Point-Of-Care Echocardiography And Electrocardiography In Assessing Suspected Pulmonary Embolism

POINT-OF-CARE ECHOCARDIOGRAPHY AND ELECTROCARDIOGRAPHY IN ASSESSING SUSPECTED PULMONARY EMBLOSIM. John Grotberg, James Daley, Richard A. Taylor, Chris L. Moore. Section of Ultrasound, Department of Emergency Medicine, Yale University, School of Medicine, New Haven, CT. Daniels and TwiST electrocardiogram (ECG) scores have been proposed to detect right heart strain (RHS). Tricuspid Annular Plane Systolic Excursion (TAPSE) is a reliable indicator of RHS in patients with acute pulmonary embolism (PE). I aimed to investigate the relationship between these ECG scores, TAPSE, and the level of care required for patients with acute PE. This was a prospective observational study of 110 patients undergoing CTA for suspected PE. ECGs were obtained and patients underwent bedside echocardiography. Low TAPSE was defined as ≤17 mm. Mean Daniels and TwiST scores were compared to mean TAPSE, and all were used to evaluate the risk of requiring “PE elevated care” (PEEC), defined as care more aggressive than simple heparination. Mean Daniels and TwiST scores were significantly different between low and high TAPSE groups (p\u3c0.0001), and high Daniels and TwiST scores correlated to low TAPSE (p\u3c0.0001, p=0.0002). PE positive (PE+) patients had lower mean TAPSE than PE negative (PE-) patients (p=0.0003). PE+ patients had a higher mean Daniels score and mean TwiST score than PE- patients (p=0.0024, p=0.0033). Patients requiring PEEC had lower mean TAPSE (p=0.047) and higher mean TwiST (p=0.020) values. TAPSE ≤17 mm and TwiST ≥5 had increased risks of 6.9 (p=0.045) and 4.4 (p=0.025) respectively for requiring PEEC. Both the Daniels and TwiST ECG scores correlated with TAPSE. All three were predictive of PE on CTA, while TAPSE and TwiST were predictive of requiring PEEC, suggesting their prognostic value in PE care

Management of severe acute respiratory distress syndrome: A primer

This narrative review explores the physiology and evidence-based management of patients with severe acute respiratory distress syndrome (ARDS) and refractory hypoxemia, with a focus on mechanical ventilation, adjunctive therapies, and veno-venous extracorporeal membrane oxygenation (V-V ECMO). Severe ARDS cases increased dramatically worldwide during the Covid-19 pandemic and carry a high mortality. The mainstay of treatment to improve survival and ventilator-free days is proning, conservative fluid management, and lung protective ventilation. Ventilator settings should be individualized when possible to improve patient-ventilator synchrony and reduce ventilator-induced lung injury (VILI). Positive end-expiratory pressure can be individualized by titrating to best respiratory system compliance, or by using advanced methods, such as electrical impedance tomography or esophageal manometry. Adjustments to mitigate high driving pressure and mechanical power, two possible drivers of VILI, may be further beneficial. In patients with refractory hypoxemia, salvage modes of ventilation such as high frequency oscillatory ventilation and airway pressure release ventilation are additional options that may be appropriate in select patients. Adjunctive therapies also may be applied judiciously, such as recruitment maneuvers, inhaled pulmonary vasodilators, neuromuscular blockers, or glucocorticoids, and may improve oxygenation, but do not clearly reduce mortality. In select, refractory cases, the addition of V-V ECMO improves gas exchange and modestly improves survival by allowing for lung rest. In addition to VILI, patients with severe ARDS are at risk for complications including acute cor pulmonale, physical debility, and neurocognitive deficits. Even among the most severe cases, ARDS is a heterogeneous disease, and future studies are needed to identify ARDS subgroups to individualize therapies and advance care

Modifying Ti6Al4V Implant Surfaces: Cell Responses and Corrosion Resistance of Annealed Titania Nanotubes

Titanium alloy (Ti-6Al-4V) is often used in orthopedic and dental implants integrated into bone tissue. However, the negative impact of in vivo corrosion of these metallic biomedical implants still remains a complex problem in the medical field. As current surface modifications of this alloy are investigated for potential application as implant materials, it is necessary to characterize these surfaces, understand how they will perform in an in vivo-like environment, and investigate the properties of corrosion resistance under simulated physiological conditions. Surface modifications of interest included the formation of titania nanotubes by anodization, as they have shown promise in providing nanoscale topography for cellular growth as well as drug-loading capabilities, and thermal oxidation, in order to induce thickening of a compact oxide layer as well as changing the crystalline structure. Thus, the primary aim was to determine the effects of electrochemical anodization (60 V, 2h) and thermal oxidation (600° C) on the corrosive behavior of Ti-6Al-4V, with serum proteins, at physiological temperature. Anodization produced a mixture of anatase and amorphous TiO2 nanotubes, while the annealing process yielded an anatase/rutile mixture TiO2 nanotubes. The surface area was analyzed by Brunauer-Emmett-Teller method and was estimated to more than 2 orders of magnitude higher than that of polished control samples. Corrosion resistance was evaluated on the parameters of open circuit potential, corrosion potential, corrosion current density, passivation current density, polarization resistance and equivalent circuit modeling. Samples both anodized and thermally oxidized exhibited shifts of open circuit potential and corrosion potential in the positive direction, indicating a more stable nanotube layer, as well as lower corrosion current densities and passivation current densities than the smooth control. They also showed increased polarization resistance and diffusion limited charge transfer within the bulk oxide layer. However, compared to the amorphous nanotubes, the thermally oxidized nanotubes showed evidence of increased corrosion in anodic regions slightly greater than the corrosion potential, and less favorable passivation behavior. As per the findings, the treatment groups analyzed were ordered from greatest corrosion resistance to least as Anodized+Thermally Oxidized > Anodized > Smooth > Thermally Oxidized

