Hasil untuk "Medical emergencies. Critical care. Intensive care. First aid"

Paweł Piwowarczyk, Marta Szczukocka, Agata Uchacz et al.

Introduction Unfractionated heparin (UFH) is the traditional anticoagulant of choice in critically ill COVID-19 patients requiring extracorporeal membrane oxygenation (ECMO). Nadroparin, a low molecular weight heparin, potentially offers advantages such as predictable pharmacokinetics and reduced bleeding risks compared to UFH, with complex pharmacokinetics, influencing activated partial thromboplastin and causing substantial haemorrhagic risks. Bleeding, the most common adverse event during ECMO, is associated by many with increased activated partial thromboplastin time. Material and methods This retrospective, bicentric analysis involved 38 consecutive ECMO-supported COVID-19 patients from two Polish hospitals. The study compared 27 patients receiving UFH and 11 patients treated with 5700 IU of nadroparin administered subcutaneously twice daily. Thrombotic and haemorrhagic complications were assessed to determine the safety and feasibility of each anticoagulant. Results Resistance to flow throughout the therapy in the ECMO membrane oxygenator was significantly lower in the group anticoagulated with UFH (1.74 mmHg × minute × L –1 [1.38–2.6] vs. 6.13 mmHg × minute × L –1 [5.93–14.81]; P < 0.001). However, the number of transfused red blood cell packs in the aforementioned group was significantly greater (10 units [5–17] vs. 4 units [2–8]; P = 0.027), and the haemoglobin level after ECMO therapy was significantly lower (7.8 g dL –1 [6.9–8.8] vs. 10.2 g dL –1 [8.5–12.2]; P = 0.003). Moreover, there was a higher number of life-threatening events in the UFH group. Conclusions UFH anticoagulation may provide better flow optimization in the oxygenator, but the risk of life-threatening bleeding may increase. The present findings need to be fully elucidated in prospective studies on a larger critically ill population supported with respiratory ECMO.

Shawky Meselhy Elshaer, Ahmed Mostafa Abdelhamid, Enas Wageh Mahdy et al.

Background Predicting the weaning outcomes is critical, since premature or delayed extubation is associated with an increased risk of mortality. This study aimed to compare two physiological indices, thoracic fluid content (TFC) and diaphragmatic excursion (DE), for predicting weaning success in mechanically ventilated patients. Methods This observational cohort study involved 100 mechanically ventilated patients with congested lungs who were eligible for weaning. Patients’ TFC and DE were measured using electrical cardiometry and ultrasonography, respectively, before starting the spontaneous breathing trial. Following extubation, patients were grouped into successful and failed-weaning groups, with failure defined as reintubation or a need for non-invasive ventilation within 48 hours. Respiratory and cardiovascular variables were compared. The receiver operating characteristic (ROC) curve was used to assess the ability of TFC and DE to predict weaning success. Results Successful weaning occurred in 73 patients (73%) and failed weaning occurred in 27 patients (27%). The two groups’ baseline characteristics were comparable; however, TFC and DE were significantly different between the failed- and successful-weaning groups (P<0.001). The area under the ROC curve (AUC) exhibited moderate predictive abilities of both the TFC and DE in predicting weaning success (AUC, 0.805; cutoff <40 kΩ−1 and AUC, 0.774; cutoff >1.45 cm). In the cardiac patient subgroup, TFC exhibited high predictive ability (AUC, 0.861), but DE did not achieve comparable results (AUC, 0.750). Conclusions Both TFC and DE are significant predictors for successful weaning from mechanical ventilators. In particular, a TFC of <40 kΩ−1 demonstrated an excellent ability to predict weaning success in patients with low ejection fraction.

