Treatment of COVID-19 is critically phase specific

Authors: Paul E. Marik, Joseph Varon, Pierre Kory

A number of beneficial (corticosteroids and remdesivir), and potentially beneficial therapies, exist for the treatment of COVID-19. What is not widely appreciated is that patients with COVID-19 progress though several distinct phases, with each stage having a different treatment strategy (Figure 1). This fact is of critical importance in achieving the best possible outcomes of this disease. The symptomatic phase is marked by enormous viral replication reaching viral loads in the upper respiratory tract in excess of a billion virions per milliliter, with a very limited host inflammatory response. While patients may remain SARS-CoV-2 PCR positive for weeks (and in...

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Low-dose heparin for sepsis-associated disseminated intravascular coagulation and septic shock

Authors: Arie Zainul Fatoni, Suwarman, Hori Hariyanto, Oloan E. Tampubolon, Wiwi Jaya

Abstract

Background: Sepsis and septic shock are severe clinical problems with high mortality rates, characterized by a systemic inflammation with substantial procoagulant elements and activating some clotting factors. Those are possible to develop the disseminated intravascular coagulation (DIC). Heparin is a well-known anticoagulant, which also provides anti-inflammatory properties. Nevertheless, the efficacy of heparin was limited by the potential risk of bleeding in critically ill patients. In this case report, we would like to explain the therapeutic effects of low-dose heparin on sepsis-associated DIC and septic shock.

Case report: We report a case of a 60-year-old male with sepsis-associated DIC and septic shock caused by pneumonia. The patient had decreased consciousness for 10 hours before hospitalization. Standard intensive care and intravenous low-dose heparin (250 IU/h) were performed in the Intensive Care Unit (ICU). On day 12 of ICU admission, the patient's condition was fully conscious and clinically stable. Therefore, the patient discharged from ICU with no bleeding manifestation and no sequelae.

Conclusion: Low-dose heparin successful treats patient with sepsis-associated DIC and septic shock.

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A case of severe respiratory distress in a patient with chronic myeloid leukemia receiving dasatinib

Authors: Natsumi T. Hamahata, Sophie Rodrigues Pereira, Ehab G. Daoud

Abstract

Introduction: Dasatinib is a multi-kinase inhibitor used primarily in the treatment of chronic myeloid leukemia (CML). The major reported side effects are pleural effusion, pulmonary hypertension, and severe infection. The most common infection among these patients is pneumonia. Here, we present a case of severe respiratory failure in a patient with CML who was taking dasatinib.

Case presentation: A 75-year-old male with CML, hypertension, hyperlipidemia presented to the emergency department with progressively worsening shortness of breath and hemoptysis for one week. The patient’s CML had been well controlled with dasatinib since his diagnosis two years ago, and the most recent BCR-ABL1 assay was undetectable. Computed tomography (CT) of the chest revealed diffuse ground glass opacity with superimposed interlobular septal thickening and intralobular lines (“crazy-paving pattern”) and a moderate-sized right pleural effusion. Therapeutic thoracentesis yielded 1.8 l of lymphocyte predominant, exudative pleural effusion. Pneumocystis jirovecii polymerase chain reaction (PCR) of induced sputum was positive, which was consistent with the CT finding of “crazy-paving pattern.” Dasatinib was held for the possibility of drug induced pneumonitis and pleural effusion, and the patient was successfully treated with trimethoprim-sulfamethoxazole for his pneumocystis jirovecii pneumonia (PCP).

Conclusion: Our case suggests that a common tyrosine kinase inhibitor, dasatinib, cannot only act as an effective antileukemic agent, but also can cause several adverse effects including pleural effusion and immunosuppression. Physicians should consider opportunistic infections in their differential when patients on dasatinib present with respiratory insufficiency.

