Thrombocytopenia risks in ARDS COVID-19 patients treated with high-dose linezolid during vvECMO therapy: an observational study.

Patients treated with ECMO are at great risk of nosocomial infections, and around 10% of isolates are gram-positive pathogens. Linezolid (LZD) is effective in the treatment of these infections but appropriate dosing is challenging. The aim was to evaluate the occurrence of thrombocytopenia during ECMO when treated with LZD. An LZD trough concentration of 8 mg/L was set as the cutoff value for thrombocytopenia occurrence among critically ill patients who received parenteral LZD therapy at a dose of 600 mg every 8 h during ECMO. Eleven patients were included in this prospective observational study. Median LZD trough concentrations were 7.85 (interquartile range (IQR), 1.95-11) mg/L. Thrombocytopenia was found in 81.8% of patients. Based on the median LZD trough concentrations cutoff value, patients were divided into two groups, 1.95 (IQR, 0.91-3.6) and 10.3 (IQR, 9.7-11.7) mg/L, respectively. Median platelet values differed significantly between groups on admission, ECMO day 0, ECMO day 1, and LZD sampling day [194 and 152.5, (p < 0.05)], [113 and 214, (p < 0.05)], [76 and 147.5, (p < 0.01)], and [26 and 96.5, (p < 0.01)], respectively. Duration of LZD therapy was similar between the groups. Significant platelet reduction was observed in both groups, emphasizing the need for closer monitoring to prevent LZD-associated thrombocytopenia.

Does adjunctive hemoadsorption provide benefit in the management of ischemia-reperfusion syndrome following near-drowning? A case report.

Drowning remains a significant global health concern, claiming over 300,000 lives annually, with a disproportionate impact on young individuals in low-and middle-income countries. Conventional mechanical ventilation, while common, falls short in addressing the hypoxemia and hypercapnia often observed in severe near-drowning cases. Veno-venous extracorporeal membrane oxygenation (vvECMO) emerges as a critical intervention for cardiopulmonary failure post-drowning. This case report delves into the pivotal role of ischemia-reperfusion injury (IRI) in a near-drowning-related pathology. Following the initial insult, reoxygenation exacerbates the inflammatory cascade, resulting in a surge of pro-inflammatory mediators. In this context, CytoSorb®, a hemoadsorption cartridge, demonstrates promise by effectively removing these mediators from circulation. This report outlines its application in a critically ill adolescent patient who experienced near-drowning, presenting a compelling case for CytoSorb as an adjunctive therapy in managing IRI-induced hyperinflammation.

Comparative Efficacy of High-Dose Dexamethasone Versus Methylprednisolone in Coronavirus Disease 2019 (COVID-19)-Associated Acute Respiratory Distress Syndrome.

OBJECTIVE: This retrospective (matched paired) clinical trial aimed to compare the efficacy of dexamethasone vs. methylprednisolone at equipotent (high) doses in patients with coronavirus disease 2019 (COVID-19)-associated acute respiratory distress syndrome (ARDS). METHODS: A total of 347 patients with moderate and severe COVID-19-associated ARDS were administered either a high (equipotent) dose of dexamethasone (32 mg) or methylprednisolone (180 mg) for a duration of up to 10 days. All participants received the standard of care for critically ill COVID-19 patients. RESULTS: The primary outcomes included length of stay in the ICU, ICU mortality, and discharge from the hospital. Based on the obtained results, a tendency towards more favorable clinical outcomes concerning the length of stay in the ICU (in the group of patients treated with non-invasive mechanical ventilation (NIV), p<0.05), ICU mortality, and discharge from the hospital (in the group of patients who were intubated, p<0.05) in patients receiving the high dose of dexamethasone compared to those receiving methylprednisolone was observed. CONCLUSION: It appears that severe cases of COVID-19, especially intubated ones, treated with high doses of dexamethasone have a more favorable clinical outcome than the use of equipotent doses of methylprednisolone. However, larger multicenter studies are needed to validate our observations.

