The role of Tocilizumab in treatment of a patient with COVID-19: a case report

SARS-CoV-2 (COVID-19) is an infectious disease caused by a new discovered Coronavirus. Most people infected with the COVID-19 virus recover without special treatment and experience mild to moderate respiratory disease. In the elderly and people with underlying diseases such as cardiovascular disease, diabetes, chronic respiratory disease and cancer, there is a higher risk of developing the severe form of the disease. So far, no specific drug has been found to prevent or treat COVID-19. A 52-years old diabetic man with COVID-19 was admitted to Ayatollah Rouhani Hospital Babol, Iran. After 12 days of hospitalization and treatment, with respiratory distress and oxygen saturation level to 60%, he was transferred to the intensive care unit. After receiving a 400 mg dose of actemra or tocilizumab, the patient became severely dehydrated and the oxygen saturation level reached over 90% within a few hours, and 8 days after receiving tocilizumzb (TCZ; Actemra), the patient was suffering from complications of pneumonia. So far, there have been reports of improvement in patients with Coronavirus (COVID-19) with severe actemra or tocilizumab. Typically the COVID-19 virus appears to be able to be cause the over-immune reaction and typically the cytokine storm, which often includes IL-6, therefor may be IL-6 antagonist improves patients’s condition

Spontaneous Pneumomediastinum Unrelated to Invasive Ventilation in a Patient with SARS-CoV-2 (COVID-19): A Case Report

Background:Spontaneous Pneumomediastinum (SP) is a rare complication that has not been reported in patients with coronavirus (COVID-19). In this report, we introduce a patient with coronavirus (COVID-19) with spontaneous Pneumomediastinum unrelated to aggressive ventilation. Case presentation : A 39-year-old woman with coronavirus (COVID-19) with ARDS sign was admitted to the ICU of Babol Rouhani Hospital. She died four days after hospitalization with Pneumomediastinum with subcutaneous emphysema. According to chest x-ray and CT scan, the patient had spontaneous Pneumomediastinum prior to admission and aggressive ventilation. Results: Spontaneous Pneumomediastinum can be a complication of acute respiratory syndrome in patients with coronavirus (COVID-19) with unclear pathogenesis. Keywords: Spontaneous Pneumomediastinum, COVID-1

The effects of Cesarean section on pulmonary parameters in a pregnant patient with Covid-19: A case report

The case report: The coexistence of physiological changes during pregnancy and infection can sometimes create challenges in the management of these patients. In this report, a term pregnant woman with coronavirus 2019 (COVID-19) infection was admitted to the ICU and underwent cesarean section (C-section) under intrathecal anesthesia according to the patient's condition. Severe respiratory distress occurred to the patient on the first day after C-section, and the patient's pulmonary parameters were measured with a non-invasive ventilation monitor. It gradually improved during the four days after the C-section. The C-section reduced the lung performance for 24 hours in a patient with COVID-19 infection, but eventually the lung symptoms improved

Long-Term Outcome of Home Parenteral Nutrition in Patients with Short Bowel Syndrome: A Case Report

Introduction: Short bowel syndrome can cause severe malnutrition. Parenteral nutrition and the prescription of water and elec[1]trolyte can increase the survival of these patients. This article introduces a patient, who received parenteral nutrition for nine months after gastric cancer surgery and chemotherapy because of the initiation of cutaneous fistula (short bowel syndrome). Case Presentation: The patient was a 33-year-old male, who had undergone total gastrectomy due to gastric adenocarcinoma. After chemotherapy, because of the peritonitis, laparotomy was performed; the abdomen was full of fecal and bile liquid, and the perfora[1]tion area was not found due to the high adhesion in the abdomen. Considering the continued secretion from the right drain area of the abdomen, with the possibility of spontaneous closure, TPN was performed for nine months. Fistula repair surgery was done and postoperative total parenteral nutrition was terminated in nine days and oral feeding was started and the patient was discharged in good condition. Conclusions: Total home parenteral nutrition (HPN) in patients with short bowel syndrome increases the survival of patients with[1]out dangerous side effects. Home parenteral nutrition can be useful to prepare the patient for surger

How to Use Non-Invasive Ventilation in Acute Respiratory Failure due to Covid 19? Early, Short-Time, Low Drive Pressure: How to use non-Invasive ventilation in acute respiratory failure

