Assessing causality by means of the Naranjo scale in a paediatric patient with life threatening respiratory failure after alemtuzumab administration: a case report.

BACKGROUND: Alemtuzumab is a T cell depleting antibody agent used as induction immunosuppressant therapy in solid organ transplant recipients. In addition, it is being increasingly used to treat severe or glucocorticoid-resistant graft rejection. Despite the effectiveness of the treatment, severe adverse events have been reported related to alemtuzumab administration. We present a similar event illustrating the severity of this adverse drug reaction (ADR) and we highlight the structure causality assessment provides in approaching such a case. CASE PRESENTATION: We report a case of life-threatening respiratory failure after alemtuzumab administration in a 17 year old paediatric kidney transplant recipient. He developed near fatal severe respiratory and circulatory failure based on acute respiratory distress syndrome (ARDS) with diffuse alveolar oedema and haemoptysis hours after his second alemtuzumab administration. As it was questionable whether alemtuzumab could be regarded as the origin of his reaction and in order to assess the causality of this reaction as well as to structure clinical reasoning, we applied a widely used ADR probability scale to systematically review our case. DISCUSSION AND CONCLUSIONS: Our case shows a severe ADR after alemtuzumab administration. It illustrates the importance of proper causality assessment, the structure it provides and the benefit of a clinical pharmacology consultation when a severe reaction is suspected to be an ADR. By taking our case as an example, we demonstrate the added value of structured causality assessment to clinical reasoning and in generating differential diagnoses.

Safe chest tube placement in a patient with tension pneumothorax receiving rivaroxaban therapy for non-valvular atrial fibrillation.

The number of patients treated with direct oral anticoagulants is increasing worldwide. Although bleeding complications associated with direct oral anticoagulants are lower than those associated with vitamin K antagonists, the increased number of patients treated with these anticoagulants suggests that a higher absolute number of patients are at risk. Tube thoracostomy is an invasive procedure with a high risk of bleeding. To date, among direct oral anticoagulants, only dabigatran has a well-studied antidote to reverse its effects during emergency procedure or surgery. This report describes a case in which emergency placement of a tube thoracostomy, in a patient with type 2 respiratory failure due to left tension pneumothorax and receiving the anticoagulant rivaroxaban, in the pharmacokinetics phase with greater anticoagulant effect, did not result in bleeding greater than that typically encountered during such interventions. The procedure ended successfully with no acute complications.

Acute asthma, prognosis, and treatment.

Asthma affects about 300 million people globally and accounts for 1 in every 250 deaths in the world. Approximately 12 million people in the United States each year experience an acute exacerbation of their asthma, a quarter of which require hospitalization. Acute asthma should be differentiated from poor asthma control. Patients with acute asthma will exhibit increasing shortness of breath, chest tightness, coughing, and/or wheezing. In contrast, poor asthma control typically presents with a diurnal variability in airflow and is a characteristic that is usually not seen during an acute exacerbation. The history should include a review of comorbidities, adherence to medications, previous episodes of near-fatal asthma, and whether the patient has experienced multiple emergency department visits or hospitalizations, particularly those requiring admission to an intensive care unit involving respiratory failure, intubation, and mechanical ventilation. Patient education is important to ensure that the patient understands that asthma is mostly a chronic disease and necessitates the avoidance of allergens, prevention of infections, adherence with routine vaccinations, management of comorbid conditions, and adherence to treatment regimens. This article is a structured review of the available literature regarding the diagnosis and management of acute asthma.

Effects of bilateral breast reduction on peak airway pressure and pulmonary function tests.

PURPOSE: Surgical reduction due to breast size is not carried out merely for anesthetic concerns but also for such complaints as breast pain belonging to breast and skeletal system, back pain, neck pain, and intertriginous rashes. This study aims to investigate the effect of bilateral breast reduction surgery on maximum inspiratory pressure (Ppeak) and pulmonary functions. This study aims to investigate the effect of bilateral breast reduction surgery on pulmonary function test. METHODS: The study included 50 patients who would undergo bilateral breast reduction. Patients were divided into two groups: group II were given positive end-expiratory pressure (PEEP), which was not administered to the group I. Patients were checked in terms of maximum inspiratory pressures (Ppeak) before surgery, after first and second breasts were removed, and after surgery. Pulmonary function tests were carried out on preoperative, postoperative second and 14th days. As RFT, forced vital capacity (FVC), FEV1 (forced expiratory volume at the first second of FVC), FEV1/FVC and PEF (peak expiratory flow rate) were measured. RESULTS: In both groups, demographic data were not found to statistically significant differences (P > 0.05). When compared both groups in terms of preoperative FVC and FEV1/FVC 14th day, a significant increase was found on the 14th day (P < 0.05). A significant difference was not established between groups in terms of Ppeak values (P > 0.05). Ppeak was found to be significantly higher in group I (22.28 ± 7.56) at the end of intubation compared with group II (19.04 ± 3.73) (P = 0.002, P < 0.05). Similarly, preoperative Ppeak was established to be 21.88 ± 7.51 in group I and it was significantly higher compared with group II (19.44 ± 4.08), (P = 0.002, P < 0.05). When compared Ppeak values at the end of intubation and before operation with entry values a statistically significant difference was not found in either group (P = 0.76, P > 0.05). CONCLUSIONS: Some researchers reported a positive correlation between FVC, FEV1/FVC, and PEF along with the excised tissue mass. We established a positive correlation between the excised tissue weight and FVC and FEV1/FVC and that PEEP application did not have an impact on Ppeak.

