A step-by-step diagnosis of exclusion in a twin pregnancy with acute respiratory failure due to non-fatal amniotic fluid embolism: a case report

<p>Abstract</p> <p>Introduction</p> <p>Respiratory failure may develop during the later stages of pregnancy and is usually associated with tocolysis or other co-existing conditions such as pneumonia, sepsis, pre-eclampsia or amniotic fluid embolism syndrome.</p> <p>Case presentation</p> <p>We present the case of a 34-year-old healthy woman with a twin pregnancy at 31 weeks and 6 days who experienced acute respiratory failure, a few hours after administration of tocolysis (ritodrine), due to preterm premature rupture of the membranes. Her chest discomfort was significantly ameliorated after the ritodrine infusion was stopped and a Cesarean section was performed 48 hours later under spinal anesthesia; however, 2 hours after surgery she developed severe hypoxemia, hypotension, fever and mild coagulopathy. The patient was intubated and transferred to the intensive care unit where she made a quick and uneventful recovery within 3 days. As there was no evidence for drug- or infection-related thromboembolic or myocardial causes of respiratory failure, we conclude that our patient experienced a rare type of non-fatal amniotic fluid embolism.</p> <p>Conclusion</p> <p>In spite of the lack of solid scientific support for our diagnosis, we conclude that our patient suffered an uncommon type of amniotic fluid embolism syndrome and we believe that this report highlights the need for extreme vigilance and a high index of suspicion for such a diagnosis in any pregnant individual.</p

A fatal case of recurrent amiodarone-induced thyrotoxicosis after percutaneous tracheotomy: a case report

<p>Abstract</p> <p>Background</p> <p>Amiodarone is a widely used antiarrythmic drug, which may produce secondary effects on the thyroid. In 14–18% of amiodarone-treated patients, there is overt thyroid dysfunction, usually in the form of amiodarone-induced thyrotoxicosis, which can be difficult to manage with standard medical treatment.</p> <p>Case presentation</p> <p>Presented is the case of a 65-year-old man, under chronic treatment of atrial fibrillation with amiodarone, who was admitted to the Intensive Care Unit with acute cardio-respiratory failure and fever. He was recently hospitalized with respiratory distress, attributed to amiodarone-induced pulmonary fibrosis. Clinical and laboratory investigation revealed thyrotoxicosis due to amiodarone treatment. He was begun on thionamide, prednisone and beta-blockers. After a short term improvement of his clinical status the patient underwent percutaneous tracheotomy due to weaning failure from mechanical ventilation, which led to the development of recurrent thyrotoxicosis, unresponsive to medical treatment. Finally, the patient developed multiple organ failure and died, seven days later.</p> <p>Conclusion</p> <p>We suggest that percutaneous tracheotomy could precipitate a thyrotoxic crisis, particularly in non-euthyroid patients suffering from concurrent severe illness and should be performed only in parallel with emergency thyroid surgery, when indicated.</p

Relation of tricuspid annular displacement and tissue Doppler imaging velocities with duration of weaning in mechanically ventilated patients with acute pulmonary edema

<p>Abstract</p> <p>Background</p> <p>Liberation from the ventilator is a difficult task, whereas early echocardiographic indices of weaning readiness are still lacking. The aim of this study was to test whether tricuspid annular plane systolic excursion (TAPSE) and right ventricular (RV) systolic (Sm) and diastolic (Em & Am) tissue Doppler imaging (TDI) velocities are related with duration of weaning in mechanically ventilated patients with acute respiratory failure due to acute pulmonary edema (APE).</p> <p>Methods</p> <p>Detailed quantification of left and right ventricular systolic and diastolic function was performed at admission to the Intensive Care Unit by Doppler echocardiography, in a cohort of 32 mechanically ventilated patients with APE. TAPSE and RV TDI velocities were compared between patients with and without prolonged weaning (≥ or < 7 days from the first weaning trial respectively), whereas their association with duration of ventilation and left ventricular (LV) echo-derived indices was tested with multivariate linear and logistic regression analysis.</p> <p>Results</p> <p>Patients with prolonged weaning (n = 12) had decreased TAPSE (14.59 ± 1.56 vs 19.13 ± 2.59 mm), Sm (8.68 ± 0.94 vs 11.62 ± 1.77 cm/sec) and Em/Am ratio (0.98 ± 0.80 vs 2.62 ± 0.67, p <0.001 for all comparisons) and increased Ε/e' (11.31 ± 1.02 vs 8.98 ± 1.70, p <0.001) compared with subjects without prolonged weaning (n = 20). Logistic regression analysis revealed that TAPSE (R²= 0.53, beta slope = 0.76, p < 0.001), Sm (R²= 0.52, beta = 0.75, p < 0.001) and Em/Am (R²= 0.57, beta = 0.32, p < 0.001) can predict length of weaning ≥ 7 days. The above measures were also proven to correlate significantly with Ε/e' (r = -0.83 for TAPSE, r = -0.87 for Sm and r = -0.79 for Em/Am, p < 0.001 for all comparisons).</p> <p>Conclusions</p> <p>We suggest that in mechanically ventilated patients with APE, low TAPSE and RV TDI velocities upon admission are associated with delayed liberation from mechanical ventilation, probably due to more severe LV heart failure.</p