Population Pharmacokinetic Model of Linezolid and Probability of Target Attainment in Patients with COVID-19-Associated Acute Respiratory Distress Syndrome on Veno-Venous Extracorporeal Membrane Oxygenation-A Step toward Correct Dosing.

During veno-venous extracorporeal membrane oxygenation (vv ECMO) therapy, antimicrobial drugs are frequently used, and appropriate dosing is challenging due to there being limited data to support the dosage. Linezolid is effective against multidrug-resistant Gram-positive pathogens frequently isolated in ECMO patients. In total, 53 steady-state linezolid levels were obtained following 600 mg intravenous (IV) injections every 8 h, and these were used to develop a population pharmacokinetic (PopPK) model in patients with COVID-19-associated acute respiratory distress syndrome (CARDS) on vv ECMO. The data were analyzed using a nonlinear mixed-effects modelling approach. Monte Carlo simulation generated 5000 patients' individual PK parameters and corresponding concentration-time profiles using the PopPK model, following the administration of 600 mg/8 h (a higher-than-standard dosing) and 600 mg/12 h (standard). The probabilities of pharmacokinetic/pharmacodynamic (PK/PD) target attainment (PTA) and the cumulative fraction of responses (CFR) for three pathogens were calculated and compared between the two dosing scenarios. Linezolid 600 mg/8 h was predicted to achieve greater than or equal to 85%Tf>MIC in at least 90% of the patients with CARDS on vv ECMO compared to only approximately two thirds of the patients after dosing every 12 h at a minimal inhibitory concentration (MIC) of 2 mg/L. In addition, for the same MIC, fAUC24/MIC ≥ 80 was achieved in almost three times the number of patients following an 8-h versus a 12-h interval. PopPK simulation predicted that a significantly higher proportion of the patients with CARDS on vv ECMO would achieve the PK/PD targets following the 8-h dosing interval compared to standard linezolid dosing. Nevertheless, the safety concern, in particular, for thrombocytopenia, with higher-than-standard linezolid dosage is reasonable, and consequently, monitoring is essential.

Post VV-ECMO Weaning Hyperinflammation-Can Prophylactic Hemoadsorption Treatment Prevent Complications?

Acute respiratory distress syndrome (ARDS) is a severe clinical condition characterized by acute respiratory failure and a high mortality risk despite conventional mechanical ventilatory support. Veno-venous extracorporeal membrane oxygenation (vvECMO) has emerged as an effective life-support technology for patients with ARDS. However, complications may arise following the decannulation of vvECMO, with a relatively frequent development of systemic hyperinflammation (SHI). Among the various treatment strategies for SHI, the use of hemoadsorption with CytoSorb® has shown promising results in removing excessive levels of cytokines and attenuating the hyperinflammatory response. In this case series, we present three critically ill patients with ARDS secondary to pneumonia who underwent vvECMO and subsequently received prophylactic hemoadsorption with CytoSorb® following decannulation as a part of our clinical practice. This case series aims to describe the potential positive effects of hemoadsorption in preventing the development of SHI after vvECMO decannulation in ARDS patients.

Boosting ICU capacity during the COVID-19 pandemic in the western Balkan region, The Republic of Srpska experience.

Background: Response to the outbreak of poliomyelitis in mid-1950 led to recognition and consequent development of critical care. Seventy years later the humankind was struck by COVID-19, another major challenge for critical care medicine which was especially big in Low-Resources-Settings where more than two thirds of the world population live, including the population of the Republic of Srpska (RS). Design and methods: The main aim was to show an overview of all interventions in order to boost hospitals' capacities to the level which is sufficient to manage high amount of critically ill COVID-19 patients in the RS. A before-after cohort study design was conducted to evaluate the effects of interventions for increase in preparedness and capacity of ICUs for admission and treatment of COVID-19 critically ill patients in nine hospitals in the RS. Results: Following interventions, the biggest and university affiliated hospital in the RS has increased ICU capacities: total number of ICU beds increased by 38% and number of ventilators by 114%. Availability of machines for veno-venous extracorporeal membrane oxygenation (vvECMO) increased by 100%. Number of doctors who were involved in treatment of critically ill patients increased by 47% and nurse/patient's ratio reached 1:2.5. Similarly, all other hospitals experienced boosting of ICU beds by 189% and ventilators by 373% while number of doctors increased by 108% and nurse/patient's ratio reached 1:4. Conclusion: All interventions implemented during COVID-19 pandemic outbreak in the RS resulted in increasing capacity for treatment of critically ill patients, but the education of health care professionals was identified as the most important conducted intervention.