Pınar Koçatakan

Objective: The research aims to identify preoperative factors that prolong surgical time in laparoscopic cholecystectomy (LC) before the procedure and to inform patient and surgeon selection decisions. Materials and Methods: Retrospective cross-sectional review of surgical records was conducted involving 400 LC cases. The patients who had LC are divided into two groups. An operative time of up to 90 minutes was classified as Group I, while a duration exceeding 90 minutes was categorized as Group II. The parameters compared for operative time of surgery are; gender, age, medical co-morbidity, single or multiple stones, previous surgery, gallbladder wall thickness, history of endoscopic retrograde cholangio pancreatography (ERCP) and endoscopic sphincterotomy (ES), laparoscopy performed by a resident or specialist, white blood cell count, and presence of adhesions in the sac site. Results: When patients who had ERCP and/or ES prior to LC in Group I and Group II were compared, preoperative ERCP/ES was associated with prolonged operative time [odds ratio (OR): 2.48; 95% confidence interval (CI): 1.3-4.58; p=0.03]. Additionally, trainee-led procedures increased operative time (OR: 1.85; 95% CI: 1.18-2.88; p=0.02). As a result of statistical analyses, the surgeon’s experience (assistant or specialist) and preoperative ERCP or ES were identified as two key determinants contributing to the extended duration of LC. Conclusion: Preoperative estimation of prolonged operative time before LC facilitates improved surgical, anesthetic, and staffing planning. Preoperative ERCP/ES, (p=0.03) and surgeon inexperience (p=0.05) independently prolonged the operative time (OR: 2.48 and 1.85, respectively). Prioritizing experienced surgeons for such cases optimizes OR scheduling.

B. S. Sukovatykh, N. V. Bolomatov, D. V. Sidorov et al.

Background: In recent years, there has been a clear trend towards an increase in the incidence of acute non-ST-segment elevation myocardial infarction compared to ST-segment elevation myocardial infarction. Accordingly, studies investigating the effect of late revascularization on cardiac function in patients with non-ST-segment elevation myocardial infarction are increasingly relevant. Objective: To analyze the outcomes of surgical and medical treatment in patients with non-ST-segment elevation myocardial infarction during the subacute phase of myocardial necrosis.Materials and methods: The outcomes of therapy in 77 patients who were examined and treated in the cardiology departments of the Oryol Regional Clinical Hospital and Kursk City Emergency Clinical Hospital were analyzed. All patients were initially admitted to the internal medicine departments of central district hospitals in the Oryol and Kursk regions with non-specific clinical presentations. In these hospitals, the patients underwent a thorough evaluation, were diagnosed with non-ST-segment elevation myocardial infarction, and received comprehensive conservative treatment. Subsequently, all patients were recommended for hospitalization in the cardiology department of the vascular center for elective coronary angiography. Based on the subsequent treatment strategy, the patients were divided into two groups: Group 1 (n = 42) included patients who underwent coronary angiography in the Kursk and Oryol regional vascular centers, Group 2 (n = 35) included patients who received medical therapy only, as they refused hospitalization in the regional vascular center for elective surgical treatment.Results: Two months after revascularization, analysis of cardiac function indicators showed that the majority of patients in Group 1 had no symptoms of angina and heart failure (52.4% and 59.5%, respectively), whereas in Group 2 these rates were 8.5% and 14.2%. At the same time, a reduction in the functional class of angina pectoris was observed in 76.1% of patients in Group 1 and 44.8% in Group 2, and functional class of heart failure improved in 69.4% and 37.6%, respectively.Conclusion: Late myocardial revascularization promotes positive changes in left ventricular systolic function in patients with non-ST-segment elevation acute coronary syndrome. The absence of timely revascularization is associated with more pronounced clinical manifestations of both angina and heart failure. These results further confirm that timely restoration of coronary blood flow plays a crucial role in improving patient prognosis and quality of life.

Ayda Kebapci, Ruhat Tilki

Endrit Shehi, Johana Vruho, Agron Dogjani

Introduction: Laparoscopic cholecystectomy is the gold standard in the management of symptomatic gallstones. However, it is estimated that there are 2–15 cases of hepatic abscesses per 100,000 people in the U.S., mostly of bacterial etiology, and approximately half of these are caused by cholangitis. Given the infrequency of cholangitis-induced pyogenic hepatic abscesses and the 0.4 % incidence of choledocholithiasis in post-cholecystectomy patients, pyogenic hepatic abscesses secondary to post-cholecystectomy choledocholithiasis comprise a rare entity. A hepatic abscess occurring post-laparoscopic cholecystectomy is a known complication that can manifest months or even years after the surgery. This case involves a 56-year-old female patient who presented with a 10-day history of abdominal pain and discomfort, primarily in the right hypochondrium, accompanied by fever unresponsive to antibiotics and antipyretics. The appropriate treatment approach was chosen based on clinical signs, abscess size, and the patient's overall condition. Conclusion: This case shows the late complications arising from gallstone spillage into the abdominal cavity during laparoscopic cholecystectomy. It underscores the importance of careful laparoscopic exploration, especially in gallbladder perforation and stone spillage cases. Detailed documentation of the operative procedure is crucial, as it aids in the prophylactic and symptomatic treatment of long-term complications such as abscess formation.  

