Pneumoperitoneum following cardiopulmonary resuscitation in a COVID19 patient

Authors: Gabriel Cervera, Daryelle S. Varon, Joseph Varon

Case presentation

An 86-year-old Hispanic lady was brought to the emergency department in acute respiratory distress. She had tested COVID-19 positive a week prior to her presentation. She had a past medical history of chronic hypertension, gastric ulcer, abdominal hernia, anxiety, and arthritis. On arrival blood pressure was 130/72 mmHg, heart rate 85/min, respiratory rate 33/min, temperature 98.8 ºF, with oxygen saturation of 82% while breathing room air. Further testing revealed ground glass opacities and interstitial infiltrates in both lungs on computed tomography. Over the next few hours, the patient deteriorated with her oxygen saturation dropping 40% followed by asystole. Cardiopulmonary resuscitation (CPR) was immediately started. She was intubated on first attempt. CPR continued for 15 minutes and multiple doses of epinephrine were given. Return of spontaneous circulation was obtained with sinus rhythm that required vasopressors to maintain reasonable mean arterial pressures. A post resuscitation chest radiograph depicted sub diaphragmatic free air suggesting spontaneous pneumoperitoneum (Figure 1). All prior imaging tests failed to reveal this new finding. Her abdomen was mildly distended but no signs of tension pneumoperitoneum or inferior vena cava compression were found on physical or ultrasonographical exam. A surgical consultation was obtained. In view of her dismal prognosis, after discussing with her family, limitation of care followed.

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Age factor and COVID-19: Are there limits to be admitted in the ICU? An ethical issue

Authors: Santiago Herrero


Objective: The aim of this article is to clarify different aspects including ethics about the elderly patients during coronavirus disease 2019 (COVID-19) scenario in Spain.

Design: Retrospective, observational.

Methods: Description and comparison of all age groups by confirmed cases and hospitalizations, with special emphasis on those elderly admitted to the intensive care unit (ICU) and mortality. Study of the ethical recommendations of different Spanish scientific societies with treatment proposals for the elderly group. Patients were divided into 6 different age groups. Group I (0-14 years), Group 2 (15-29 years), Group 3 (30-49 years), Group 4 (50-69 years), Group 5 (70-79 years), and Group 6 (>80 years).

Results: The number of confirmed cases during the study was 250,273 and 20,534 deaths. The global mortality was 8.2%. Number of hospitalized patients was 37.1% and 18.25% died. Three point one percent were admitted to the ICU with a mortality of 30.4%. ICU admission ratio: Group 4 51.7%, Group 5 28.4%, and Group 6 4.95%. Average age survivors were 58 (44-76 years), 83 (75-89 years) corresponding to Group 5-6. Non-ICU mortality increased to 14.6% in Group 5, while Group 6 achieved the highest mortality (21.7%).

Conclusion: The number of elderly patients admitted to the ICU was exceptionally low.

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Ultrasound cardiac output monitor inter-rater agreement in Pediatric Intensive Care Unit

Authors: Putu Aditya Wiguna, Indah Kartika Murni, Desy Rusmawatiningtyas


Objective: Although Ultrasound Cardiac Output Measurement (USCOM) is relatively simple to operate, its reliability for novice user needs to be assessed. This study aims to determine inter-rater agreement of USCOM between pediatric residents as novices and pediatric intensivist as experienced operator.

Design: An observational study.

Setting: A single-center study in Pediatric Intensive Care Unit.

Patients and participants: Pediatric residents underwent in-house training and 20 practice scans, followed by blinded trans-aortic USCOM cardiac index (CI) measurements made by one of two randomly selected pediatric residents paired with one pediatric intensivist. CI, its categorization and image quality, were noted.

Measurements and results: Paired measurements were performed on 48 subjects. Median of subjects age were 2 years (1 month to less than 18-year-old). Spearman’s rank showed strong positive correlation of CI (rs=0.77; 95% CI=0.62-0.86). Inter-rater agreement by Cohen’s kappa showed substantial agreement on CI (ĸ=0.78).

Conclusion: Following training, pediatric residents were able to measure CI using USCOM with substantial inter-rater agreement.

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Comparison of the resuscitative effects between lactated ringer and lactated ringer/hydroxyethyl starch 6% (200/0.5) combination to serum lactate level in hemorrhagic shock in Lepus nigricollis rabbits

Authors: Faisal Muchtar, Syafri Kamsul Arif, Andi Husni Tanra, Arif Santoso, Made Wiryana, Agussalim Bukhari, Nurpudji Astuti Daud, Hisbullah, Warsinggih, Ilhamjaya Patellongi


Objective: The ideal resuscitative strategy in hemorrhagic shock remains a matter of debate. The standard resuscitation fluid comprises of crystalloid and colloid, such as lactated Ringer’s (LR) and hydroxyethyl starch (HES), respectively. Whether the administration of LR/HES combination can provide better microcirculatory improvements than LR alone is still unknown.

Design: Experimental analytic study comparing the effect between LR and LR/HES (200/0.5) 2:1 combination to serum lactate level in hemorrhagic shock in rabbit (Lepus nigricollis).

Setting: This study was conducted at Hasanuddin University Medical Research Center (HUMRC), Makassar, Indonesia, from July to October 2019.

Patients and participants: A total of 30 Lepus nigricollis rabbits were included in this study. Fifteen animals were allocated in each group.