Dynamic changes in coagulation, hematological and biochemical parameters as predictors of mortality in critically ill COVID-19 patients: A prospective observational study.

INTRODUCTION: This study was created to analyze dynamic alterations in coagulation, hematological and biochemical parameters and their association with mortality of COVID-19 patients. To identify the most sensitive biomarkers as predictors of mortality more research is required. METHODS: The present study was a prospective, one-year-long observational study conducted on all critically ill, COVID-19 patients with respiratory failure. The following data were collected: demographic and clinical characteristics of the study population, comorbidities, coagulation, biochemical and hematological parameters. The primary outcome was the proportion of patients who died. RESULTS: 91 patients with median age 60 (50-67), 76.9% male, met the acute respiratory distress syndrome criteria. It was tested whether dynamic change (delta-Δ) of parameters that were found to be predictors of mortality is independently associated with poor outcome. Adjusted (multivariate) analysis was used, where tested parameters were corrected for basic and clinical patients characteristics. The only inflammatory parameter which dynamic change had statistically significant odds ratio was ΔCRP (p < 0.005), while among coagulation parameters statistically significant OR was found for Δ fibrinogen (p < 0.005) in predicting mortality. CONCLUSION: Monitoring of coagulation, hematological and biochemical parameters abnormalities and their dynamical changes can potentially improve management and predict mortality in critically ill COVID -19 patients.

Characteristics and Outcomes of Critically Ill Pregnant/Postpartum Women with COVID-19 Pneumonia in Western Balkans, The Republic of Srpska Report.

Background and Objectives: Coronavirus disease 2019 (COVID-19) is a novel infectious disease that has spread worldwide. As of 5 March 2020, the COVID-19 pandemic has resulted in approximately 111,767 cases and 6338 deaths in the Republic of Srpska and 375,554 cases and 15,718 deaths in Bosnia and Herzegovina. Our objective in the present study was to determine the characteristics and outcomes of critically ill pregnant/postpartum women with COVID-19 in the Republic of Srpska. Materials and Methods: The retrospective observational study of prospectively collected data included all critically ill pregnant/postpartum women with COVID-19 in a university-affiliated hospital between 1 April 2020 and 1 April 2022. Infection was confirmed by real-time reverse transcriptase polymerase chain reaction (RT-PCR) from nasopharyngeal swab specimens and respiratory secretions. Patients' demographics, clinical and laboratory data, pharmacotherapy, and neonatal outcomes were analysed. Results: Out of the 153 registered pregnant women with COVID-19 treated at the gynaecology department of the University Clinical Centre of the Republic of Srpska, 19 (12.41%) critically ill pregnant/postpartum women (median age of 36 (IQR, 29-38) years) were admitted to the medical intensive care unit (MICU). The mortality rate was 21.05% (four patients) during the study period. Of all patients (19), 14 gave birth (73.68%), and 4 (21.05%) were treated with veno-venous extracorporeal membrane oxygenation (vvECMO). Conclusions: Fourteen infants were born prematurely and none of them died during hospitalisation. A high mortality rate was detected among the critically ill pregnant/postpartum patients treated with mechanical ventilation and vvECMO in the MICU. The preterm birth rate was high in patients who required a higher level of life support (vvECMO and ventilatory support).

Does the Prolonged Duration of Continuous Ambulatory Peritoneal Dialysis Affect the Serum Levels of Endothelin-1 and Nitric Oxide?