  How to use non-Invasive ventilation in acute respiratory failure due to  Covid 19? Early, short-time, low drive pressure. Parviz Amri 1 Clinical Research Development Unit of Ayatollah  Rouhani  Hospital,  Babol University of Medical Sciences, Babol, Iran   Special recommendations for patients with Covid 19 who use non-invasive ventilation: It is recommended that patients who are candidates for non-invasive ventilation be admitted to the ICU or to a ward reserved only for non-invasive ventilated patients with Covid 19 disease.Due to the risk of transmission of the disease to the patient's staff and nurse, all instructions related to hospital infection control should be followed especially wearing masks and hats and glasses and clothing. Use ventilators that have both inhaled and exhaled arms and nonvented masks to reduce the risk of infection with low leakage. (1, 2).  Non-invasive ventilation should be started in the early stages of Covid 19 disease. This means that non-invasive ventilation is helpful when the lungs have not yet reached a low compliance level, and the oxygen saturation is not too low, especially in obese patients when atelectasis occurs, the lungs will not open with non-invasive ventilation. And if recruiting maneuvers are performed, it has many complications such as cardiac arrest, subcutaneous emphysema, pneumomediastinum and pneumothorax.In mild cases, even if the patient has normal oxygen with mask or reservoir bag, to prevent the disease from progressing to lung atelectasis, the patient should attach the oronasal mask for 5 minutes every hour. During non-invasive ventilation, if the oxygen saturation is acceptable, it should be oxygen-free. In the patient's recovery, sometimes non-invasive ventilation is left every one to two hours for 1 to 2 minutes to keep the lungs open and prevent atelectasis.If the disease is good without oxygen, be sure to check the oxygen saturation after walking or after activity (walking for 6 minutes). It comes down most of the time. So give oxygen after activity. The main reason for the decrease in oxygen saturation in this situation is the involvement of Interstitial tissues of the lungs.NIV setting: To adjust the ventilator (aggressive and non-invasive), the drive pressure should be between 12 and 14 cm of water. The mod of PSV + PEEP is more easily tolerated in different experiments. In this method, PSV = 12-14 cm/H2O of water and PEEP = 6-8 cm/H2O are usually required. Higher pressure is not necessary and can cause discomfort to the patient and even damage to the lungs (3). When the lungs open slowly for the first time and the patient has a frequent cough, in these cases, first set the IPAP and EPAP to the minimum pressure and then gradually increase it. If the cough continues, you can use morphine or dexmedetomidine in the ICU. Increase EPAP in cases of hypoxia and Bipap with Back up rate in hypercarbia(3).If you have a decrease in oxygen saturation during non-invasive ventilation, one of the reasons could be the simultaneous heart injury that we have in Covid 19(4). I recommend giving furosemide 10 mg per 6 hour. Patients often have diastolic dysfunction and therefore patients are sensitive to both hypovolemia and hyperolomia. If the patient develops severe respiratory distress, hypoxia, and hypercarbia during non-invasive ventilation, the patient should be intubated. Excessive delay in intubation increases mortality.If intubated, use pressure control modes (with a pressure of less than 20 if the volumes are slightly more than 300 ml).  Conflicts of Interest I declare that there are no conflicts of interes

Efficiency and outcome of non-invasive versus invasive positive pressure ventilation therapy in respiratory failure due to chronic obstructive pulmonary disease

Background: Application noninvasive ventilation in the patients with exacerbation of chronic obstructive pulmonary disease (COPD) reduced mortality. This case-control study was designed to compare efficiency and outcome of non-invasive (NIV) versus invasive positive pressure ventilation (IPPV) in respiratory failure due to COPD Methods: The patients were assigned to NIV or IPPV intermittantly.The clinical parameters, including RR (respiratory rate), BP (blood pressure), HR (heart rate) and PH, PaCO2, PaO2 before and 1, 4 and 24 h after treatment were measured. Demographic information such as age, sex, severity of disease based on APACHE score, length of stay and outcome were recorded Results: Fifty patients were enrolled in the NIV group and 50 patients in IPPV. The mean age was 70.5 in NIV and 63.9 in invasive ventilation group (p>0.05). In IPPV group, the average values of PH: PCO2: and PO2, were 7.22&plusmn;0.11, 69.64 + 24.25: and 68.86&plusmn;24.41 .In NIV, the respective values were 7.30&plusmn;0.07, 83.94&plusmn;18.95, and 60.60&plusmn;19.88. &nbsp;In NIV group, after 1, 4 and 24 h treatment, the clinical and ventilation parameters were stable. The mean APACHE score in was IPPV, 26.46&plusmn;5.45 and in NIV was 12.26&plusmn;5.54 (p<0.05). The average length of hospital stay in IPPV was 15.90&plusmn;10 and in NIV 8.12&plusmn;6.49 days (p<0.05). The total mortality in the NIV was 4 (8%) and in IPPV, 27 patients (54%) (p<0.05). Conclusion: This study indicates that using NIPPV is a useful therapeutic mode of treatment for respiratory failure with acceptable success rate and lower mortality. The application of NIPPV reduces hospital stay, intubation and its consequent complication

