Pneumomediastinum diagnosed from a remote tele-ICU center?


Background: The propagation of remote “telemedicine” has allowed intensivists (and other medical professions) to expand their ability to provide critical care medicine services to intensive care units (ICUs). The physical exam is a pertinent skill that all providers learn early in their medical careers. Key components of the physical exam can help a clinician narrow the differential diagnosis. Even with modern monitoring devices and high-powered imaging, it is hard to replicate the physical exam on a critical care patient from a tele-medicine center.

Case presentation: An experienced intensivist working in a telemedicine (Tele-ICU) center reviewed the daily chest radiograph on a patient with a complex prolonged ICU course. The radiograph was immediately recognized as being concerning for an acute case of pneumomediastinum in a patient with recent tracheostomy manipulation. However, the intensivist was unable to corroborate his suspicions with a good physical exam as the differential diagnosis list was explored.

Conclusions: Acute pneumomediastinum is a severe disease process arising from numerous etiologies that can be life threatening. This disease process can often times be diagnosed from plain chest radiography alone. However remote telemedicine patient care should never supersede a direct bedside physical exam. Every good clinician knows that the fundamental physical exam truly is fundamental.

Authors: Keith Azevedo, Brian T. Wessman

Critical care medicine ocular emergency presentation: Can you see it?


Introduction: Ocular emergencies are not a common presentation in the intensive care unit. Intensivists should have a broad differential for the “red eye” and involve ophthalmology appropriately for ocular emergencies.

Background: Ocular emergencies can lead to permanent vision loss if not identified in a timely fashion.

Case description: A patient with hyponatremia and bacteremia admitted to the intensive care unit (ICU) developed an acute painful red eye. Physical exam findings and images are shared.

Conclusion: Due to an acute ocular emergency, this critically-ill patient required transfer to a higher level of care and subspecialty management.

Clinical significance: Education about ocular emergencies is provided for the intensivist; including diagnosis, management, and complications.

Authors: Stephanie Charshafian, Brian T. Wessman

Post-sternotomy mediastinitis: What the intensivist needs to know


Deep sternal wound infection (DSWI) is a dreaded complication after cardiac surgery, which dramatically increases health costs, in addition to high morbidity and mortality. The diagnosis and treatment of post-sternotomy mediastinitis (PSM) is a professional challenge. The aim of this current narrative mini review, we will consider epidemiology, implicit risk factors, the basis of diagnosis, preoperative, intraoperative, and postoperative prevention, and antimicrobial procedures, as well as the management of an optimal antimicrobial policy including an antimicrobial switch therapy.

Antibiotic cost represents a significant part of hospital budgets all over the world and more when the cost falls directly on the patient in those health systems that do not cover assistance and treatment. The management of switch therapy is not yet well known in patients with mediastinitis and it is common to find some objection in its use due to the change from long-acting intravenous antimicrobial antibiotics to oral regimen in this type of patients, most of them with high hospitalization rates.

Authors: Santiago Herrero

Correlation between elevated TNF-α, syndecan 1, and urine IL 18 levels in acute kidney injury following on pump cardiac surgery


Objective: This study aims to determine the correlation between elevated tumor necrosis factor alpha (TNF-α) and syndecan-1 with urine interleukin (IL)-18 levels as post-cardiac surgery-related acute kidney injury (AKI) marker.

Design: This study was an analytical observational study with a cross sectional design.

Setting: This study was conducted at Dr. Wahidin Sudirohusodo Central General Hospital. The period of study was from October 2019 to February 2020.

Patients and participants: Population of study was all patients who underwent adult on pump cardiac surgery. Study samples were patients who were included in inclusion criteria. Patient’s characteristics were presented as frequency and percentage.

Measurement and results: All interval data with normal distribution were analyzed using T-pair test. Spearman correlation test was performed to determine the correlation between TNF-α, syndecan-1, and IL-18 levels toward AKI incidence. The data was presented with odds ratio (OR) 95% confidence interval (CI). There were 33 subjects who underwent adult cardiac surgeries including coronary artery bypass grafting (CABG), valve, and congenital disorder surgeries. Twenty-one people (63.6%) had AKI and 12 people (36.4%) did not. In AKI patients there was an increased syndecan-1 level of 61.94±36.58 ng/ml with relative risk (RR)=1.11 (95% CI 1.02-1.21), TNF-α level of 6.85±4.05 pg/ml, RR=2.61 (95% CI 1.19-5.71), and IL-18 level of 205.5±121.35 pg/ml, RR=1.38 (95% CI 1.06-1.79). There was a significant correlation between syndecan-1, TNF-α, and IL-18 levels. AKI incidence in post-cardiac surgery patients had a significant elevated IL-18 level (p=0.016), with RR=1.38 (95% CI 1.06-1.79).Conclusion: Elevated syndecan-1, TNF-α, and IL-18 levels were correlated with AKI incidence in post-cardiac surgery patients.