End-stage renal disease and its treatment with continuous ambulatory peritoneal dialysis (CAPD) can affect almost all organs and organ systems including vascular endothelium. Consequently, disturbance in the production of vasoactive substances endothelin-1 (ET-1) and nitric oxide (NO) occurs in these patients. There are only a small number of studies that investigated the impact of long-term CAPD on imbalance in production of vasoactive substances ET-1 and NO among these patients. Therefore, our study aimed to investigate the impact of duration of CAPD on potential overproduction of ET-1 and NO in uremic patients. This study included 23 uremic patients [10 males, mean age: 56.3 (±16.2) years] treated with CAPD. All studied patients were further divided into subgroups, groups A and B. Group A included patients on treatment with CAPD <5 years, and group B included those on treatment longer than five years. Our results showed that serum levels of these vasoactive substances are significantly higher among patients treated with CAPD longer than five years (ET-1: 51.24 ± 32.11 vs. 139.53 ± 42.42; NO: 15.50 ± 2.57 vs. 26.57 ± 5.96, respectively). We concluded that imbalance in production of vasoactive substances is present in long-term CAPD treatment and this imbalance can lead to disturbance in the local blood flow control.

Successful Outcomes of Critically Ill Patients with Extreme Metabolic Acidosis Treated with Structured Approach: Case Series.

INTRODUCTION: Hydrogen ion concentration which is expressed as pH value is in human blood maintained in narrow physiological range (7.36-7.44 in arterial blood). This range is crucial for normal functioning of most biochemical reactions. Extreme acidosis with pH < 6.8 is incompatible with life, unless pathophysiologic process is rapidly reversed. Timely, standardized, and structured approach to assessment and management of extreme critical illness is essential to maximize the chances of patient's survival. CASES: We present a series of 3 critically ill patients admitted to Medical intensive care unit (MICU) diagnosed with extreme metabolic acidosis (pH ⩽ 6.8). Each patient was treated using Checklist for Early Recognition and Treatment of Acute Illness and INjury (CERTAIN) which is a standard decision support tool in our MICU. Causes of extreme metabolic acidosis included hemorrhagic shock, sepsis, and acute renal failure and diabetic ketoacidosis. Rapid assessment, prompt resuscitation (IV fluids, vasopressors, mechanical ventilation, and renal replacement), and application of specific causal treatment led to positive outcomes in all 3 patients. DISCUSSION: Medical physiology textbooks set the lower limit of pH value at which life is possible to 6.8. However, examples from clinical practice show that if adequate resuscitation measures are taken early in the acute phase of the disease, the biochemical cascade of reactions that are considered irreversible (at pH ⩽ 6.8) may be reversed after all. CONCLUSION: Critical care approach to extreme metabolic acidosis is a prime example of applied clinical physiology where basic science and clinical practice connect. With these case series we show that timely and structured approach to critical illness shifts the boundaries of reversibility for some of the most severe physiologic derangements.

Impact of Checklist for Early Recognition and Treatment of Acute Illness on Treatment of Critically Ill Septic Patients in a Low-Resource Medical Intensive Care Unit.

