RESUMEN
Simultaneous bilateral spontaneous pneumothorax is a rare life-threatening condition that can cause severe respiratory distress, hypoxemia, and death. Spontaneous pneumothorax has been reported as an uncommon but severe complication in patients recovering from COVID-19 pneumonia. Even fewer cases of spontaneous bilateral tension pneumothorax have been reported as a result of infection. We present a patient with spontaneous bilateral tension pneumothorax 18 days after COVID-19 infection. The patient's symptoms began with a substernal tearing sensation and pain radiating to the back with dyspnea. Physical exam was significant for oxygen saturation of 75% on room air, tachycardia, and diminished breath sounds bilaterally. Imaging confirmed large bilateral pneumothoraces, and chest tubes were inserted emergently to restore lung volume. Pneumothorax is predominantly observed in those with severe infection but has been seen with mild symptoms as well. The development of pneumothorax is thought to result from diffuse lung injury that occurred from a cytokine storm during COVID infection. We speculate that our patient developed bulla as a result of infection, and the bulla spontaneously ruptured, inducing the bilateral collapse of the lungs. The mortality of such an event remains unknown, but without proper intervention, mortality increases significantly in these patients. As we continue to learn about the multitude of sequelae that can result from COVID-19 infection, pneumothorax should be considered in patients with a history of COVID pneumonia that presents with acute onset of dyspnea and chest pain. It is important to quickly recognize such cases as these patients have a narrow time frame for intervention, especially in the event of bilateral tension pneumothorax. Therefore, pneumothorax should be adequately assessed on initial examination, with the possibility of bilateral pneumothoraces in mind, to minimize morbidity and mortality.
RESUMEN
OBJECTIVES: Recombinant thrombin (rThrombin) is a potential hemostatic alternative to bovine and human plasma-derived thrombin. This report examines the clinical results for the vascular surgery subgroup of patients enrolled in a larger double-blind, randomized, multicenter trial, which evaluated the comparative safety and efficacy of rThrombin and bovine plasma-derived thrombin (bThrombin) when used as adjuncts to surgical hemostasis. METHODS: Data from the 164 vascular patients who underwent either a peripheral arterial bypass (PAB) or arteriovenous graft (AV) procedure are included in this analysis. Time to hemostasis at proximal and distal anastomotic sites at 1.5-, 3-, 6-, and 10-minute intervals was determined by procedure (PAB or AV) and overall (PAB + AV). Baseline and day 29 immunologic sera were analyzed. The incidences of postoperative adverse events were compared between treatment groups. Categorical adverse events were evaluated in relation to thrombin product antibody formation. RESULTS: Patients were randomized to either bThrombin (n = 82) or rThrombin (n = 82). Procedures included PAB (n = 88) and AV (n = 76). The bThrombin and rThrombin groups were well matched for demographics and baseline characteristics. A comparable incidence of anastomotic hemostasis was observed in both treatment groups at 10 minutes (94% bThrombin, 91% rThrombin). The incidence of hemostasis was lower at all time points for PAB procedures compared with AV procedures. In the PAB group, a significantly greater proportion of patients receiving rThrombin (55%) achieved hemostasis at 3 minutes compared with bThrombin (39%; P < .05). Adverse event profiles and laboratory findings were similar between groups. No patients in the rThrombin group developed anti-rThrombin product antibodies at day 29, whereas 27% of patients in the bThrombin group developed antibodies to bThrombin product (P < .0001). CONCLUSIONS: rThrombin or bThrombin used as a hemostatic ancillary for anastomotic bleeding was equally effective at 10 minutes; however, rThrombin compared with bThrombin may provide a more rapid onset of hemostasis at 3 minutes in PAB procedures. Adverse events were similar between the two thrombins. In patients undergoing vascular surgery, both treatments were similarly well tolerated, although rThrombin demonstrated a superior immunogenicity profile.
