SARS, MERS and COVID-19, the story continues

Although the three viruses corona viruses (SARS-CoV: 2003, MERS-CoV: 2012 and SARS-CoV-2: 2019) have similarities especially regarding clinical features, there are key differences between them that limit the relevance of experiences from previous crises. Regarding treatment in the absence of vaccine, it is recommended an the first stage to use pharmaceuticals and their combinations (protease inhibitors, interferon compounds, antiviral antibodies) aiming to suppress diverse targets during virus propagation and during the second disease stage, it seems crucial and reasonable to rely on administration of pathogenetic drugs to restrict life threatening events resulting in marked inflammation, intoxication, hypoxia and infection. The most important method to prevent viral zoonosis is to maintain the barriers between natural reservoirs and human society

Brain Natriuretic Peptide as a Predictive Marker in Perioperative Cardiac Care: Ready for Use?

Coronary Artery Bypass Graft surgery(CABG) has an important value in the management of patients with coronary or valvular heart disease. Because of increasing the interest to perform less invasive interventions in these patients, CABG is now performed for patients with higher comorbidities and more severe cases having more post operative complications1. Thus, clinical risk stratification has a great role in preoperative evaluation of patients undergoing CABG2. Electrocardiography, hemodynamic parameters, biochemical markers like creatinin kinase (CK), myoglobulin creatinin kinase (CK-MB) and troponins and transthoracic/transesophageal echocardiography are routinely used for the diagnosis of preoperative cardiac problems and prediction of perioperative comorbidities3. BNP is secreted by ventricular myocytes due to increased ventricular wall tension related to volume expansion. BNP is a simple blood test, which can easily be performed in most biochemistry laboratories as part of a routine preoperative assessment. Previous studies showed that increased level of preoperative BNP is associated with higher morbidities and mortality after cardiac surgeries4-6.  Postoperative BNP has the potential to show the preoperative condition of heart and cardiac injury induced by surgical intervention but its value as a prognostic marker has not been largely evaluated7,8.Totonchi et al evaluated the association of preoperative and post operative BNP with morbidity in 50 adult patients who were scheduled for elective CABG in Tehran Shahid Rajaie heart center from Sep 2016 to May 2017. Patients with emergency situations, hematocrit less than 25 and patients on inotropic therapy were excluded. Samples were taken for BNP levels 24 hours pre and post operative. They showed that perioperative BNP didn’t have any correlation with other comorbidities and major complications after cardiac surgeries except for ejection fraction. Their results showed that patients with higher perioperative BNP levels had significantly higher risk factor for low ejection fraction and heat failure after CABG9. Fox and coworkers in their prospective longitudinal study of 1,183 patients undergoing primary coronary artery bypass  grafting surgery, compared the utility of preoperative with postoperative BNP for predicting hospital LOS and mortality after primary PCI. After multivariable adjustment for preoperative  BNP and clinical covariates, peak postoperative BNP predicted hospital LOS (hazard ratio [HR] = 1.28, 95% CI = 1.002-1.64, P = 0.049) but not mortality. Whereas preoperative BNP independently predicted hospital LOS (HR = 1.09, CI = 1.01-1.18, P = 0.03) and was defined as an independent predictor of mortality (HR = 1.36, CI = 0.96-1.94, P = 0.08). When preoperative and peak postoperative BNP were separately adjusted for the clinical multivariable models, each independently predicted hospital LOS and mortality10. Previous studies showed that post operative BNP levels which measured 24 hours after surgery did not significantly predict adverse cardiovascular events and peak post operative BNP measurement should be considered as a surrogate for cardiovascular complications. Peak postoperative BNP tends to occur later in the postoperative course, around day 3 or 5.The study of Totonchi et al has some major limitations. It has been performed in a single center which has inherent limitations. The study’s HF outcome did not delineate specific etiologies of observed postoperative HF events (e.g., systolic vs. diastolic dysfunction or left atrial enlargement).  BNP has been affected by kidney function and pulmonary disease but patients with kidney and lung disease were enrolled in this study. Moreover, the authors didn’t perform long term follow up after discharge. The authors measured BNP by electrochemiluminescence immunoassay, which measures only nonglycoNT-proBNP. This method understimates the BNP level compared to NT-proBNP assay system currently being used. Therefore, careful interpretation of the BNP levels and clinical application may be required. Finally, the authors didn’t use logistic regression analysis for adjustment of clinical risk factors; so, interpreting and globalization of these results is not possible.Based on literature review, there is little added benefit to measure postoperative BNP either instead of or in combination with preoperative BNP. So, it seems that we do not need to measure both preoperative and postoperative BNP together for the purposes of risk stratifying of CABG patients. But if preoperative BNP measurement is not possible, we can use peak post operative BNP measurement for prediction of major cardiovascular complications. Patients at high risk should be considered for less invasive procedures and must receive optimized perioperative care. Further research with a larger number of patients having various types of surgeries and good methodologic design is needed to confirm the clinical utility of this prognostic test.