Introduction: Treatment of sepsis and septic shock can be a challenge even for intensive care units (ICUs) in high income countries, but it is especially difficult for ICUs with limited resources. Aim: To evaluate the impact of CERTAIN on treatment of critically ill septic patients in low-resource medical ICU. Materials and Methods: In a before-and-after study design, we compared clinical outcomes, processes, and complications (hospital acquired infections) 1 year before and 2 years after (2016 and 2017) introduction of CERTAIN. Results: A total of 125 patients with sepsis were prospectively identified for a 3-year period. Mean patient age, gender distribution, number of patients on mechanical ventilation (33 [76.7%] vs. 42 [84%] vs. 24 [75%]) and vasopressor use (23 [53.5%] vs. 34 [68%] vs. 24 [75%]) were similar before (2015) and 2 years after (2016 and 2017) the implementation of CERTAIN. Severity of illness (Simplified Acute Physiology Score II [SAPS II score]) was higher after the implementation. The checklist was incorporated in the daily practice with 100% adherence to its use. The duration of mechanical ventilation (5.3 ± 5.3 vs. 4.2 ± 3.6 vs. 3.7 ± 5.5), antibiotic treatment (8.2 ± 5.4 vs. 6.9 ± 4.1 vs. 5.8 ± 5.6), central venous catheter use (6.2 ± 5.7 vs. 5.7 ± 4.6 vs. 4.2 ± 6.1), ICU stay (8.4 ± 5.4 vs. 7.1 ± 4.1 vs. 5.8 ± 5.6), and the incidence of nosocomial infection (33.3% vs. 30% vs. 12.5%) decreased in the period after the onset of the intervention, but the results did not reach statistical significance. When adjusted for baseline characteristics, CERTAIN was not associated with hospital mortality (odds ratio 0.88, 0.38-2.04). Conclusion: CERTAIN was readily adopted in the ICU workflow and was associated with improvement in treatment of critically ill patients with sepsis.

Impact of prolonged duration of different types of renal replacement therapies on serum levels of endothelin-1 and pulmonary function tests.

INTRODUCTION: This study was carried out to investigate the impact of duration of different renal replacement therapies such as hemodialysis and continuous ambulatory peritoneal dialysis on potential overproduction of endothelin-1 (ET-1) and pulmonary function tests in these patients. MATERIALS AND METHODS: The study included 26 patients (14 males, mean age 54.9±16.2 years) with end stage renal diseases (ESRD) receiving regular hemodialysis (HD) and 23 patients (10 males, mean age 55.8±15.8 years) with ESRD treated with continuous ambulatory peritoneal dialysis (CAPD). The spirometry values were recorded before the onset of HD and prior to emptying the peritoneal cavity in CAPD patients and ET-1 was measured using the enzyme immunoassay (EIA) methodology. Two groups of patients (groups 1 and 2) were further divided into subgroups (group A and group B). Groups A (1-A and 2-A) included patients treated with any type of renal replacement therapy (RRT) (HD or CAPD) less than 5 years, and groups B (1-B and 2-B) included patients treated with any type of RRT (HD or CAPD) longer than 5 years. RESULTS: Patients treated with HD or CAPD for more than five years were found to have significantly higher serum levels of ET-1 (HD = 41.49±21.28 vs. 185.13±73.67, p<0.01; PD = 51.24±32.11 vs. 139.53±42.42, p<0.01, respectively). Values of most pulmonary function parameters differed significantly between groups treated longer or shorter than 5 years: FVC (HD = 108.4±13.34 vs. 80.82±11.26, p<0.01; CAPD = 97.20±18.99 vs. 73.25±10.73, p<0.01, respectively), FEV1 (HD = 108.33±15.8 vs. 76.73±4.9, p<0.01; CAPD = 100.67±18.31 vs. 66.75±6.25, p<0.01, respectively). CONCLUSIONS: Prolonged duration of any type of renal replacement therapy is associated with higher serum levels of ET-1 and with lower pulmonary function tests in ESRD patients.

Characteristics and outcomes of critically ill patients with influenza A (H1N1) in the Western Balkans during the 2019 post-pandemic season.

