Lung injury prediction score as a predictor of acute respiratory distress syndrome in intensive care unit

Authors: Tjokorda Gde Agung Senapathi, Made Wiryana, I Made Gede Widnyana, Christopher Ryalino, Budi Hartono

Abstract

Background: Acute respiratory distress syndrome (ARDS) is a clinical syndrome characterized by acute hypoxemia and bilateral infiltrates in the lung after a triggered injury. A major obstacle in ARDS prevention is the identification of patients at risk of ARDS. The goal of this study was to assess the validity of lung injury prediction score (LIPS) as a predictor of ARDS in the intensive care unit (ICU).

Patients and methods: This is a retrospective observational study conducted in the ICU of Sanglah General Hospital (Bali, Indonesia) in 2019 with 451 subjects were eligible after a systematic random sampling method. Receiver operating characteristics (ROC) analysis was used to assess the ability of LIPS to predict ARDS and determine the best cutoff point for LIPS in predicting ARDS.

Results: The area under ROC curve (AUC) value was 0.86 (95% CI 0.81-0.91). The best cutoff point was at LIPS ≥5 (sensitivity 85.71%, specificity 80.77%). From a cross tabulation calculation, we obtained a relative risk of 18.6 (95% CI 7.4-46.77). A logistic regression analysis obtained an odds ratio of 1.71 (95% CI 1.45-2.03).

Conclusion: LIPS is valid for predicting the incidence of ARDS in ICU patients. It can be used as a screening tool to identify those with a high risk of developing ARDS.

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The use of COVID-19 IgM rapid test in the setting of negative RT-PCR to diagnose infection by SARS-CoV-2: A challenging case

Authors: Elizabeth Gamboa, Melanie Duran, Alan Araiza, Daryelle Varon, Mariya Mohiuddin, Joseph C Gathe Jr, Joseph Varon

Abstract

In December 2019, a novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) caused an outbreak of respiratory disease in Wuhan, China, that quickly spread to other countries causing a global pandemic. Although the reverse transcriptase polymerase chain reaction (RT-PCR) test for SARS-CoV-2 infection has become the standard method of diagnosis, this test has limitations that cause false negative results. The sudden onset, and spread of this virus, has created an urgency to find reliable screening and diagnostic tools to identify infected patients, prevent further transmission, and provide treatment for these patients. A rapid and accurate diagnostic tool, the COVID-19 combined IgG and IgM “Rapid” test can detect these antibodies against SARS-CoV-2 using a finger prick blood sample detecting infection in 15 minutes. We report the use of the COVID-19 IgM Rapid Test in the presence of high clinical suspicion, along with typical chest computed tomography findings suggestive of COVID-19 infection, in a patient who tested negative twice for the nasopharyngeal swab specimen RT-PCR test.

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COVID-19-induced hepatic encephalopathy: A case report

Authors: Elizabeth Gamboa, Diego Montelongo, Hussein Berjaoui, Daryelle S. Varon, Joseph C Gathe Jr, Joseph Varon

Abstract

By the end of December 2019, a single stranded ribonucleic acid (RNA) virus, Coronavirus, was said to be responsible for an outbreak of respiratory infections of unknown origin in Wuhan, China. Globally, this virus has caused over 160,000 deaths and is expected to increase as the pandemic continues. The majority of patients with the coronavirus disease 2019 (COVID-19) infection present symptomatically with fever, shortness of breath, or cough; however, given that the Coronavirus targets the angiotensin converting enzyme 2 receptors (ACE2), it has been suspected that the virus also exhibits neuroinvasive effects. We present a case of a 32-year-old man with a one-week history of progressive shortness of breath, myalgias, arthralgias, fever peaks, who tested positive for COVID-19 and developed acute hepatic encephalopathy with altered mental status.

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Early mobilization of the critically ill patient: Literature systematic review

Authors: João Vítor Vieira, Rogério Ferrinho Ferreira, Margarida Palma Goes, Henrique Oliveira, Raquel Guerreiro Pacheco, Jorge Pereira

Abstract

Introduction: The immobility and prolonged bed rest, to which the critically ill patient admitted to the intensive care unit, is subjected harmful and have potential adverse effects, especially on the musculoskeletal system and, consequently, on motor functionality.

Objectives: To characterize the impact of early mobilization on the critical patient admitted to an intensive care unit.

Method: Systematic review of the literature that used the PI[C]OD methodology to compile the research question, which led to the search in the EBSCOHost search engine, in the CINAHL Complete and MEDLINE Complete databases, for the identification of studies published between 2016 and 2019. Four systematic reviews of the literature and three randomized controlled trials were selected. This review considered the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendation. Levels of evidence were secured by the levels of evidence from The Joanna Briggs Institute and methodological quality was analyzed using the Critical Appraisal Skills Program.

Results: Most of the articles included in this review point to the benefits of early mobilization in intensive care units, mainly for the improvement of motor functionality and functional capacity, and only one revision, due to the poor quality of the articles included, is inconclusive to the benefits of this intervention in this population.