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Correction to: Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

The original version of this article unfortunately contained a mistake

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Blind randomized clinical study in prevention of intrathecal morphine induced pruritus

The intrathecally administered morphine offers powerful and lingering postoperative analgesia. Today it is applied widely for relief of postoperative pain associated with crowd of surgical interventions. The most common side effects of intrathecally administered morphine are pruritus with reported frequency between 60% and 100%, followed by postoperative nausea and vomiting (PONV) with a reported incidence between 30 and 50%. The intrathecal morphine induced pruritus because of its central mechanism is resistant to treatment with usual antipruritic drugs. Nonetheless, successful treatment of intrathecal morphine induced pruritus with opioid antagonists is accompanied with reversal of postoperative analgesia. Antagonists of subtype 3 receptors of 5-hydroxytryptamine (serotonin) - 5-ΗΤ3 antagonists are central acting antiemetic drugs. The 5-ΗΤ3 antagonists are indicated in patients whose postoperative analgesia is based on intrathecal morphine because this kind of analgesia is associated with increased risk of PONV. Administration of ondansetron, a 5-ΗΤ3 antagonist, was reported by three authors as effective preventive antipruritic measure for intrathecal morphine induced pruritus. As 5-ΗΤ3 antagonists do not affect patients’ awareness and postoperative analgesia and their side effects in usual doses for PONV prevention are very rare they approach the ideal drug for prevention of intrathecal morphine pruritus. However antipruritic efficacy for other 5-ΗΤ3 antagonists did not reported until now, as result from our research in pubmed database. So we deigned and performed a double blind, controlled clinical study in effectiveness of four 5-ΗΤ3 antagonists (ondansetron, dolasetron, granisetron and tropisetron) in prevention of intrathecal morphine induced pruritus. In our study were included 200 patients underwent surgical procedures with spinal anaesthesia with addition of 0, 25 mg morphine for postoperative analgesia. Patients were randomly allocated in five groups of 40 patients to receive placebo (group P), or 5-ΗΤ3 antagonists in i.v. doses indicated for prevention of PONV ( ondansetron 8 mg group O, dolasetron 12,5 mg -group D, granisetron 3 mg -group G and tropisetron 5 mg - group T). Patients with contraindication for spinal anaesthesia or any drug included in the study were excluded from the study. Patients with diseases associated with pruritus or which received drugs modifying pruritus were also excluded. Spinal anesthesia was performed with hyperbaric bupivacaine 0,5% 12,5 mg to 17,5 mg plus 0,25 mg preservative free morphine. The patients were followed intraoperatively and during the first 24 postoperative hours, data collection was performed immediately after end of surgery in postanesthesia care unit and in surgical ward at 2, 4, 6, 8, 12, and 24 hours postoperatively by a blinded resident anesthesiologist. Severity of pruritus was evaluated and recorded in ordinal scale 0 - no pruritus, 1 - mild pruritus, 2 - moderate pruritus, 3 - severe pruritus. The patients with severe pruritus were treated with nalbouphine 3 mg i.v. Postoperative nausea and vomiting were recorded with the following scale 0 - no nausea, 1 - mild nausea, 2 - moderate nausea, 3 severe nausea or episode of vomiting. Severe nausea and vomiting were treated with metoclopramide 10 mg i.v. Severity of postoperative pain at rest was evaluated and recorded using 10 cm visual analogue pain scale with gradation from 0 cm - no pain to 10 cm the worst experienced pain. Additional analgesia was provided with meperidine via patient controlled analgesia device. Vital sings were followed and recorded.