Addition of intrathecal Dexamethasone to Bupivacaine for spinal anesthesia in orthopedic surgery

Objectives: Spinal anesthesia has the advantage that profound nerve block can be produced in a large part of the body by the relatively simple injection of a small amount of local anesthetic. Intrathecal local anesthetics have limited duration. Different additives have been used to prolong spinal anesthesia. The effect of corticosteroids in prolonging the analgesic effects of local anesthetics in peripheral nerves is well documented. The purpose of this investigation was to determine whether the addition of dexamethasone to intrathecal bupivacaine would prolong the duration of sensory analgesia or not. Methods: We conducted a randomized, prospective, double-blind, case-control, clinical trial. A total of 50 patients were scheduled for orthopedic surgery under spinal anesthesia. The patients were randomly allocated to receive 15 mg hyperbaric bupivacaine 0.5% with 2 cc normal saline (control group) or 15 mg hyperbaric bupivacaine 0.5% plus 8 mg dexamethasone (case group) intrathecally. The patients were evaluated for quality, quantity, and duration of block; blood pressure, heart rate, nausea, and vomiting or other complications. Results: There were no signification differences in demographic data, sensory level, and onset time of the sensory block between two groups. Sensory block duration in the case group was 119±10.69 minutes and in the control group was 89.44±8.37 minutes which was significantly higher in the case group (P<0.001). The duration of analgesia was 401.92±72.44 minutes in the case group; whereas it was 202±43.67 minutes in the control group (P<0.001). The frequency of complications was not different between two groups. Conclusion: This study has shown that the addition of intrathecal dexamethasone to bupivacaine significantly improved the duration of sensory block in spinal anesthesia without any changes in onset time and complications

Serum and alveolar procalcitonin had a weak diagnostic value for ventilator-associated pneumonia in patients with pulmonary infection score ≥ 6

Background. Measuring the serum and alveolar procalcitonin level as inflammatory marker in the diagnosis of ventilator-associated pneumonia (VAP) has been taken into account. In this study, serum and alveolar procalcitonin levels in patients with suspected VAP and patients with confirmed VAP were compared

Antimicrobial resistance pattern in ventilator—associated pneumonia in an intensive care unit of Babol, northern Iran

Objective: To investigate antibiotic resistance pattern of ventilator-associated pneumonia (VAP) generating microorganisms, and quantitative culture and determining antibiotic sensitivity. Methods: This cross sectional study was performed on 50 patients suffering from VAP in intensive care unit of Ayatollah Rouhani Hospital, Babol, Iran during 2014–2015. VAP was probable for them based on clinical signs and the criteria of Clinical Pulmonary Infection Score standards. Lower respiratory samples were given under bronchoalveolar lavage and quantitative culture was done on them. Afterwards by microdilution method, minimal inhibitory concentration based on respective microorganisms, considering clinical pulmonary infection score were determined. Results: From 50 investigated samples in this study, the most common microorganisms were Acinetobacter baumannii (A. baumannii) (70%) then Pseudomonas aeruginosa (12%), Staphylococcus aureus (8%) and Klebsiella pneumonia (3%). In our study A. baumannii showed approximate 100% resistance to all antibiotics, in a way that A. baumannii resistance to imipenem and meropenem and piperacillin/tazobactam each was 97.1%. The most resistance of Pseudomonas aeruginosa was 66.7% to each cefepime and ceftazidime and clavulanate/ticarcillin. Staphylococcus aureus showed 75% resistance to nafcillin, cloxacillin and resistance in case of vancomycin was not seen. Conclusion: In current study, A. baumannii had the most prevalence among VAP and this species is resistant to most of antibiotics. Using ceftazidime, cefepime and clavulanate/ticarcillin, in treatment of the patients suffering VAP is not reasonable

Impact of Negative Fluid Balance on Mortality and Outcome of Patients with Confirmed COVID-19

Purpose. Maintaining the proper fluid balance is a fundamental step in the management of hospitalized patients. The current study evaluated the impact of negative fluid balance on outcomes of patients with confirmed COVID-19. Methods. We considered the negative fluid balance as a higher output fluid compared to the input fluid. The fluid balance was categorized into four groups (group 4: −850 to −500 ml/day; group 3: −499 to −200 ml/day, group 2: −199 to 0 ml/day, and group 1 : 1 to 1000 ml/day) and included ordinally in the model. The outcomes were all-cause mortality, length of hospitalization, and improvement in oxygen saturation. Results. The fluid balance differed significantly among nonsurvivors and survivors (MD: −317.93, 95% CI: −410.21, −225.69, and p781 pg/mL and fluid balance >−430 mL might be the predictors for positive fluid balance and mortality, respectively