[Extracorporeal CO2 Elimination (ECCO2R) for Hypercapnic Respiratory Failure: From Pathophysiology to Clinical Application]. / Extrakorporale CO2-Elimination (ECCO2R): von der Pathophysiologie zur klinischen Anwendung beim hyperkapnischen respiratorischen Versagen.

Extracorporeal CO2 removal (ECCO2R) is becoming an increasingly established treatment option for patients with acute severe hypercapnic respiratory failure. Technically, pumpless arterio-venous systems using the natural arterio-venous pressure gradient and also pump-driven veno-venous systems are available. Here, veno-venous ECCO2R has become the preferred technique, as settings for arterio-venous ECCO2R are restricted and side effects are more common with arterio-venous ECCO2R. Using veno-venous ECCO2R with blood flow rates up to 450 ml/min 60 to 80 ml CO2 can be removed per minute corresponding to 20 to 30 % of the total amount of CO2 production. However, in case of very severe hypercapnic respiratory failure with severe respiratory acidosis (pH 7.1 or less) blood flow rates of around 1000 ml/min are required for compensating severe respiratory acidosis corresponding to the elimination of 50 to 60 % of the total amount of CO2 production. Relevant side effects include the activation of blood coagulation and associated bleeding complications. Two recent case-control studies in severely exacerbated COPD patients could demonstrate that intubation rates can be reduced by the application of ECCO2R, but this was associated with non-ignorable side effects. Therefore, randomized controlled trials are urgently needed to more precisely establish the risks and benefits of ECCO2R when aimed at avoiding intubation.

[Nasal Highflow (NHF): A New Therapeutic Option for the Treatment of Respiratory Failure]. / Nasaler Highflow (NHF): Eine neue Therapiealternative zur Behandlung der respiratorischen Insuffizienz.

The therapy of choice in hypoxemic respiratory failure (type 1) is the application of supplemental oxygen at flow rates of 1 to 15 l/min via nasal prongs or mask. Non-invasive or invasive positive pressure ventilation will be initiated when the oxygen therapy effects are not sufficient or if hypercapnic respiratory failure (type 2) is the underlying problem. Recently, an alternative therapy option is available, from the pathophysiology it can be classified between oxygen therapy and positive pressure ventilation. The therapy called Nasal High Flow (NHF) is based on the nasal application of a heated and humidified air oxygen mixture with a flow range of up to 60 l/min. The precise pathophysiological principles of NHF are only partly understood, yet various aspects are well studied already: it is possible to deliver high oxygen concentrations, airway dryness can be avoided, dead space ventilation reduced and clearance of nasal dead space is achieved. Additionally, an end expiratory positive pressure is built up, which helps to prevent airway collapse, thus resulting in an improvement of respiratory efficiency and reduction of breathing work. Current studies demonstrate improvement in gas exchange and reduction of reintubation rate when applying the NHF treatment in acute respiratory failure. Thus the NHF therapy attracts attention in intensive care medicine. The application in other fields like chronic respiratory insufficiency is less well clarified. The objectives of this review are to present the pathophysiological effects and mechanisms of NHF, as far as understood, and to give an overview over the current state of relevant studies.

POSTOPERATIVE PULMONARY COMPLICATIONS AND ACUTE RESPIRATORY DISTRESS SYNDROME -BETTER PREVENT THEN TREAT.

In parallel with increasing number, duration and extensiveness of surgical interventions, postoperative pulmonary complications (PPC) and acute respiratory distress syndrome (ARDS) remain the major challenges for anesthesiologists and surgical ICU physicians. PPC and ARDS have multiple risk factors that should be recognized early and modifed within the appropriate "time window ". Today we possess reliable models (ARISCAT LIPS, EALI etc.) to predict the risk of non-infectious (hypoxemia, atelectases, pleuritis) and infectious PPC (postoperative pneumonia). The bundle of primaty and secondary prevention strategies is available and can be implemented both in the perioperative settings and in the ICU in patients at risk of PPC and ARDS. The prophylactic approach is realized as a bundle of strategies presented in "Checklist for Lung Injury Prevention" (CLIP). The bundle of preventive protective ventilation comprises low tidal volume (6-8 ml/kg predicted body weight), control of respiratory plateau and driving pressures, moderate positive end- expiratory pressure (PEEPS cm H20), and minimal safe level of inspired oxygen fraction. Pharmacological prevention ofARDS has shown quite satisfactory experimental results and needs further clinicql investigations.