Η υπαραχνοειδής χορήγηση μορφίνης προσφέρει ισχυρή και μακράς διάρκειας μετεγχειρητική αναλγησία και σήμερα εφαρμόζεται ευρύτατα σε συνδυασμό με την ραχιαία αναισθησία σε ασθενείς που υποβάλλονται σε ποικιλία χειρουργικών επεμβάσεων. Η συχνότερες ανεπιθύμητες ενέργειες της υπαραχνοειδώς χορηγουμένης μορφίνης είναι ο κνησμός με συχνότητα από 60 ως 100% και η μετεγχειρητική ναυτία και εμετός με συχνότητα που κυμαίνεται μεταξύ 30 και 50%. Ο κνησμός από υπαραχνοειδή χορήγηση μορφίνης, καθώς είναι κεντρικής αιτιολογίας, δεν αντιμετωπίζεται αποτελεσματικά με του συνήθεις αντικνησμώδεις φαρμακευτικούς παράγοντες. Ενώ η χορήγηση ανταγωνιστών των οπιοειδων που αντιμετωπίζει αποτελεσματικά τον κνησμό ελαττώνει παράλληλα τη διάρκεια και την ισχύ της αναλγησίας που προσφέρει η μορφίνη. Οι ανταγωνιστές των τύπου τρία υποδοχέων της 5 - υδροξυτρυπταμίνης (σεροτονίνης) -5-ΗΤ3 ανταγωνιστές- είναι κεντρικώς δρώντες αντιεμετικοί παράγοντες που έχουν ένδειξη χορήγησης στους ασθενείς που λαμβάνουν μορφίνη υπαραχνοειδώς λόγω της υψηλής συχνότητας μετεγχειρητικής ναυτίας και εμέτου που εμφανίζουν. Ένας αντιπρόσωπος των 5-ΗΤ3 ανταγωνιστών -η οντανσετρόνη αναφέρεται από τρεις συγγραφείς ως αποτελεσματικό μέσο πρόληψης και αντιμετώπισης του κνησμού από υπαραχνοειδή χορήγηση μορφίνης. Καθώς οι εκπρόσωποι της ομάδας των 5-ΗΤ3 ανταγωνιστών δεν επηρεάζουν την εγρήγορση του ασθενούς και την αναλγητική δράση της μορφίνης ενώ παράλληλα εμφανίζουν ελάχιστες ανεπιθύμητες ενέργειες στις χορηγούμενες δόσεις για την πρόληψη της μετεγχειρητικής ναυτίας και εμέτου πλησιάζουν τα χαρακτηριστικά του ιδανικού φαρμακευτικού παράγοντα για την πρόληψη του κνησμού από υπαραχνοειδή χορήγηση μορφίνης. Η αντικνησμώδης δράση ωστόσο των άλλων αντιπροσώπων της κατηγορίας των 5-ΗΤ3 ανταγωνιστών δεν έχει αποτελέσει μέχρι σήμερα αντικείμενο κλινικής μελέτης όπως προκύπτει από την ερεύνα της διεθνούς βιβλιογραφίας. Έτσι σχεδιάσαμε και πραγματοποιήσαμε μια διπλή, τυφλή, πλασέμπο ελεγχόμενη και τυχαιοποιημένη μελέτη με στόχο να ερευνήσουμε την αποτελεσματικότητα των τεσσάρων 5-ΗΤ3 ανταγωνιστών (οντανσετρόνη, ντολασετρόνη, γκρανισετρόνη και τροπισετρόνη) στη πρόληψη του κνησμού που προκαλείται από την υπαραχνοειδή χορήγηση μορφίνης. Η μελέτη μας πραγματοποιήθηκε σε 200 ασθενείς που υποβλήθηκαν σε χειρουργικές επεμβάσεις υπό ραχιαία αναισθησία και στους οποίους χορηγήθηκε μορφίνη υπαραχνοειδώς (0,25 mg) για μετεγχειρητική αναλγησία. Μετά από τυχαιοποίηση οι ασθενείς χωρίστηκαν σε πέντε ίσες ομάδες και τους χορηγήθηκε ενδοφλέβια 30 min πριν την πραγματοποίηση της ραχιαίας αναισθησίας πλασέμπο - (ομάδα Π) ή ένας από τους τέσσερεις 5-ΗΤ3 ανταγωνιστές στις δόσεις που ενδείκνυνται για την πρόληψη της μετεγχειρητικής ναυτίας και εμέτου (οντανσετρόνη 8 mg -ομάδα Ο, ντολασετρόνη- ομάδα Δ, 12,5 mg, γκρανισετρόνη 3 mg- ομάδα Γ και τροπισετρόνη 5 mg -ομάδα Τ). Από τη μελέτη εξαιρέθηκαν οι ασθενείς με αντένδειξη για ραχιαία αναισθησία ή με αντένδειξη χορήγησης κάποιου από τα φάρμακα της μελέτης. Εξαιρέθηκαν επίσης ασθενείς με νοσήματα που εκδηλώνουν κνησμό ή αγωγές που τροποποιούν τον κνησμό. Η ραχιαία αναισθησία πραγματοποιήθηκε με υπέρβαρες διάλυμα μπουπιβακαϊνης 12,5 mg ως 17,5 mg (ανάλογα με το ύψος των ασθενών) στο οποίο προστέθηκαν 0,25 mg μορφίνης

Apneic oxygenation for elimination of respiratory motion artefact in an intubated patient undergoing helical computed tomography pulmonary angiography

Respiratory motion artifact in intubated and mechanically ventilated patients often reduces the quality of helical computed tomography pulmonary angiography (CTPA). Apneic oxygenation is a well established intra-operative technique that allows adequate oxygenation for short periods (up to 10 min) in sedated and paralyzed patients. We describe the use of the apneic oxygenation for elimination of respiratory motion artefact in an intubated patient undergoing CTPA