H.B. Koltunova

The assessment of risk factors for in-hospital mortality in patients with infective endocarditis is important for identifying variables associated with treatment regimens, aiming to improve outcomes. Early identification of high-risk patients may contribute to better outcomes through timely medical and surgical interventions. Objective: to study the clinical characteristics and risk factors associated with in-hospital mortality among patients with infective endocarditis. Materials and methods. A retrospective single-center study was conducted, which included clinical data of 311 consecutive patients from January 1, 2019, to October 22, 2021, at the Amosov National Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine. The primary outcome of the study was in-hospital mortality among patients with infective endocarditis. Clinical and laboratory data, as well as the results of echocardiographic examinations and postoperative complications were recorded and statistically analyzed. Results. The overall in-hospital mortality rate was 13 cases (4.2 %), including 6 (1.9 %) patients with infective endocarditis who died at the preoperative stage despite medical treatment. Postoperative in-hospital mortality accounted for 7 cases (2.3 %), 298 patients (95.8 %) underwent successful surgery and were discharged under the supervision of a cardiologist in their locality. A univariate analysis of preoperative clinical and laboratory characteristics revealed the following risk factors for in-hospital mortality among patients with infective endocarditis at the preoperative stage: fever (p = 0.021), mechanical ventilation (p < 0.001), acute kidney injury (р < 0.001), heart failure (р < 0.001). Similarly, a univariate analysis of intraoperative and postoperative clinical and laboratory characteristics revealed risk factors for in-hospital mortality among patients with infective endocarditis at the postoperative stage to be aortic cross-clamping time (p = 0.010), duration of cardiopulmonary bypass (p = 0.006), ultrafiltration volume (p < 0.001) and N-terminal pro-B-type natriuretic peptide level (p = 0.017). Conclusions. Our study demonstrated that risk factors for in-hospital mortality among patients with infective endocarditis included fever, heart failure, respiratory failure, acute kidney injury, and duration of cardiac surgery. These findings underscore the necessity for a multidisciplinary approach to the treatment of infective endocarditis.

Jason P. Li, MD, Charles Slocum, MD, John Sbarbaro, BA et al.

Background: Peak oxygen consumption and oxygen pulse along with their respective percent predicted measures are gold standards of exercise capacity. To date, no studies have investigated the relationship between percent predicted peak oxygen pulse (%PredO2P) and ventricular-vascular response (VVR) and the association of %PredO2P with all-cause mortality in heart failure with preserved ejection fraction (HFpEF) patients. Objectives: The authors investigated the association between: 1) CPET measures of %PredO2P and VVR; and 2) %PredO2P and all-cause mortality in HFpEF patients. Methods: Our cohort of 154 HFpEF patients underwent invasive CPET and were grouped into %PredO2P tertiles. The association between percent predicted Fick components and markers of VVR (ie, proportionate pulse pressure, effective arterial elastance) was determined with correlation analysis. The Cox proportional hazards model was used to identify predictors of mortality. Results: The participants’ mean age was 57 ± 15 years. Higher %PredO2P correlated with higher exercise capacity. In terms of VVR, higher %PredO2P correlated with a lower pressure for a given preload (effective arterial elastance r = −0.45, P < 0.001 and proportionate pulse pressure r = −0.22, P = 0.008). %PredO2P distinguished normal and abnormal percent predicted peak stroke volume and correlated positively with %PredVO2 (r = 0.61, P < 0.001). Participants had a median follow-up time of 5.6 years and 15% death. Adjusted for age and body mass index, there was a 5% relative reduction in mortality (HR: 0.95, 95% CI: 0.92-0.98, P = 0.003) for every percent increase in %PredO2P. Conclusions: In HFpEF, %PredO2P is a VVR marker that can stratify invasive parameters such as percent predicted peak stroke volume. %PredO2P is an independent prognostic marker for all-cause mortality and those with higher %PredO2P exhibited longer survival.