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Resuscitation incoherence after cardiac arrest due to acute intraoperative pulmonary emboli related acute right heart failure: A case report

Authors: Ade Susanti, Mayang Indah Lestari, Dita Aditianingsih

Abstract

Resuscitation incoherence is a mismatch between macrocirculation, microcirculation, and cellular parameters after resuscitation. We report a 34-year-old obese male patient, suffering from end-stage renal disease or chronic kidney disease (CKD), underwent routine hemodialysis three times a week and hypercoagulability state with rivaroxaban therapy. He had a cardiac arrest during kidney transplant surgery. Acute right heart failure causing cardiac arrest was presumably caused by acute intraoperative pulmonary embolism. Hemodynamic and resuscitation incoherence occurred and proper treatment was needed. At the time of cardiac arrest, hemodynamic coherence was lost and resuscitation was performed to restore this loss by correcting the possible causes of cardiac arrest. Although the return of spontaneous circulation (ROSC) was successfully achieved, a type 1 resuscitation incoherence occurred where the macrocirculation was optimal but cellular parameters were disturbed by cell hypoxia, characterized by high levels of lactate. Type 2 resuscitation incoherence was also found in this patient until the end of treatment in the intensive care unit (ICU). Cellular parameters such as lactate levels and the venoarterial carbon dioxide tension difference to arteriovenous oxygen content difference ratio (P[v-a]CO2)/(C[a-v]O2) continued to improve during ICU treatment, but cell hypoxia might occur since the central venous pressure (CVP) value as a macrocirculation parameter was likely to increase, presumed to be caused by incomplete resolved acute pulmonary embolism related chronic thromboembolic pulmonary hypertension.

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Are preinjury anticoagulant and antiplatelet medications a pitfall in the bleeding tendencies of elderly trauma patients in intensive care?

Authors: Se Heon Kim, Young Hoon Sul, Jin Young Lee, Joong Suck Kim

Abstract

Purpose: The elderly are more likely to be on anticoagulant or antiplatelet medications, which increase bleeding. We aimed to determine the effect of preinjury anticoagulant or antiplatelet medications on required blood transfusions and the trauma outcomes of elderly patients.

Methods: We retrospectively reviewed the medical records of all elderly trauma patients admitted to Chungbuk National University Hospital from January 2016 to June 2019. We compared the required number of blood transfusion units, complications, and mortality rate between those on anticoagulant or antiplatelet medications and those that were not, using the chi-squared test, independent t-test, linear regression analysis, and logistic regression analysis.

Results: Out of 466 patients, 142 were on anticoagulant or antiplatelet medications while 324 were not. There was a significant statistical difference in the unit amount of red blood cells transfused within 4 hours of arriving at the hospital between the medicated and non-medicated groups (0.89 vs 1.43 units, respectively, p=0.02); however, multivariate analysis showed no statistical difference (p=0.28). The medication group showed a higher rate of complications compared to the non-medicated group (47.9% vs 29.6%, respectively, p=0.001), bleeding (17.6% vs 2.8%, respectively, p=0.001), and pneumonia (24.4% vs 14.2%, respectively, p=0.01). There was no statistical difference in the mortality rate (16.9% vs 22.2%, respectively, p=0.21).

Conclusion: Preinjury anticoagulant or antiplatelet medications in elderly trauma patients increased bleeding and complications such as pneumonia but did not affect transfusion requirement, or mortality rate.

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Does preinjury anticoagulant or antiplatelet medication increase the need for blood transfusions in patients aged older than 65 years with traumatic brain injury?

Authors: Se Heon Kim, Young Hoon Sul, Jin Young Lee, Jin Bong Ye, Jin Suk Lee, Hong Rye Kim, Soo Young Yoon, Joong Suck Kim, Moon Sang Ahn

Abstract

Background: Anticoagulant or antiplatelet medications are commonly prescribed in older adults, increasing bleeding tendency and affecting traumatic brain injury (TBI)-related morbidity and mortality.

Objectives: This study aimed to determine the effects of preinjury anticoagulant or antiplatelet medication on blood transfusions and outcomes in patients aged >65 years with TBI.

Methods: We retrospectively reviewed records of patients with TBI without other injuries admitted to our hospital between January 2016 and June 2019. We compared the number of blood transfusions administered and outcomes between patients who were receiving anticoagulant/antiplatelet medication and those who were not.

Results: Overall, 82 patients (66% male) with an average±standard deviation age of 76.6±7.29 years were enrolled. Thirty-one patients were receiving anticoagulants or antiplatelets and 51 were not. There were no differences in age, medical history, Injury Severity Score, and Glasgow Coma Scale score between the groups. International normalized ratios of patients who were on warfarin were significantly higher than those of patients who were not (p<0.05). Analysis of covariance demonstrated that patients who were receiving medications needed more plasma transfusions than did those who were not (p<0.05). The incidence of complications was 64.5% and 37.3% in patients who were and were not receiving medication, respectively (p<0.05). Multivariate regression analysis showed that patients who were receiving medications bled 5.62 times more than did those who were not (95% confidence interval: 1.52~20.70).