Background: This study looked at the characteristics and outcomes of critically ill patients with confirmed influenza A (H1N1) pdm09 infection in the Western Balkans in the post-pandemic period. Materials and Methods: This retrospective observational study of medical records and associated data collected during the post-pandemic period included all mechanically ventilated adult patients of two university-affiliated hospitals of the Western Balkans between 1 January and 31 March 2019 who had influenza A (H1N1) pdm09 infection confirmed by real-time reverse transcriptase-polymerase chain reaction from nasopharyngeal swab specimens and respiratory secretions. Results: The study included 89 patients, 49 males (55.1%), aged 56.09 ± 12.64 years. The median time from shift from hospital time to intensive care unit was 1 day (range: 1-2). In the post-pandemic period, cases observed in this study were found to have the following comorbidities: cardiovascular diseases in 44 (49.4%) patients and diabetes in 21 (23.6%) patients. Thirty-one patients (34.8%) in this study were obese. All 89 patients (100%) experienced some degree of acute respiratory distress syndrome, and 39 (44%) had multiorgan failure. Eighty-three patients (93%) were intubated and mechanically ventilated, 6 (7%) received non-invasive mechanical ventilation, 12 (13%) were treated with vvECMO and 36 (40%) received renal replacement therapy. Vasoactive support was needed by 56 (63%) patients. The median duration of mechanical ventilation was 9 (6-15.5) days. The hospital mortality rate was 44%. Conclusion: Critically ill patients with confirmed influenza A (H1N1) pdm09 infection in the post-pandemic season were older, required vasoactive drugs more often, and there was a trend of higher survival compared to H1N1 infection patients in the previous pandemic seasons.

Serum levels of nitric oxide and endothelin-1 in vasculopathy managed with hyperbaric oxygen therapy.

Roles of nitric oxide (NO) and endothelin-1 (ET-1) in the local regulation of blood flow under physiological conditions are important and well known, while data on their effects and interactions in conditions of hyperbaric hyperoxia is still insufficient. This was a prospective observational study which included patients who underwent hyperbaric oxygen therapy (HBOT) in accordance with existing therapeutic protocol for peripherial arterial disease (PAD) during time period of six months, between january and july of 2016. Clinical stage of PAD according to Fontain was taken into account, as well as risk factors, demographic, anthropometric and clinical characteristics of studied patients. The study included 64 patients with a mean age (±Sd) 60.2±12.7 years, of whom 28 were female. Patients' NO serum levels in all observed categories before and after HBOT were not signifficantly different, except for stage II PAD (NObefore HBOT 21.9±9.6 vs. NOafter HBOT 26.2±12.1 (p = 0.04)). On the contrary, in all studied patients ET-1 level increased signifficantly after HBOT (ET-1before HBOT 4.2±11.6 vs. ET-1after 18.3±21.0 (p < 0.001)). Treatment of PAD using HBOT leads to the predominance of vasoconstrictor effects probably caused by elevation of serum ET-1 concentrations, while other factors such as exposure time to hyperbaric conditions, activation of antioxidant molecules, and the influx of other interfering substances must be considered in interpreting the effects of NO molecules.

Use of CytoSorb® as a therapeutic option in a critically ill patient with acute respiratory distress syndrome caused by influenza A (H1N1) pneumonia: A case report.

Acute respiratory distress syndrome is an acute inflammatory lung process, which leads to protein-rich nonhydrostatic pulmonary edema, refractory hypoxemia, and lung "stiffness". There are a number of therapies that are currently being investigated in the treatment of sepsis; one of the most promising treatment options at this moment is cytokine removal by hemoperfusion (CytoSorb®). We present the case of a 29-year-old male patient who was admitted to the Medical Intensive Care Unit in a state of multiple organ dysfunction and massive bilateral pneumonia caused by influenza type A. The patient was healthy before hospital admission. Due to acute respiratory failure and altered state of consciousness, the patient was intubated using analgosedation and connected to a controlled mechanical ventilation mode immediately after admission. The initial computed tomography scan showed massive bilateral pneumonia, and few days later, the patient's condition progressively worsened and he developed signs of multiorgan failure. Given the patient's progressing hemodynamic instability and uncontrolled inflammatory response, a CytoSorb® adsorber was added into the continuous renal replacement therapy circuit. The combination of pharmacotherapy, supportive measures, and application of CytoSorb® resulted with complete recovery of the patient (hemodynamic stability improved as evidenced by decreased vasopressor requirements).

Population pharmacokinetic model of Vancomycin based on therapeutic drug monitoring data in critically ill septic patients.

