Cardiogenic shock due to probable SARS-CoV-2 myocarditis:a case report

BACKGROUND: Since the start of the COVID-19 pandemic, many case reports have been presented describing different cardiac symptoms due to the SARS-CoV-2 infection. However, severe cardiac failure due to COVID-19 seems to be rare.CASE SUMMARY: A 30-year-old woman presented with COVID-19 and cardiogenic shock due to a lymphocytic myocarditis. Since she deteriorated under treatment with inotropes, she was referred to our centre, and veno-arterial extracorporeal life support was started. Subsequently, the aortic valve only opened sporadically, and spontaneous contrast appeared in the left ventricle (LV), pointing towards difficulties with unloading LV. Therefore, an Impella for venting the LV was implanted. After 6 days of mechanical circulatory support, her heart function recovered. All support could be weaned, and 2 months later, she had made a full recovery.DISCUSSION: We presented a patient with severe cardiogenic shock due to an acute virus-negative lymphocytic myocarditis associated with a SARS-CoV-2 infection. Since the precise aetiology of SARS-CoV-2-related myocarditis remains to be elucidated and no virus could be detected in the heart, a causal relationship remains speculative.</p

A prolonged ICU stay after interhospital transport?

Transport of critically ill patients can be complicated [1-3]. Barratt and colleagues studied patients transferred for nonclinical reasons to evaluate the consequences of transportation [4]. Th ere was no diff erence in mortality but the ICU length of stay (LOS) increased by 3  days, which was explained as a negative impact of the transport on patient physiology. We disagree with this conclusion. First, by including only transports to level 3 ICUs the received level of care for transported patients will increase, introducing a bias. Second, the increase in LOS can be interpreted as a result of selection bias, because patients with a short expected LOS would often not be considered eligible for transport. Also, since there was no increase in mortality, which would have been expected with an increased LOS, we might be looking at a mortality reduction as a result of the transfer to a higher-level ICU. Th ird, Barrett and colleagues suggest that deterioration of patient physiology during transport is probably respon sible for the increase in LOS. However, the reported Intensive Care National Audit and Research Centre scores before and after transport (although not validated for sequential patient assessments) do not support this assumption. Fourth, the method of transportation should have been included in this study. Specialised transport teams deliver patients with a better acute physiology compared with nonspecialised teams [2,5], making a need for regaining physiological stability unlikely. In conclusion, we congratulate Barratt and colleagues for their research. However, we think their conclusion is premature because multiple possible confounders were not taken into account

Quality of interhospital transport of the critically ill: impact of a Mobile Intensive Care Unit with a specialized retrieval team

Introduction: In order to minimize the additional risk of interhospital transport of critically ill patients, we started a mobile intensive care unit (MICU) with a specialized retrieval team, reaching out from our university hospital-based intensive care unit to our adherence region in March 2009. To evaluate the effects of this implementation, we performed a prospective audit comparing adverse events and patient stability during MICU transfers with our previous data on transfers performed by standard ambulance. Methods: All transfers performed by MICU from March 2009 until December 2009 were included. Data on 14 vital variables were collected at the moment of departure, arrival and 24 hours after admission. Variables before and after transfer were compared using the paired-sample T-test. Major deterioration was expressed as a variable beyond a predefined critical threshold and was analyzed using the McNemar test and the Wilcoxon Signed Ranks test. Results were compared to the data of our previous prospective study on interhospital transfer performed by ambulance. Results: A total of 74 interhospital transfers of ICU patients over a 10-month period were evaluated. An increase of total number of variables beyond critical threshold at arrival, indicating a worsening of condition, was found in 38 percent of patients. Thirty-two percent exhibited a decrease of one or more variables beyond critical threshold and 30% showed no difference. There was no correlation between patient status at arrival and the duration of transfer or severity of disease. ICU mortality was 28%. Systolic blood pressure, glucose and haemoglobin were significantly different at arrival compared to departure, although significant values for major deterioration were never reached. Compared to standard ambulance transfers of ICU patients, there were less adverse events: 12.5% vs. 34%, which in the current study were merely caused by technical (and not medical) problems. Although mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score was significantly higher, patients transferred by MICU showed less deterioration in pulmonary parameters during transfer than patients transferred by standard ambulance. Conclusions: Transfer by MICU imposes less risk to critically ill patients compared to transfer performed by standard ambulance and has, therefore, resulted in an improved quality of interhospital transport of ICU patients in the north-eastern part of the Netherlands

Hemorrhagic complications during extracorporeal membrane oxygenation - The role of anticoagulation and platelets