Conclusions: Early mobilization is a feasible, beneficial, and safe intervention for the critical patient admitted to an intensive care unit. However, due to the lack of studies on the subject and the limitations of the studies analyzed, it is suggested that more quantitative studies, with more representative samples, be carried out.

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A primary biomarker examination in preventing progressivity of acute respiratory distress syndrome: the role of surfactant protein-D in sepsis induced ARDS

Authors: Anna Surgean Veterini

Abstract

Sepsis is one of the most unreachable conditions of hospitalization and a major contributor to hospital mortality, representing a major worldwide health burden. Sepsis is a syndrome characterized by an irregular host response to pathogens invasion, which involving hemodynamic changes that lead to multiple life-threatening organ dysfunctions. Among the injured organs, the lung is the first and most frequent organ to fail. Acute respiratory distress syndrome (ARDS) develops with many serious medical disorders. At least, mortality is 40% and there is no specific therapy. ARDS is an acute inflammatory process in the lung caused by infection direct or indirectly to the alveolar-capillary membrane. Currently, ARDS is diagnosed based on a combination of clinical and physiological variables. In this article, we will review the current understanding of surfactant protein-D as one of many biomarkers in ARDS diagnosis.

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Can emergency medicine residents diagnose neurogenic stunned myocardium in the emergency department by Focused Assessment Diagnostic Echocardiography?

Authors: Ehsan Karimialavijeh, Aaliyeh Zarrabi, Hamideh Akbari, Mehrad Aghili, Elnaz Vahidi, Fatemeh Rasooli

Abstract

Purpose: To assess the ability of trained emergency medicine (EM) residents to diagnose neurogenic stunned myocardium (NSM) in patients with acute intracranial events in the emergency department (ED) using the Focused Assessment diagnostic Echocardiography (FADE).

Methods: This prospective cross-sectional study was conducted between February 2018 and January 2019. First, four postgraduate year-3 (PGY-3) EM residents were trained through participation in 10 hours of theoretical FADE education and 20 hands-on FADE on ED patients. Then, adult patients (aged over 18 years old) with acute cerebrovascular accidents (CVAs) were enrolled in the study. Patients with a history of prior cardiac disease, concurrent CVA and ST-elevation myocardial infarction (STEMI), and cardiopulmonary arrest in the ED were excluded. The results of echocardiography by the cardiologists were considered as the gold standard.

Results: Eighty-five cases were enrolled in the final analysis. The mean age of participants was 62.7 years, and 47 (55.3%) were male. There was a good agreement between the EM residents and cardiologists in diagnosing left ventricular (LV) dysfunction (Cohen’s Kappa=0.7, 95%CI=0.65-0.8). Troponin I was positive in 3 (3.5%) patients. Based on the diagnosis of cardiologists, all three patients had heart failure and received a definitive diagnosis of NSM. Whereas, according to the FADE exam by EM residents, 2 out of 3 cases with positive enzyme had heart failure (interrater agreement=66.6%).

Conclusion: Our study showed that trained EM residents could use the FADE exam to diagnose the NSM in CVA patients in the ED.

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Vasopressor dependency index: a quick prognostic parameter of septic shock patient in emergency and intensive care unit in remote area

Authors: Imamuddin Arif Wicaksono, Arie Utariani, Kuntaman

Abstract

Objective: The aim of the this study was to find out the outcome differences in septic shock patients based on the vasopressor dependency index (VDI) value at Dr. Soetomo General Hospital Surabaya.

Design: This was an analytical observational research.

Setting: Resuscitation Room of Dr. Soetomo General Hospital Surabaya from March to May 2019. This study was approved by the Research Ethics Committee of Dr. Soetomo General Hospital Surabaya.

Patients and participants: The inclusion criteria was septic shock patient who met sepsis-3 criteria. There were 44 samples in the inclusion criteria.

Interventions: Samples were taken by consecutive sampling. VDI was measured starting from 10 minutes, 1 hour, 6 hours, 12 hours, 24 hours, and 48 hours after the treatment of vasopressor drug.

Measurements and results: The most common causes of sepsis was pneumonia (47.7%). Septic shock patients were given norepinephrine (80.0%) as the first line vasopressor drug. There were patient outcome differences within 7 days of treatment based on the VDI value. The VDI value at the 24th hour and the 48th hour were the most influential variable to the patient outcome (p=0.034). The VDI value threshold of the 24th hour was 0.176/mmHg (81.8% sensitivity; 85.2% specificity; 95% CI 0.818-1.000; p=0.000) and of the 48th hour was 0.150/mmHg (88.9% sensitivity; 92.6% specificity; 95% CI 0.859-1.000; p=0.000).