S2k-Guideline "Prolonged Weaning".

All mechanically ventilated patients must be weaned from the ventilator at some stage. According to an International Consensus Conference the criteria for "prolonged weaning" are fulfilled if patients fail at least 3 weaning attempts (i. e. spontaneous breathing trial, SBT) or require more than 7 days of weaning after the first SBT. This occurs in about 15 - 20 % of patients.Because of the growing number of patients requiring prolonged weaning a German guideline on prolonged weaning has been developed. It is an initiative of the German Respiratory Society (Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin e. V., DGP) in cooperation with other societies (see acknowledgement) engaged in the field chaired by the Association of Scientific and Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF).This guideline deals with the definition, epidemiology, weaning categories, underlying pathophysiology, therapeutic strategies, the weaning unit, transition to out-of-hospital ventilation and therapeutic recommendations for end of life care. This short version summarises recommendations on prolonged weaning from the German guideline.

[Drowning - An update on prehospital and intrahospital treatment strategies]. / Update Ertrinkungsunfall - Präklinische und klinische Therapiestrategien.

500000 people die from unintentional drowning each year worldwide. Drowning accidents occur to humans of every age, while fatal drowning is the leading cause of death among boys 5 to 14 years of age. In Germany, however, most drowning victims are elderly people. Considering the multitude of accident settings, ranging from bathing accidents in lakes to shipwrecks at sea, professional first responders need to adapt to various scenarios. This article summarizes the pathophysiology of drowning, particular features of prehospital life support and current knowledge on the further therapy of victims of near fatal drowning accidents.

[The first experience of transporting a patient with severe respiratory failure in conditions of extracorporeal membrane oxygenation].

This publication is the first case report, in the Russian Federation aircraft evacuation of a patient with severe respiratory failure due to pneumonia of viral and bacterial etiology with the use of extracorporeal membrane oxygenation. The use of this method helped to stabilize the patient's condition and safely carry out transportation to a specialized medical institution for further treatment.

Respiratory failure.

On the basis of research evidence, (1)(2) numerous diseases and conditions can impair gas exchange, resulting in failure to meet the body's metabolic demands and leading to respiratory failure. On the basis of consensus, (1)(2)(7)(8)(9)(10) the clinical presentations of respiratory failure depend on the underlying cause and the level of hypoxemia and hypercapnia. Early diagnosis, close monitoring, and timely intervention are of utmost importance. On the basis of research evidence, (5)(14)(25) interventions range from noninvasive methods, such as close monitoring and supplemental oxygen, to full respiratory support with mechanical ventilation and in extreme cases even the use of extracorporeal membrane oxygenation.

Comparison of remimazolam and dexmedetomidine for intraoperative sedation in patients undergoing lower extremity surgery under spinal anesthesia: a randomized clinical trial.

BACKGROUND: Dexmedetomidine sedation has advantages, such as low incidence of respiratory depression and prolonged block duration, but also significant disadvantages, such as slow onset, high rate of sedation failure, and a long context-sensitive half-life. Remimazolam provides rapid sedation and recovery, high sedation efficacy and has minimal hemodynamic effects. We hypothesized that patients who received remimazolam would require less rescue midazolam than dexmedetomidine. METHODS: Patients (n=103) scheduled for surgery under spinal anesthesia were randomized to receive dexmedetomidine (DEX group) or remimazolam (RMZ group) targeting a Modified Observer's Assessment of Alertness/Sedation score of 3 or 4. Rescue midazolam was administered if the patient failed to be sedated after the initial loading dose or despite infusion rate adjustment. RESULTS: Rescue midazolam administration was significantly higher in the DEX group (0% vs 39.2%; p<0.001). Patients in the RMZ group reached the target sedation level more rapidly. The incidences of bradycardia (0% vs 25.5%; p<0.001) and hypertension (0% vs 21.6%; p<0.001) were higher in the DEX group. Respiratory depression occurred at a higher rate in the RMZ group (21.2% vs 2.0%; p=0.002), but no patients required manual ventilation. Patients in the RMZ group recovered faster, had a shorter PACU stay and higher satisfaction scores. Hypotensive episodes in the PACU were more frequent in the DEX group (1.9% vs 29.4%; p<0.001). CONCLUSIONS: Remimazolam showed excellent sedation efficacy, minimal hemodynamic effects, and fewer adverse events in the PACU than dexmedetomidine. However, it is important to note that respiratory depression was more frequent with the use of remimazolam. TRIAL REGISTRATION NUMBER: NCT05447507.