Interventions: After the initiation of induced hemorrhagic shock, a hypotension period was maintained for 30 minutes using infusion of LR/HES 6% (200/0.5) 1:2 combination if mean arterial pressure (MAP) decreased more than 30% from baseline, or if there was continuous bleeding if MAP was decreased less than 20% from baseline. The animals in LR group were then resuscitated with LR, while the animals in combination group were resuscitated with LR/HES 6% (200/0.5) 2:1 30 ml/kg/hour, then continued with 3 ml/kg/hour.

Measurements and results: Serum lactate level was measured at baseline, after the initiation of hemorrhagic shock, and after resuscitation. After hemorrhage was initiated, 19 animals had a <20% decrease in MAP and 11 animals had a ≥20% decrease in MAP. There was a significant decrease in serum lactate level in both LR and combination group with <20% decrease in MAP. LR group had a significant difference in serum lactate level from before and after resuscitation, whereas in combination group, only those with <20% decrease in MAP had a significant difference. There were no significant differences in the changes of serum lactate level between both groups.

Conclusions: Resuscitation in both groups may decrease serum lactate level in hemorrhagic shock, and resuscitation with LR/HES 6% (200/0.5) 2:1 combination provided better improvement than LR alone.

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Optic nerve and transcranial doppler ultrasonography for diagnosing increased intracranial pressure in adult traumatic brain injury patients: A systematic review and meta-analysis

Authors: Nancy Margarita Rehatta, Merlin Guntur Jaya, Corinne Prawira Putri, Ricardo Adrian Nugraha, Dana Hendrawan Putra, Imran Harsam Kamal, Nabila Ananda Kloping, Taufan Adityawardhana, Michael Jonatan, Yudhistira Pradnyan Kloping


Objective: To evaluate the accuracy of ultrasonography to assess the increase of intracranial pressure by assessing optic nerve sheath diameter (ONSD) and transcranial Doppler (TCD), consisting of the black box (BB) model, arterial diastolic flow velocity (FVd), critical closing pressure (CrCp), and pulsatility index (PI) as parameters, in adult traumatic brain injury (TBI) patients.

Methods: A systematic search through the electronic databases including Medline through PubMed and Embase for studies evaluating the use of optic nerve and TCD USG to evaluate increased intracranial pressure (ICP) compared with the invasive method. Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool was used to assess the risk of bias.

Results: Ten studies consisting of 727 patients were included in this study. The overall pooled sensitivity and specificity for the prediction of elevated ICP by measuring ONSD were 94% (95% CI: 89%-97%) and 88% (95% CI: 81%-95%), respectively. Positive and negative likelihood ratios were 12.7 (95% CI: 6.6-25.3; Cochran Q-statistic =14.6; p=0.04) and 0.06 (95% CI: 0.03-0.10; Cochran Q-statistic =14.1; p=0.05), respectively. All I2 values were >0.50. The area under the receiver operating characteristic (ROC) curve was 0.92 (95% CI: 0.81-0.98) as shown in the summary ROC (sROC) plot. A meta-analysis could not be performed for the TCD subgroup due to several incomplete sensitivity and specificity data and differences in the evaluated parameters. Four studies evaluated the role of TCD with mixed results. In one study, averaging the parameters of TCD displayed favorable results.

Conclusion: ONSD can be used as a parameter to evaluate the increase of ICP in TBI patients. BB model, FVd, and CrCp are potential promising parameters of TCD ultrasonography for noninvasive ICP estimation as opposed to PI. However, more studies with complete accuracy results are required in the future.

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Dabigatran-induced hemopericardium with tamponade

Authors: Zouheir Ibrahim Bitar, Ossama Sajeh Maadarani, Mahmoud Jaber Mohsen, Tamer Mohamed Zaalouk


Background: Rapidly changing the pharmacokinetics and pharmacodynamics in critically ill patients with acute kidney injury leads to patients having a high risk of bleeding despite the early cessation of direct oral anticoagulant (DOAC). Bleeding complications can occur at a rare hidden site, the hemopericardium; this type of complication requires point-of-care ultrasound examinations (POCUS) for early detection and the performance of ultrasound-guided drainage as a lifesaving procedure.

Case presentation: An 84-year-old woman with atrial fibrillation who was taking 110 mg bid dabigatran and who presented with obstructive sleep apnea and deteriorated renal function as well as type 2 respiratory failure. The patient was compliant with the dosage of dabigatran (110 mg twice daily), and the last dose was taken a few hours prior to being transferred to the critical care unit. Within 24 hours, the patient was notably lethargic and oliguric. Laboratory examination demonstrated a deterioration in renal function. Serial transthoracic echocardiography demonstrated new mild pericardial effusion that progressively increased for the next 4 hours with signs of early cardiac tamponade. Idarucizumab was administered. The patient underwent successful echocardiography guided pericardiocentesis without complications. A 500 ml of grossly hemorrhagic fluid was removed. The patient recovered to baseline status over the course of one week, with laboratory and clinical resolution of multiorgan failure and no echocardiographic evidence of hemopericardium.

Conclusion: Life-threatening hidden hemorrhagic complications warrant caution in patients receiving DOAC. Our case highlights both a rare bleeding complication of dabigatran, and the effectiveness of idarucizumab, the approved reversal agent. Clinicians should closely monitor patient renal function in the setting of critical care area. Urgent POCUS detected the complication early, and ultrasound guided pericardiocentesis was followed by improved hemodynamic.

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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


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


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


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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