Conclusion: There were significant differences in septic shock patient's outcome in the first 7 days of treatment based on VDI value. The VDI value at the 24th hour and the 48th hour were the most influential variables to the patient outcome (p=0.034). The threshold of VDI at the 24th hour was 0.176/mmHg. The threshold value of VDI at 48th hour was 0.150/mmHg.

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Venous-arterial CO2 difference to arterial-venous O2 content difference ratio as marker of resuscitation in pediatric septic shock

Authors: Yos Kowara, Arie Utariani, Bambang Pujo Semedi, Purwo Sri Rejeki

Abstract

Objective: Sepsis is still a major cause of mortality in pediatric intensive care units. During initial resuscitation, central venous oxygen saturation (ScvO2) and/or lactate level have become a standard monitoring target nowadays. Carbon dioxide (CO2) partial pressure difference between central vein and artery (Pv-aCO2) has also been recommended as an additional marker to identify persistent global hypoperfusion. Recently, the Pv-aCO2/Ca-vO2 ratio, which represents respiratory quotient, is presumed to be superior in detecting anaerobic metabolism.

Design: Single center observational analytic research with cross-sectional study.

Setting: Resuscitation Room at academic hospital.

Patients and participants: Twenty-four pediatric patients with septic shock, aged 2 months to 12 years old.

Interventions: Patients were resuscitated at the Emergency Department of Dr. Soetomo General Academic Hospital, Surabaya. Initial first hour therapy included oxygenation, antibiotic administration, fluid bolus, and catecholamine titration. Central venous catheter was inserted in all patients through subclavian or jugular veins.

Measurements and results: Lactate was measured in the first and third hour after patient arrival. Arterial and central vein blood gas analysis was performed concurrently at the third hour. Patients were followed up after 48 hours to assess outcome. Pv-aCO2/Ca-vO2 ratio was more effective compared to ScvO2 and lactate clearance in predicting the 48-hour mortality rate (p 0.047). The cutoff value of the Pv-aCO2/Ca-vO2 ratio of 1.54 had the highest sensitivity and specificity to represent global hypoxia in pediatric patients with sepsis.

Conclusion: Pv-aCO2/Ca-vO2 ratio is a useful marker in predicting mortality in pediatric patients with septic shock.

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Prediction of respiratory complications guided by Clara cell protein CC16 in plasma in polytrauma patients

Authors: Kamel Abd El Aziz Mohammed Abd Allah, Moataz Mohamed Ibrahim Aly, Ibrahim Mohamed Atia, Samir El Hadedy Tawfik, Khaled Farid Mohamed Hassan

Abstract

Objective: To evaluate the value of serum levels of Clara cell protein (CC16) as a diagnostic and prognostic utility in patients with polytrauma and relate these levels to respiratory complications compared to plasma levels of healthy control group.

Subjects and methods: A prospective cohort study was carried out on one hundred and fifty patients with polytrauma (blast, blunt, and penetrating) who admitted to Intensive Care Units of Maadi and Kobry El Kobba Hospitals, Cairo, Egypt, from June 2016 and June 2019. Full history taking, clinical examination, radiology investigations, laboratory investigations, CC16 protein and other inflammatory biomarkers were investigated.

Results: There was no statistically significant difference between both groups as regarding age (p=0.09), comorbid conditions (p>0.05), Glasgow coma scale (p=0.09), Acute Physiology and Chronic Health Evaluation (APACHE) II score (p=0.07) and abbreviated injury scale (p=0.08). Along 5 days there was a significantly higher C-reactive protein (CRP) level, neutrophil-lymphocyte ratio in Group I. PO2 level was significantly higher in the first 2 days in Group II than Group I. Chest computed tomography (CT) scan revealed the presence of lung contusion in 30 patients, hemothorax in 20 patients, and pneumothorax in 25 patients, all in Group I. Also, there was a statistically significant difference on day 0 between both groups with much higher serum CC16 in Group I than Group II, while on day 3 the difference was insignificant. Whereas, respiratory complications were significantly higher serum and broncho alveolar lavage (BAL) level of CC16 on day 3, while this difference was insignificant on day 0.

Conclusions: These findings showed that we may benefit from detecting serum CC16 levels in polytrauma victims in prediction of respiratory complications.

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Internal jugular vein thrombosis and central venous catheter

Authors: Ricardo de Jesús Avendaño-Garnica, Santiago Herrero, Joseph Varon

A sixty-seven-year-old gentleman, with atherosclerotic cardiovascular disease, stable angina, and hypertension was admitted to the hospital with several episodes of chest pain. An electrocardiogram revealed ST-T changes in the anterior wall. A coronary angiography followed by an angioplasty resulted in placement of 2 stents for critical lesions on the left anterior descendent artery. Within minutes, the patient became hypotensive with signs of hypoperfusion. Bedside echocardiography revealed cardiac tamponade. An emergency pericardial drainage was placed, and the patient taken to the cardiac catheterization laboratory where a repeat angiogram revealed a right coronary artery perforation as well as a small distal branch of the posterior descendent artery.

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