A Simple Strategy for the Sterile Use of Reusable Laryngoscope Blades in Resource Limited Countries

The laryngoscope blade has a potential role for crossinfection due to its contamination with bacteria, blood,and microorganisms. Cleaning the laryngoscope bladehas various methods in different countries. Most operatingrooms have no guidelines for laryngoscope disinfectionafter each usage (1). Some use tap water for cleaningwhich is an inadequate method while others add disinfectantto tap water which is more effective for the controlof infection, but this may result in the emergence ofresistant bacteria. There are so many disinfectants likealdehyde-free biguanide and Chlorine dioxide or chlorhexidinewithout any international guideline for commonpractice. Cleaning with most of these disinfectants istime consuming and needs at least 10 minutes for disinfection(2). In some centers, anesthesiologists use disposableblade laryngoscopes which brings, sometimes, difficultyin airway management especially in the emergencysituations compared to standard laryngoscopes, becauseof the shape of the blade or light carrying capacity. Most ofthe single-use laryngoscopes tested were significantly inferiorto the standard Macintosh blade. This raises concernover their use in clinical practice, particularly if intubationis difficult (3). The cost of disposable blades for laryngoscopesis almost 5 to 10 dollars

A Comparison of Verapamil and Digoxin for Heart Rate Control in Atrial Fibrillation

Purpose: Atrial fibrillation (AF) is one of the most common types of sustained dysrhythmia and there are some disagreements about its treatment. The goals of AF treatment include the control of ventricular rate, the establishment of sinus rhythm and the prevention of thromboembolic events. In this study, the effect of verapamil was compared to digoxin on heart rate control in patients with AF. Methods:This descriptive study was conducted in an emergency department (ED) in Iran. Sixty patients with a new onset AF and rapid ventricular response receiving digoxin or verapamil were included and observed. Results:Two thirty-patient groups receiving verapamil or digoxin were evaluated. The heart rate was significantly decreased in both groups (p = 0.002); however, the cardioversion was not noticed in both of them. The best rate control in verapamil and digoxin groups was observed after 5.9 mg (46.7%) and 0.6 mg (36.7%), respectively. Conclusion: Administration of verapamil in comparison with digoxin has no difference to control the heart rate in AF patients. It should be taken into consideration that prospective randomized studies should be conducted to identify the efficacy and select the best of these two drugs to treat AF patients

Antimicrobial susceptibility patterns among bacteria isolated from intensive care units of the largest teaching hospital at the northwest of Iran