Timing of Intubation in COVID-19: When It Is Too Early and When It Is Too Late

The timing of initiating mechanical ventilation in patients with acute respiratory distress syndrome due to COVID-19 remains controversial. At the outset of the pandemic, “very early” intubation was recommended in patients requiring oxygen flows above 6 L per minute but was followed closely thereafter by avoidance of invasive mechanical ventilation (IMV) due to a perceived (yet over-estimated) risk of mortality after intubation. While the use of noninvasive methods of oxygen delivery, such as high-flow nasal oxygen (HFNO) or noninvasive positive pressure ventilation (NIV), can avert the need for mechanical ventilation in some, accumulating evidence suggests delayed intubation is also associated with an increased mortality in a subset of COVID-19 patients. Close monitoring is necessary in COVID-19 patients on HFNO or NIV to identify signs of noninvasive failure and ensure appropriate provision of IMV

Venovenous extracorporeal membrane oxygenation after cardiac arrest for acute respiratory distress syndrome caused by Legionella: a case report

Abstract Background Legionella remains underdiagnosed in the intensive care unit and can progress to acute respiratory distress syndrome (ARDS), multiorgan failure and death. In severe cases, venovenous extracorporeal membrane oxygenation (VV-ECMO) allows time for resolution of disease with Legionella-targeted therapy. VV-ECMO outcomes for Legionella are favorable with reported survival greater than 70%. Rapid molecular polymerase chain reaction (PCR) testing of the lower respiratory tract aids in diagnosing Legionella with high sensitivity and specificity. We present a unique case of a patient with a positive COVID-19 test and ARDS who suffered a cardiac arrest. The patient was subsequently cannulated for VV-ECMO, and after lower respiratory tract PCR testing, Legionella was determined to be the cause. She was successfully treated and decannulated from VV-ECMO after eight days. Case presentation A 53-year-old female presented with one week of dyspnea and a positive COVID-19 test. She was hypoxemic, hypotensive and had bilateral infiltrates on imaging. She received supplemental oxygen, intravenous fluids, vasopressors, broad spectrum antibiotics, and was transferred to a tertiary care center. She developed progressive hypoxemia and suffered a cardiac arrest, requiring ten minutes of CPR and endotracheal intubation to achieve return of spontaneous circulation. Despite mechanical ventilation and paralysis, she developed refractory hypoxemia and was cannulated for VV-ECMO. Dexamethasone and remdesivir were given for presumed COVID-19. Bronchoscopy with bronchoalveolar lavage (BAL) performed with PCR testing was positive for Legionella pneumophila and negative for COVID-19. Steroids and remdesivir were discontinued and she was treated with azithromycin. Her lung compliance improved, and she was decannulated after eight days on VV-ECMO. She was discharged home on hospital day 16 breathing room air and neurologically intact. Conclusions This case illustrates the utility of rapid PCR testing to diagnose Legionella in patients with respiratory failure and the early use of VV-ECMO in patients with refractory hypoxemia secondary to Legionella infection. Moreover, many patients encountered in the ICU may have prior COVID-19 immunity, and though a positive COVID-19 test may be present, further investigation with lower respiratory tract PCR testing may provide alternative diagnoses. Patients with ARDS should undergo Legionella-specific testing, and if Legionella is determined to be the causative organism, early VV-ECMO should be considered in patients with refractory hypoxemia given reported high survival rates

Thermally oxidized titania nanotubes enhance the corrosion resistance of Ti6Al4V

© 2015 Elsevier B.V. The negative impact of in vivo corrosion of metallic biomedical implants remains a complex problem in the medical field. We aimed to determine the effects of electrochemical anodization (60 V, 2 h) and thermal oxidation (600 °C) on the corrosive behavior of Ti-6Al-4V, with serum proteins, at physiological temperature. Anodization produced a mixture of anatase and amorphous TiO2 nanopores and nanotubes, while the annealing process yielded an anatase/rutile mixture of TiO2 nanopores and nanotubes. The surface area was analyzed by the Brunauer-Emmett-Teller method and was estimated to be 3 orders of magnitude higher than that of polished control samples. Corrosion resistance was evaluated on the parameters of open circuit potential, corrosion potential, corrosion current density, passivation current density, polarization resistance and equivalent circuit modeling. Samples both anodized and thermally oxidized exhibited shifts of open circuit potential and corrosion potential in the noble direction, indicating a more stable nanoporous/nanotube layer, as well as lower corrosion current densities and passivation current densities than the smooth control. They also showed increased polarization resistance and diffusion limited charge transfer within the bulk oxide layer. The treatment groups studied can be ordered from greatest corrosion resistance to least as Anodized + Thermally Oxidized \u3e Anodized \u3e Smooth \u3e Thermally Oxidized for the conditions investigated. This study concludes that anodized surface has a potential to prevent long term implant failure due to corrosion in a complex in-vivo environment

sj-pdf-1-jao-10.1177_03913988241234543 – Supplemental material for Physiologic benefits of veno-pulmonary extracorporeal membrane oxygenation for COVID-19 ARDS: A single center experience

Supplemental material, sj-pdf-1-jao-10.1177_03913988241234543 for Physiologic benefits of veno-pulmonary extracorporeal membrane oxygenation for COVID-19 ARDS: A single center experience by John C Grotberg, Jon Greenberg, Mary Sullivan, Amit A Pawale, Kunal D Kotkar and Muhammad F Masood in The International Journal of Artificial Organs</p