Spontaneous massive hemothorax as a complication of necrotizing pneumonia in a patient with severe acute respiratory syndrome coronavirus 2 induced acute respiratory distress syndrome: a case report

Background!#!We present an unusual bleeding complication in a patient with severe acute respiratory distress syndrome in coronavirus disease 2019.!##!Case presentation!#!The patient, a 63-year-old Caucasian man, received venovenous extracorporeal membrane oxygenation support after rapid deterioration of lung function on day 6 after admission to hospital. After initial stabilization on lung protective ventilation and prone positioning, he started to develop mild bleeding complications until he went into occult profound hemorrhagic shock. Causative was a massive hemothorax of the right hemithorax with mediastinal shifting due to spontaneous bleeding from a pulmonal artery in a heavily remodeled right inferior lobe. Histopathological examination of the resected tissue showed signs of an organizing fibrinous pneumonia with focal parenchyma necrosis. After surviving a massive bleeding event caused by necrotizing pneumonia, the patient made a swift recovery and was discharged to rehabilitation 31 days after initial hospital admission.!##!Conclusions!#!The combination of severely elevated inflammatory markers and pulmonary hemorrhage should arouse suspicion of necrotizing pneumonia. In necrotizing pneumonia, the possibility of severe intrathoracic bleeding complications should be kept in mind if it comes to sudden deterioration of the patient

Butyrylcholinesterase activity in patients with postoperative delirium after cardiothoracic surgery or percutaneous valve replacement- an observational interdisciplinary cohort study

Abstract Background and objectives Postoperative delirium is a frequent and severe complication after cardiac surgery. Activity of butyrylcholinesterase (BChE) has been discussed controversially regarding a possible role in its development. This study aimed to investigate the relevance of BChE activity as a biomarker for postoperative delirium after cardiac surgery or percutaneous valve replacement. Methods A total of 237 patients who received elective cardiothoracic surgery or percutaneous valve replacement at a tertiary care centre were admitted preoperatively. These patients were tested with the Montreal Cognitive Assessment investigating cognitive deficits, and assessed for postoperative delirium twice daily for three days via the 3D-CAM or the CAM-ICU, depending on their level of consciousness. BChE activity was measured at three defined time points before and after surgery. Results Postoperative delirium occurred in 39.7% of patients (n = 94). Univariate analysis showed an association of pre- and postoperative BChE activity with its occurrence (p = 0.037, p = 0.001). There was no association of postoperative delirium and the decline in BChE activity (pre- to postoperative, p = 0.327). Multivariable analysis including either preoperative or postoperative BChE activity as well as age, MoCA, type 2 diabetes mellitus, coronary heart disease, type of surgery and intraoperative administration of red-cell concentrates was performed. Neither preoperative nor postoperative BChE activity was independently associated with the occurrence of postoperative delirium (p = 0.086, p = 0.484). Preoperative BChE activity was lower in older patients (B = -12.38 (95% CI: -21.94 to -2.83), p = 0.011), and in those with a history of stroke (B = -516.173 (95% CI: -893.927 to -138.420), p = 0.008) or alcohol abuse (B = -451.47 (95% CI: -868.38 to -34.55), p = 0.034). Lower postoperative BChE activity was independently associated with longer procedures (B = -461.90 (95% CI: -166.34 to -757.46), p = 0.002), use of cardiopulmonary bypass (B = -262.04 (95% CI: -485.68 to -38.39), p = 0.022), the number of administered red cell-concentrates (B = -40.99 (95% CI: -67.86 to -14.12), p = 0.003) and older age (B = -9.35 (95% CI: -16.04 to -2.66), p = 0.006). Conclusion BChE activity is not independently associated with the occurrence of postoperative delirium. Preoperative BChE values are related to patients’ morbidity and vulnerability, while postoperative activities reflect the severity, length and complications of surgery

Stroke, Seizures, Hallucinations and Postoperative Delirium as Neurological Complications after Cardiac Surgery and Percutaneous Valve Replacement

(1) Background: Neurological complications such as acute ischemic stroke or postoperative delirium are frequent after cardiac surgery or percutaneous valve replacement. This study aimed to identify corresponding risk factors. (2) Methods: 297 patients with percutaneous valve replacement or cardiac surgery were postoperatively screened for neurological complications such as delirium, stroke, seizures and hallucinations twice daily for three days. Pre- and perioperative risk factors were evaluated in a multivariate model. (3) Results: Neurological complications occurred in 43.8% (n = 130) as composed of delirium (43.43%, n = 129), stroke (2.7%, n = 8), seizures (1.35%, n = 4) and real hallucinations (3.36%, n = 10). Multiple logistic regression revealed an association of neurological complications with lower Montreal Cognitive Assessment scores (Exp(B) 2.042; 95% CI, 1.183–3.525, p = 0.010), older age (Exp(B) 1.071; 95% CI, 1.036–1.107, p < 0.001), red blood cell transfusions until postoperative day 3 (Exp(B) 1.157; 95% CI, 1.030–1.300, p = 0.014), history of heart failure (Exp(B) 1.985; 95% CI, 1.130–3.487, p = 0.017) and increased CRP levels (Exp(B) 1.004; 95% CI, 1.000–1.008, p = 0.037). (4) Conclusions: Postoperative delirium remains a frequent complication after cardiac surgery, while stroke and seizures occur rarely. A preoperative risk profile including older age, history of heart failure and cognitive impairment was identified for a complicated postoperative course. However, the impact of an intense inflammatory response must not be neglected