blood pressure and electrocardiogram before confirming that a patient is actually dead.

A Case of Pneumocephalus Due to an Untreated Atrial-Esophageal Fistula Post-Left Atrial Ablation Therapy

Air embolisms can be caused by trauma, barotrauma, or due to surgical procedures in neurosurgery, vascular surgery, and cardiac surgery. An atrial-esophageal fistula (AEF) is a life-threatening complication that can occur following left atrial ablation therapy, which is used to treat refractory atrial fibrillation (Afib). AEF, if left untreated, can lead to serious neurological complications such as pneumocephalus. We present a rare case of pneumocephalus in a 60-year-old male who recently underwent left atrial ablation therapy after which he presented to the ER following a fall. On examination, the patient was confused and had difficulty getting up. A left hemiparesis and a rightward gaze preference were also observed. The CT scan of the head confirmed pneumocephalus. Our report is unique as it explores a very rare entity and highlights the implications of a delay in the treatment of AEF. Early surgical intervention is the key to ensuring the survival of patients with an AEF.

Thoracic Liposarcoma In An End Stage Renal Disease Patient

Liposarcoma arising in the thoracic cavity is a rare entity. It is usually found in the retroperitoneal space and the extremities. No case of thoracic liposarcoma in a patient suffering from the end-stage renal disease has been reported in the literature. We herein present the first case of thoracic liposarcoma in a patient suffering from the end-stage renal disease. Metabolic disturbances, increased use of erythropoietin and increased diagnostic workup attributes to greater risk of cancer in patients suffering from renal failure. A chemotherapeutic drug, Trabectedin has been approved for advanced liposarcoma. Prognosis of such tumours depends on the size, location, and their histological subtype.