PURPOSE: Hemorrhagic complications during extracorporeal membrane oxygenation are frequent and have a negative impact on outcome. We studied the association between activated partial thromboplastin time or platelet count and the occurrence of hemorrhagic complications. The secondary objective was to determine risk factors for hemorrhagic complications. METHODS: Retrospective cohort study in a single-center Dutch university hospital. We included all adult patients on extracorporeal membrane oxygenation admitted to the intensive care unit between 2010 and 2017. RESULTS: We included 164 consecutive patients of which 73 (45%) had a hemorrhagic complication. The most prevalent hemorrhagic complications were surgical site (62%) and cannula site bleeding (18%). Survival to discharge was 67% in the patients without a hemorrhagic complication and 33% in the patients with hemorrhagic complications (p < .01). A higher activated partial thromboplastin time in the 24 h prior was associated with the occurrence of hemorrhagic complications (adjusted hazard ratio per 10 s increase 1.14; (95% CI 1.05-1.24). Venoarterial extracorporeal membrane oxygenation, duration of support, and higher activated partial thromboplastin time were risk factors for the occurrence of hemorrhagic complications. CONCLUSIONS: Higher activated partial thromboplastin time is associated with the occurrence of hemorrhagic complications

Inter-hospital transport of critically ill patients; expect surprises

INTRODUCTION: Inter-hospital transport of critically ill patients is increasing. When performed by specialized retrieval teams there are less adverse events compared to transport by ambulance. These transports are performed with technical equipment also used in an Intensive Care Unit (ICU). As a consequence technical problems may arise and have to be dealt with on the road. In this study, all technical problems encountered while transporting patients with our mobile intensive care unit service (MICU) were evaluated. METHODS: From March 2009 until August 2011 all transports were reviewed for technical problems. The cause, solution and, where relevant, its influence on protocol were stated. RESULTS: In this period of 30 months, 353 patients were transported. In total 55 technical problems were encountered. We provide examples of how they influenced transport and how they may be resolved. CONCLUSION: The use of technical equipment is part of intensive care medicine. Wherever this kind of equipment is used, technical problems will occur. During inter-hospital transports, without extra personnel or technical assistance, the transport team is dependent on its own ability to resolve these problems. Therefore, we emphasize the importance of having some technical understanding of the equipment used and the importance of training to anticipate, prevent and resolve technical problems. Being an outstanding intensivist on the ICU does not necessarily mean being qualified for transporting the critically ill as well. Although these are lessons derived from inter-hospital transport, they may also apply to intra-hospital transport

Bedside lung ultrasound in the critically ill patient with pulmonary pathology:different diagnoses with comparable chest X-ray opacification

The differential diagnosis and treatment of opacifications on the chest X-ray in critically ill patients may be challenging. This holds in particular the patient that suffers from respiratory failure with hemodynamic instability. Opacification in the chest X-ray could be the result of hematothorax, pleural effusion, atelectasis, or consolidation. Physical examination of such patients may not always indicate what the cause of the opacification is and thus may not always help indicate the correct therapeutic approach. In such cases, bedside ultrasound may be very helpful. We present two cases with similar chest X-ray opacifications but different diagnoses established with the help of a bedside lung ultrasound. There is documented accuracy of ultrasound in differentiating pleural effusions from consolidation. Ultrasound is safe and may be an alternative for computed tomography scan in a hemodynamically or respiratory unstable intensive care patient

Incidence and risk factors of deep vein thrombosis after extracorporeal life support

Background: Deep vein thrombosis (DVT) after decannulation of extracorporeal life support (ECLS) is not uncommon. Moreover, the impact of anticoagulation and potential risk factors is unclear. Furthermore, it is unclear if cannula-associated DVT is more common in ECLS patients compared to critically ill patients without ECLS. Methods: All adult patients who were successfully weaned from ECLS and were screened for DVT following decannulation were included in this observational cohort study. The incidence of post-ECLS-DVT was assessed and the cannula-associated DVT rate was compared with that of patients without ECLS after central venous catheter (CVC) removal. The correlation between the level of anticoagulation, risk factors, and post-ECLS-DVT was determined. Results: We included 30 ECLS patients and 53 non-ECLS patients. DVT was found in 15 patients (50%) of which 10 patients had a DVT in a cannulated vein. No correlation between the level of anticoagulation and DVT was found. V-V ECLS mode was the only independent risk factor for post-ECLS-DVT (OR 5.5; 95%CI 1.16–26.41). We found no difference between the ECLS and non-ECLS cohorts regarding cannula-associated DVT rate (33% vs. 32%). Conclusion: Post-ECLS-DVT is a common finding that occurs in half of all patients supported with ECLS. The incidence of cannula-associated DVT was equal to CVC-associated DVT in critically ill patients without ECLS. V-V ECLS was an independent risk factor for post-ECLS-DVT