Hiroshi Morisaki

Tarun Sharma, Ashley Grant

Xin-Xin Wu, Jin-Jian Yao, Jin Qian et al.

Objective: To systematically evaluate the incidence of adverse reactions to coronavirus disease 2019 (COVID-19) vaccination. Methods: We systematically searched PubMed, Embase, The Cochrane Library, Web of Science, CNKI, WanFang Data, and VIP Database from the inception of each database to August 31, 2021. Randomized controlled clinical trials (RCTs) on the safety of different types of COVID-19 vaccines were retrieved and analyzed. A random or fixed-effects model was used with an odds ratio as the effect size. The quality of each reference was evaluated. The incidence of the adverse reactions of the placebo group and the vaccination group was compared. Heterogeneity and publication bias were taken care of by meta-regression and sub-group analyses. Results: A total of 13 articles were included, with 81 287 subjects. Compared with the placebo group, the vaccination group showed a higher combined risk ratio (RR) of total adverse reactions (RR=1.67, 95% CI: 1.46-1.91, P<0.01), local adverse reactions (RR=2.86, 95% CI: 2.11-3.87, P<0.01), systemic adverse reactions (RR=1.25, 95% CI: 0.92-1.72, P=0.16), pain (RR=2.55, 95% CI: 1.75-3.70, P<0.01), swelling (RR=4.16, 95% CI: 1.71-10.17, P=0.002, fever (RR=2.34, 95% CI: 1.84-2.97, P<0.01), fatigue (RR=1.36, 95% CI: 1.32-1.41, P<0.01) and headache (RR=1.22, 95% CI: 1.18-1.26, P<0.01). The subgroup analysis showed the incidence of adverse reactions of the vaccination group after injection of the three COVID-19 vaccines (inactivated viral vaccines, mRNA vaccines and adenovirus vector vaccines) was higher than that of the placebo group, and the difference between the placebo group and the vaccination group in the mRNA vaccine subgroup and the adenovirus vector vaccine subgroup was statistically significant (P<0.01). The incidence of adverse reactions after injection of COVID-19 vaccine in subgroups of different ages was significantly higher than that in the placebo group (P<0.01). Conclusions: COVID-19 vaccines have a good safety, among which adenovirus vector vaccine has the highest incidence of adverse reactions. Both adolescents and adults vaccinated with novel coronavirus vaccine have a certain proportion of adverse reactions, but the symptoms are mild and can be relieved by themselves. Our meta-analysis can help boost global awareness of vaccine safety, promote mass vaccination, help build regional and global immune barriers and effectively curb the recurrency of COVID-19.

Leah M. Bralow

Anna M. Cervantes-Arslanian, MD, Chakradhar Venkata, MD, Pria Anand, MD et al.

OBJECTIVES:. To describe the prevalence, associated risk factors, and outcomes of serious neurologic manifestations (encephalopathy, stroke, seizure, and meningitis/encephalitis) among patients hospitalized with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. DESIGN:. Prospective observational study. SETTING:. One hundred seventy-nine hospitals in 24 countries within the Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study COVID-19 Registry. PATIENTS:. Hospitalized adults with laboratory-confirmed SARS-CoV-2 infection. INTERVENTIONS:. None. RESULTS:. Of 16,225 patients enrolled in the registry with hospital discharge status available, 2,092 (12.9%) developed serious neurologic manifestations including 1,656 (10.2%) with encephalopathy at admission, 331 (2.0%) with stroke, 243 (1.5%) with seizure, and 73 (0.5%) with meningitis/encephalitis at admission or during hospitalization. Patients with serious neurologic manifestations of COVID-19 were older with median (interquartile range) age 72 years (61.0–81.0 yr) versus 61 years (48.0–72.0 yr) and had higher prevalence of chronic medical conditions, including vascular risk factors. Adjusting for age, sex, and time since the onset of the pandemic, serious neurologic manifestations were associated with more severe disease (odds ratio [OR], 1.49; p < 0.001) as defined by the World Health Organization ordinal disease severity scale for COVID-19 infection. Patients with neurologic manifestations were more likely to be admitted to the ICU (OR, 1.45; p < 0.001) and require critical care interventions (extracorporeal membrane oxygenation: OR, 1.78; p = 0.009 and renal replacement therapy: OR, 1.99; p < 0.001). Hospital, ICU, and 28-day mortality for patients with neurologic manifestations was higher (OR, 1.51, 1.37, and 1.58; p < 0.001), and patients had fewer ICU-free, hospital-free, and ventilator-free days (estimated difference in days, –0.84, –1.34, and –0.84; p < 0.001). CONCLUSIONS:. Encephalopathy at admission is common in hospitalized patients with SARS-CoV-2 infection and is associated with worse outcomes. While serious neurologic manifestations including stroke, seizure, and meningitis/encephalitis were less common, all were associated with increased ICU support utilization, more severe disease, and worse outcomes.