Conclusions: Bleeding incidence and plasma transfusion requirements are increased by preinjury anticoagulant or antiplatelet medication in patients aged >65 years with TBI.

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Future views on nanonutrition for critically ill patients: The role of extra virgin olive oil nanoemulsion in sepsis enteral nutrition

Authors: Anna Surgean Veterini, Subijanto Marto Soedarmo, Hasanul, Annis Catur Adi, Heni Rachmawati, Nancy Margarita Rehatta

Abstract

Enteral nutrition (EN) can maintain the structure and function of the gastrointestinal mucosa better than parenteral nutrition. Early intervention by enteral nutrition in critically ill patient may help the patient from fatality of multiple organ failure. Oral nutrition is an attempt to provide a physiological nutrition that is expected to trigger the immune system, prevent blood stream infection from the intravenous route, and reduce cost of therapy. One of the problems that inhibits supply of enteral nutrition in critically ill patients is absorption disorders that cause the body’s nutritional needs to be hampered. Administration of extra virgin olive oil (EVOO) in the form of nanoemulsion is expected to improve pharmacokinetics and pharmacodynamics in those patients. EVOO is one functional food that has a lot of health benefits. Nanoemulsion-based delivery systems are proven to increase utilization of lipophilic bioactive components in food, personal care, cosmetic, and pharmaceutical applications. So far, there is no report describes the use of enteral nanonutrition in critically ill patients. This review discusses the perspective view of using EVOO nanoemulsion to care the critically ill patients.

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Giant extrathoracic hematoma in a COVID-19 patient

Authors: Elizabeth Gamboa, Joseph C Gathe Jr, Joseph Varon

Case presentation

A 69-year-old lady presented to our emergency department with a two week history of shortness of breath, fever, and dry cough. Chest computed tomography revealed patchy ground glass opacities throughout both lungs, most pronounced in the mid-to-lower lung zones bilaterally, with peripheral distribution. She was admitted to the hospital with the presumptive diagnosis of coronavirus disease 2019 (COVID-19) pneumonia. She received our standard MATH+ protocol (hydroxychloroquine, intravenous ascorbic acid, zinc, thiamine, melatonin, azithromycin, vitamin D3, and enoxaparin). This was followed by oral anticoagulation with warfarin. On day 18, she complained of severe right breast pain. Upon examination she...

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Acute necrotizing encephalopathy secondary to COVID-19

Authors: Swethen Dushianthan, Elizabeth Gamboa, Joseph Varon

A 54-year-old gentleman without significant past medical history presented to our emergency department with complaints of shortness of breath and fever. On arrival he was very disoriented, and unable to communicate well. He was found to be positive for SARS-CoV-2 and had severe pneumonia. On hospital day 8, he abruptly began to decline, initially presenting with elevation in blood pressure, and soon thereafter with severely decreased level of consciousness. This was followed by a cardiac arrest, that was treated, and he had eventual return of spontaneous circulation within 15 minutes. Despite this, the patient never regained consciousness. A head computed...

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Acute ischemic stroke – an extrapulmonary COVID-19 presentation

Authors: Beena Yousuf, Abdalaziz HRH Gh S. Alsarraf, Huda Alfoudri

Abstract

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that causes coronavirus disease 2019 (COVID-19) has emerged as a high contagious and deadly virus, with an endless capacity to surprise clinicians with new presentations and complications. Although COVID-19 typically presents as respiratory infection but it can present with thromboembolic event. Our hospital, one of the main territory care hospitals in Kuwait, experiencing sudden surge of stroke cases in last few weeks of COVID-19 pandemic. Stroke is a medical emergency which needs early recognition and management for better neurological outcome. In the COVID-19 pandemic, when seeing patients with neurological manifestations, clinicians should consider COVID-19 as a differential diagnosis and should take full protective measures until proven to be negative. Based on our experience, we want to highlight that COVID-19 patients can present with extrapulmonary manifestation like stroke. Emergency physicians, stroke team and intensivist should be wary of this fact. Triaging and COVID-19 screening is the key to minimize the virus spread and to ensure staff and other patients safety.

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