Pompe disease, the must-not-miss diagnosis: A report of 3 patients.

INTRODUCTION: Pompe disease is a progressive and debilitating neuromuscular disorder that presents with a heterogeneous array of signs and symptoms including proximal muscle weakness, respiratory insufficiency, and/or elevated creatine kinase levels. It mimics other neuromuscular disorders, making its diagnosis challenging and often significantly delayed, thereby increasing morbidity and early mortality of the disease. METHODS: Three Pompe disease patients are discussed to highlight the challenging path to diagnosis and the common cluster of symptoms that could lead to timely and accurate diagnosis. RESULTS: After significant delays in diagnosis, Pompe disease was diagnosed on the basis of the pattern of proximal weakness. CONCLUSIONS: Suspicion and recognition of the characteristic symptoms of Pompe disease may improve both the timing and accuracy of the diagnosis, which will improve clinical outcomes and minimize disease progression.

Economics and ethics of paediatric respiratory extra corporeal life support.

Extra corporeal membrane oxygenation (ECMO) is a form of life support, which facilitates gas exchange outside the body via an oxygenator and a centrifugal pumping system. A paediatric cardiac ECMO programme was established in 2005 at Our Lady's Children's Hospital, Crumlin (OLCHC) and to date 75 patients have received ECMO, the majority being post operative cardiac patients. The outcome data compares favourably with international figures. ECMO has been most successful in the treatment of newborn infants with life threatening respiratory failure from conditions such as meconium aspiration, respiratory distress syndrome and respiratory infections. There is no formal paediatric respiratory ECMO programme at OLCHC, or anywhere else in Ireland. Currently, neonates requiring respiratory ECMO are transferred to centres in Sweden or the UK at an average cost of 133,000 Euros/infant, funded by the Health Service Executive E112 treatment abroad scheme. There is considerable morbidity associated with the transfer of critically ill infants, as well as significant psycho-social impact on families. OLCHC is not funded to provide respiratory ECMO, although the equipment and expertise required are similar to cardiac ECMO and are currently in place. The average cost of an ECMO run at OLCHC is 65,000 Euros. There is now a strong argument for a fully funded single national cardiac and respiratory paediatric ECMO centre, similar to that for adult patients.

A 52-Year-Old Man Who Smokes With Rapidly Progressive Respiratory Failure.

CASE PRESENTATION: A 52-year-old White man, who currently smokes, was admitted to the medical ICU with worsening shortness of breath. The patient was dyspneic for a month and had been clinically diagnosed with COPD by his primary care doctor and started on bronchodilators and supplemental oxygen. He had no known medical history or recent illness. His dyspnea worsened rapidly over the next month, prompting admission to the medical ICU. He was on high-flow oxygen followed by noninvasive positive pressure ventilation and then mechanical ventilation. He denied cough, fever, night sweats, or weight loss at the time of admission. There was no history of work-related or occupational exposures, drug intake, or recent travel. Review of systems was negative for arthralgia, myalgia, or skin rash.

Rescue hypothermia for refractory hypercapnia.

Hypothermia may reduce the CO(2) production by decreasing the metabolism of the cooled tissue. We describe the first clinical use of hypothermia to lower hypercarbia in a case of bronchiolitis related respiratory failure unresponsive to maximal respiratory support. In this case, hypothermia allowed sparing the use of extracorporeal life support. Conclusion Hypothermia might be useful for severe acute respiratory failure unresponsive to aggressive respiratory support.

Preventing Postoperative Opioid-Induced Respiratory Depression Through Implementation of an Enhanced Monitoring Program.

BACKGROUND: Opioid-induced respiratory depression (OIRD) is a serious complication that can lead to negative outcomes. There are known risk factors for OIRD; however, a lack of national guidelines for the prevention and early detection of OIRD exists. METHODS: An evidence-based practice study was conducted to create an enhanced monitoring (EM) program. The EM program consisted of risk stratification of surgical spine patients, including the use of STOP-BANG screening for obstructive sleep apnea, capnography monitoring, use of home positive airway pressure therapy, capnography alarm optimization, hospitalist consultation, nursing education, and patient education. RESULTS: Approximately 17% (N = 937/5,462) of surgical spine patients were enrolled in the EM program. Fifty-six percent of EM patients were monitored with capnography and had out of range end-tidal carbon dioxide levels 17% of the time. The rate of transfers to the intensive care unit (ICU) for OIRD decreased, though not statistically significant (p = .151). CONCLUSIONS: The EM program with risk stratification was found to reduce transfers to the ICU for OIRD. Although not statistically significant, the decreased number of transfers was clinically significant. Engagement of the interprofessional team and capnography alarm parameter optimization helped to reduce nonactionable alarms.