PURPOSE: The present study aimed to establish a population pharmacokinetic model of vancomycin, including adult critically ill septic patients, with normal and impaired renal function. MATERIALS AND METHODS: A prospective analysis of 146 concentrations from 73 adult critically ill septic patients treated with 1-h intravenous infusion of vancomycin were included in the study. A nonlinear mixed effects modeling (NONMEM) approach was applied for data analysis and evaluation of the final model. The influence of creatinine clearance calculated by the Cockcroft-Gault equation (CrCl), and other potential covariates on vancomycin clearance (CL) were evaluated. RESULTS: The final one-compartment pharmacokinetic model includes the effect of CrCl on CL. Population pharmacokinetic values for a typical subject were estimated at 0.024 l/h for CL dependent on renal function (CLCrCl), 1.93 l/h for residual portion of CL (not dependent on renal function), and 0.511 l/kg for volume of distribution (V). According to the final model, for patients with CrCl = 120 ml/min, the median vancomycin total CL is 4.81 l/h, while CrCl-dependent fraction accounts for approximately 60% of CL. CONCLUSIONS: The developed population vancomycin model may be used in estimating individual CL for adult critically ill septic patients, and could be applied for individualizing dosage regimens taking into account the continuous effect of CrCl.

Disfunção de múltiplos órgãos causada por corpo estranho no esôfago / Multiple organ dysfunction caused by a foreign body in the esophagus

RESUMO Apresentamos o caso de uma paciente de 71 anos de idade admitida à unidade de terapia intensiva clínica em condição de falência de múltiplos órgãos. Após o quarto dia, com aplicação de todas as modalidades de suporte à vida (estímulo com vasopressores, ventilação mecânica, terapia com diálise contínua, terapia com antibióticos de amplo espectro e outras medidas de suporte), dados inespecíficos fornecidos por acompanhante revelaram que a paciente vinha apresentando dificuldade persistente para deglutir líquidos e alimentos sólidos por alguns dias antes da admissão ao hospital. Após a realização de procedimentos adicionais de diagnóstico radiológico e endoscópico, detectou-se a presença de um corpo estranho no esôfago: um fragmento de fio de aço com cerca de 6 cm de comprimento e dobrado ao meio, que havia penetrado a parede do esôfago e se projetava ao nível da sétima vértebra cervical. Conseguimos remover o corpo estranho por via endoscópica sem maiores complicações e, a seguir, estabilizar nossa paciente, com utilização de medidas terapêuticas adicionais, conforme necessário.

ABSTRACT We present the case of a 71-year-old patient who was admitted to the medical intensive care unit in a state of multiple organ dysfunction. After the fourth day of applying all needed life-saving measures (vasopressor stimulation, mechanical ventilation, continuous dialysis treatment, broad spectrum antibiotic therapy, and other supportive measures), nonspecific heteroanamnestic data revealed that the patient had been having a persistent difficulty in swallowing liquids and food for a few days prior to hospital admission. After performing additional radiological and endoscopic diagnostic procedures, a foreign body was detected; a steel wire that had a length of approximately 6cm and was bent in a half had penetrated the esophagus and was projected into the seventh neckline. We managed to evacuate the foreign body endoscopically without further complications, and we stabilized our patient using additional therapeutic measures as needed.

The Effect of Hypoalbuminemia on the Therapeutic Concentration and Dosage of Vancomycin in Critically Ill Septic Patients in Low-Resource Countries.

PURPOSE: To determine whether severe hypoalbuminemia (<25 mg/L) has a significant effect on serum levels of vancomycin and whether it can effect vancomycin dosage regimen and the loading dose administration. MATERIAL AND METHODS: Prospective, cohort, and a single-center study included 61 patients whose vancomycin serum levels were measured in steady state. Vancomycin trough levels (C min) that were in the range 15 to 20 µg/mL were considered therapeutic and trough levels higher than 15 µg/mL were considered potentially nephrotoxic. RESULTS: In the group of patients with severe hypoalbuminemia, C min was significantly higher compared to the those with nonsevere hypoalbuminemia (>25 mg/L; 23.04 [19.14] vs 13.28 [11.28], P = .01). In the group of patients who received the vancomycin loading dose of 2 g, C min was significantly higher in patients with severe hypoalbuminemia compared to the patients with nonsevere hypoalbuminemia (34.52 [25.93] vs 15.37 [10.48], P = .04). CONCLUSION: In critically ill septic patients with severe hypoalbuminemia, there is a high probability that the loading dose of vancomycin is not necessary since it is associated with potentially toxic vancomycin C min, while in the patients with nonsevere hypoalbuminemia the loading dose may be necessary to achieving therapeutic C min.