Matteo Danielis, Fabrizio Bellomo, Federico Farneti et al.

Jarva Chow, MD, MS, MPH, Talar W. Markossian, PhD, MPH, Fritzie S. Albarillo, MD et al.

OBJECTIVES:. To examine the impact before and after adoption of a procalcitonin-based protocol to guide sepsis management has on antibiotic use, care costs, and outcomes of critically ill patients. DESIGN:. Before-after study. SETTING:. ICU of an academic tertiary care center. PATIENTS:. Adults over 18 years old admitted to the ICU from January 1, 2017, to January 31, 2020. INTERVENTIONS:. In this before-after study, we compared the use of medications, outcomes, and overall cost before and after the introduction of a procalcitonin-based protocol for evaluation and treatment of sepsis. MEASUREMENTS AND MAIN RESULTS:. The final study cohort consisted of 1,793 patients admitted to the ICU, 776 patients pre-procalcitonin and 1,017 patients in the post-procalcitonin period. Patients were not different in the pre-procalcitonin adoption period compared with post-procalcitonin adoption with regard to gender, age (62.0 vs 62.6), race, or comorbidities. Patients admitted during the post-procalcitonin adoption period were less likely to receive the examined broad-spectrum antibiotics (odds ratio, –0.58; CI, –0.99 to –0.17; p < 0.01) than patients during the pre-procalcitonin adoption period. The odds of inhospital death did not differ after procalcitonin adoption when compared with before (0.87; CI, 0.70–1.09; p = 0.234). Total charges for each admission were significantly less in the post-procalcitonin adoption period $3,834.99 compared with pre-procalcitonin adoption $4,429.47 (p < 0.05). Patients post-procalcitonin adoption incurred $1,127.18 per patient less in total charges (–1,127.18; CI, –2,014.74 to –239.62; p = 0.013) after controlling for relevant factors. CONCLUSIONS:. In critically ill patients in a large U.S. tertiary care hospital, the adoption of a procalcitonin-based protocol for evaluation and treatment of sepsis may be associated with decreased antibiotic use and significant cost savings, with no change in mortality.

Ine Henriette Fossum Taylor, Alfhild Dihle, Kristin Hofsø et al.

Jordan Sexe, Chadwick Mayes, Peter Tofts

Diabetic ketoacidosis is a leading cause of morbidity and mortality in diabetic patients, and its diagnosis should be timely and accurate. SGLT2 inhibitors are a new class of antidiabetic medications that increase the renal excretion of glucose. It is thought that increased urinary excretion of glucose will mask hyperglycemia during DKA. This can lead to a delayed diagnosis of DKA and worsen outcomes. In this report, we detail a case of euglycemic DKA in a patient who presented to the Emergency Department meeting criteria for septic shock.

Ofer Sadan, Owen Samuels

Abstract In response to comments raised, we acknowledge the shortcomings of our study. It is a small study. However, it is a pilot study, which is not meant to create generalizable data, rather to explore new potential directions. To this end, our conclusions were clearly supported by the results. We demonstrated that administration of 16.4% NaCl/Na-acetate solution was feasible, safe, and was associated with lower rates of AKI. We share the call that large RCTs are required to follow this pilot study and hope that our data will stimulate the ongoing discussion regarding the role of chloride in AKI mechanism.