This study was conducted to determine the antimicrobial susceptibility patterns among common pathogens in the intensive care units (ICUs) of a university hospital in northwestern Iran. A retrospective study was done on laboratory records of patients with nosocomial infection who were admitted to five ICUs of Imam Reza Hospital during a 21-month period from March 2010 to January, 2012. A total number of 556 isolates from 328 patients were evaluated. The most common sites of infections included respiratory (51.7%), urinary (24.8%), and blood (10.4%). The most frequently isolated microorganisms were Enterobacter aerogenes (50.6%) followed by Escherichia coli (16.7%) and Pseudomonas aeruginosa (7.5%). Staphylococcus aureus was the most frequent pathogen among gram-positives (39.7%). The rate of methicillin-resistant Staphylococcus aureus (MRSA) was 87.5%. Multidrug-resistant (MDR) gram-negative bacteria were documented in 25.8% of Acinetobacter, 20% of Klebsiella, and 16.6% of Pseudomonas. The most active antimicrobials were vancomycin (93.5%) followed by amikacin (71.5%) and gentamicin (46%). The overall antibiotic susceptibility was as follows: 36% ciprofloxacin, 19% imipenem, 20% trimethoprim-sulfamethoxazole, 20.5% ceftazidime, and 12% ceftriaxone. Due to the high rate of antimicrobial resistance in the ICU setting, more surveillance and control of the use of antimicrobials is needed to combat infections

Effect of A Probiotic Preparation on Gut Microbiota in Critically Ill Septic Patients Admitted to Intensive Care Unit: A Pilot Randomized Controlled Trial

Background: Sepsis promotes severe physiologic alterations in patients, and it has been reported to induce profound changes in the gut microbial composition. The decrease of ‘health‑benefiting’ microbes and the increase in dysbiosis in critically ill patients are thought to induce or aggravate sepsis. In this study, we aimed to explore the effect of a probiotic preparation, Lactocare®, on gut microbiota in critically ill septic patients admitted to the intensive care unit (ICU). Methods: Forty critically ill patients diagnosed with sepsis were assessed in this pilot randomized controlled trial. Patients were randomized into two groups: Lactocare and control groups. Patients in the Lactocare group received two capsules of Lactocare® for 10 days. Fecal samples were taken from all patients on days 1 and 10 for determining the gut microbial pattern. The primary outcome was gut microbial flora, and secondary outcomes were intensive care unit (ICU) length of stay and mortality. Results: Intragroup changes showed that all microbial flora considerably changed during the study period; the number of microbial flora significantly decreased in the control group and increased in the Lactocare group. Patients in the Lactocare group had a significantly lower incidence of diarrhea and infection with multidrug-resistant organisms. There was no difference in ICU length of stay in the Lactocare group compared to the control group (p= 0.289). The mortality rate was 30% in the control group compared to 20% in the Lactocare group (p: 0.465). Conclusion: This study showed a remarkable effect of the probiotic preparation on the gut microbiota in critically ill septic patients as it decreased the number of opportunistic pathogens. However, additional clinical research is needed to translate research into clinical practice to refine the clinical indication of the specific probiotic strains

Lipid Profile as a Predictive Marker for Organ Dysfunction after Thoracoabdominal Surgery: A Cross-sectional Study

Background: Plasma total cholesterol is considered a negative acute phase reactant. In various pathological conditions, such as trauma, sepsis, burns, and liver dysfunction, as well as post-surgery, serum cholesterol level decreases. This study aimed to investigate the role of lipid profiles in determining the probability of organ dysfunction after surgery.Methods: This cross-sectional study included patients who underwent thoracoabdominal surgery and were admitted to the intensive care unit of Imam Reza Hospital in Tabriz, Iran, between October 2016 and September 2018. During the first two days of admission, blood samples were taken, and serum levels of total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), Low-density lipoprotein cholesterol (LDL-C), triglycerides (TG), and albumin were measured. The relation between the changes in these laboratory markers and six organ functions including cardiovascular, respiratory, renal, central nervous system, hepatic, and hematologic, length of stay in the hospital and intensive care unit, mechanical ventilation duration, and vasopressor use were investigated. The independent t test was used to compare continuous variables. The association between different variables and organ dysfunction and mortality was evaluated by using logistic regression.Results: The serum TC increased the risk of mortality (OR=1.09, 95%CI=1.06-1.11, P<0.001), renal dysfunction (OR=1.09, 95%CI=1.06-1.12; P<0.001), liver dysfunction (OR=1.07, 95%CI=1.03-1.10; P<0.001), respiratory dysfunction (OR=1.08, 95%CI=1.05-1.13; P<0.001). Moreover, LDL, HDL, and TG were found to be inversely related to mortality, organ dysfunction, length of stay in the hospital and intensive care unit, mechanical ventilation duration, and vasopressor use. Conclusion: TC could be considered a risk factor for mortality, organ dysfunction, and clinical outcomes. On the other hand, LDL, HDL, and TG played a protective role in the patients’ mortality, organ dysfunction, and clinical outcomes