Authors: Andi Adil, Setiawan P, Yan Efrata Sembiring, Budiono

Clinical characteristics and outcomes of critically ill COVID-19 patients admitted to an Infectious Diseases Intensive Care Unit in Portugal


Objective: We aimed to describe the characteristics and outcomes of patients with coronavirus disease 2019 (COVID-19) admitted to an intensive care unit (ICU) in Portugal.

Design: This is an observational retrospective study. Demographic and clinical data were collected. Respiratory failure treated with invasive mechanical ventilation (IMV) and death during ICU stay were the main outcomes evaluated.

Setting: This study was conducted in the Infectious Diseases ICU of Centro Hospitalar e Universitário de São João, in Porto, Portugal, between March 11 and August 17, 2020.

Patients and participants: All consecutive patients with confirmed Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection, admitted to the ICU during the study period were enrolled, and 62 patients were included.

Measurements and results: The median age was 71 years (IQR, 54-78) and 39 (62.9%) were male. Thirty-four (54.8%) patients received IMV in contrast to 28 (45.2%) who were not intubated and the median lowest PaO2/FiO2 was 86 (IQR, 70-113) in IMV and 150 (94-257) in non-IMV patients. Several patients with severe hypoxemic COVID-19 were treated without IMV, especially with high flow nasal cannula (HFNC). Overall mortality was 21.8% and older age, male sex, active cancer, lower lymphocyte count, higher aspartate aminotransferase (AST) level, and higher creatinine level at admission, hematologic dysfunction, and renal dysfunction during ICU stay were all associated with fatal outcome. Mortality was lower than observed in other series of critically ill patients, although comparisons are limited by different ICU admission criteria, management practices, and duration of follow-up.Conclusions: This study provides data regarding the characteristics and outcomes of COVID-19 critically ill patients that can be used to optimize ICU preparedness in the future.

Authors: António Martins, Margarida Mouro, João Caldas, André Silva-Pinto, Ana Sofia Santos, Sandra Xerinda, Alcina Ferreira, Paulo Figueiredo, António Sarmento, Lurdes Santos

Brain stem infarction as a complication of probable meningitis/encephalitis associated with COVID-19: A case report from Lombok, West Nusa Tenggara

AbstractCoronavirus disease 2019 (COVID-19), firstly discovered in Wuhan, China, has spread globally and was declared by the World Health Organization (WHO) as a pandemic since March 11, 2020. By June 13, 2020, the number of Covid cases in Indonesiawas 37420 with 2091 mortality cases. Lombok is situated in the province of West Nusa Tenggara, currently the number of Covid-19 cases 937. We report a case of probable meningitis/encephalitis associated with COVID-19 with symptoms of fever, headache, and cough. The patient was brought to the Emergency Room with decreased of consciousness, seizures, and neck rigidity. The thoracic examination and head computed tomography (CT) scan revealed pneumonia and brain stem infarction, respectively. Nasopharyngeal swab examination was performed and identified the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ribonucleic acid (RNA) leading to meningitis due to COVID-19.

Authors: Ilsa Hunaifi, Karina Anindita, Elya Endriani, Sri Kartika Sari, Ririn Setyawati, Indah Widya Astuti, Sandra Yuliana Andini Putri, Zainul Muttaqin

A case report: Does amynophilline have opportunity in COVID-19 management?

AbstractThe novel coronavirus disease 2019 (COVID-19) is caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV-2), which causes severe acute respiratory distress syndrome (ARDS). ARDS causes the patient to have difficulty breathing, the appearance of pneumonia from chest radiological images, and from the examination results by pulse oximetry, the picture of oxygenation is poor. Most clinical complaints require mechanical ventilation and treatment in the intensive care unit (ICU). We made several attempts to increase oxygenation and ventilation from a pharmacological and non-pharmacological perspective. From pharmacology, given drugs that help from an immunological aspect, reduce preload, help cardiac contractility, and anti-virus. In this case report, we report aminophylline administration as a therapeutic modality in critically ill patients' handling due to COVID-19.

Authors: Anna Surgean Veterini, Lucky Andriyanto, Hamzah

Pneumoperitoneum following cardiopulmonary resuscitation in a COVID19 patient

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.

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

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


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.

Authors: Santiago Herrero

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


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.

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

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


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.

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

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


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.

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

Dabigatran-induced hemopericardium with tamponade


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.

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

Treatment of COVID-19 is critically phase specific

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...

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

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


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.

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