An Alternative Approach to Treatment of Hypophosphatemia in Nonsurgical Critically Ill Patients in Countries With Limited Resources.

BACKGROUND: Hypophosphatemia can complicate and prolong the treatment of critically ill patients, and it is even thought to be related to mortality rate. OBJECTIVES: The aim of this study is to determine whether using extemporary prepared phosphate buffer in pharmacy would help correct serum phosphate in critically ill patients. METHODS: A prospective study was conducted at the medical intensive care unit over a period of 1 year and included 50 patients who were diagnosed with hypophosphatemia. Phosphate buffer was prepared at the pharmacy, and the dose range was recommended by a clinical pharmacist. RESULTS: Patients were administered phosphate buffer via the nasogastric tube, and the doses chosen by the physicians depended on serum phosphate level and the severity of the patients' clinical status. Serum phosphate levels were successfully corrected in all treated patients. The most frequently used dose was 60 mmoL/d, and in most patients 1-day therapy was sufficient. No adverse effects were observed. CONCLUSION: The phosphate buffer is an adequate alternative for the treatment of hypophosphatemia of nonsurgically critically ill patients. One-day therapy with the 60 mmoL phosphate dose divided into 3 single doses resulted in normalization of serum phosphate values in most patients.

Impact of weekly case-based tele-education on quality of care in a limited resource medical intensive care unit.

BACKGROUND: Limited critical care subspecialty training and experience is available in many low- and middle-income countries, creating barriers to the delivery of evidence-based critical care. We hypothesized that a structured tele-education critical care program using case-based learning and ICU management principles is an efficient method for knowledge translation and quality improvement in this setting. METHODS AND INTERVENTIONS: Weekly 45-min case-based tele-education rounds were conducted in the recently established medical intensive care unit (MICU) in Banja Luka, Bosnia and Herzegovina. The Checklist for Early Recognition and Treatment of Acute Illness (CERTAIN) was used as a platform for structured evaluation of critically ill cases. Two practicing US intensivists fluent in the local language served as preceptors using a secure two-way video communication platform. Intensive care unit structure, processes, and outcomes were evaluated before and after the introduction of the tele-education intervention. RESULTS: Patient demographics and acuity were similar before (2015) and 2 years after (2016 and 2017) the intervention. Sixteen providers (10 physicians, 4 nurses, and 2 physical therapists) evaluated changes in the ICU structure and processes after the intervention. Structural changes prompted by the intervention included standardized admission and rounding practices, incorporation of a pharmacist and physical therapist into the interprofessional ICU team, development of ICU antibiogram and hand hygiene programs, and ready access to point of care ultrasound. Process changes included daily sedation interruption, protocolized mechanical ventilation management and liberation, documentation of daily fluid balance with restrictive fluid and transfusion strategies, daily device assessment, and increased family presence and participation in care decisions. Less effective (dopamine, thiopental, aminophylline) or expensive (low molecular weight heparin, proton pump inhibitor) medications were replaced with more effective (norepinephrine, propofol) or cheaper (unfractionated heparin, H2 blocker) alternatives. The intervention was associated with reduction in ICU (43% vs 27%) and hospital (51% vs 44%) mortality, length of stay (8.3 vs 3.6 days), cost savings ($400,000 over 2 years), and a high level of staff satisfaction and engagement with the tele-education program. CONCLUSIONS: Weekly, structured case-based tele-education offers an attractive option for knowledge translation and quality improvement in the emerging ICUs in low- and middle-income countries.