Taurine in Septic Critically Ill Patients: Plasma versus Blood

Purpose: Sepsis and systemic inflammatory response syndrome (SIRS) encompass various problems throughout the body, and two of its major problems are the creation of oxidative substances in the body and decrease of the body’s antioxidant capacity to deal with the stress and organ damage. Optimal enteral nutrition fortified with antioxidant or immunomodulator amino acid is a hot topic concerning sepsis in the critical care setting. Taurine plays a protective role as an antioxidant in cells that is likely to have a protective role in inflammation and cytotoxicity. Methods: In the present study, 20 septic patients and 20 healthy volunteers were enrolled. The blood and plasma taurine levels of the patients on days 1, 3 and 7 were measured. Blood and plasma taurine level and the correlation between them, organ failure, and severity of the disease were assessed. Results: Taurine concentrations in the plasma of the septic patients were significantly lower than control group, and the whole blood concentrations were significantly higher than those of the control group (P<0.001). There was not a significant correlation between the blood and plasma taurine levels in control and septic patients. In addition, there was not any correlation between the severity of the disease, organ failure, mortality, and plasma as well as the blood concentration of taurine. Conclusion: In septic patients, taurine concentration in plasma and blood are low and high, respectively. These concentrations are not linked to each other and not associated with the patients’ outcome, and the disease severity, and organ failure

Different epidemiology of bloodstream infections in COVID-19 compared to non-COVID-19 critically ill patients: A descriptive analysis of the Eurobact II study

Background: The study aimed to describe the epidemiology and outcomes of hospital-acquired bloodstream infections (HABSIs) between COVID-19 and non-COVID-19 critically ill patients. Methods: We used data from the Eurobact II study, a prospective observational multicontinental cohort study on HABSI treated in ICU. For the current analysis, we selected centers that included both COVID-19 and non-COVID-19 critically ill patients. We performed descriptive statistics between COVID-19 and non-COVID-19 in terms of patients’ characteristics, source of infection and microorganism distribution. We studied the association between COVID-19 status and mortality using multivariable fragility Cox models. Results: A total of 53 centers from 19 countries over the 5 continents were eligible. Overall, 829 patients (median age 65 years [IQR 55; 74]; male, n = 538 [64.9%]) were treated for a HABSI. Included patients comprised 252 (30.4%) COVID-19 and 577 (69.6%) non-COVID-19 patients. The time interval between hospital admission and HABSI was similar between both groups. Respiratory sources (40.1 vs. 26.0%, p < 0.0001) and primary HABSI (25.4% vs. 17.2%, p = 0.006) were more frequent in COVID-19 patients. COVID-19 patients had more often enterococcal (20.5% vs. 9%) and Acinetobacter spp. (18.8% vs. 13.6%) HABSIs. Bacteremic COVID-19 patients had an increased mortality hazard ratio (HR) versus non-COVID-19 patients (HR 1.91, 95% CI 1.49–2.45). Conclusions: We showed that the epidemiology of HABSI differed between COVID-19 and non-COVID-19 patients. Enterococcal HABSI predominated in COVID-19 patients. COVID-19 patients with HABSI had elevated risk of mortality. Trial registration ClinicalTrials.org number NCT03937245. Registered 3 May 2019