A.B.C. approach proposal for POCUS in COVID-19 critically ill patients.

The rapid spread of SARS-CoV-2 (COVID-19) since December 2019 forced Intensive Care Units to face high numbers of patients admitted simultaneously with limited resources. COVID-19 critically ill patients, especially those on mechanical ventilators, demand special attention as they can develop potential complications with critical hemodynamic and respiratory consequences. Point of Care Ultrasound (POCUS) might have important roles in assessing the critically ill SARS-CoV-2 patient. Mostly, lung ultrasound has been presented as having a role in diagnosis and monitoring, but airway examination and hemodynamic evaluation are of interest also. We propose an A.B.C. POCUS approach focusing on A-airway (orotracheal intubation), B-breathing (interstitial syn-dromes, pneumothorax, atelectasis, pneumonia), and C-circulation (cardiac function, pulmonary embolism, volume status, deep veins thrombosis). This A.B.C. approach has emerged during ICU care for 22 adult COVID-19 critically ill patients, along with the analysis of recent papers describing ultrasound in COVID-19 patients including the use of ultrasound that is currently applied in the management of the general critically ill population. This A.B.C- POCUS algorithm parallels the well-established clinical A.B.C. algorithms. There are few extensive ultrasonographic studies in COVID-19 critically ill patients up to now, but techniques extrapolated from non-COVID studies seem reasonable even though comparative studies are not available yet.

Central venous catheter colonization and catheter-related bloodstream infections in critically ill patients: a comparison between standard and silver-integrated catheters.

BACKGROUND AND OBJECTIVE: Catheter-related bloodstream infections are one of the main complications affecting patients in intensive care units. This prospective, randomized, unblinded, controlled study investigated colonization and infection rates of standard central venous catheters in comparison with the rates for silver-integrated catheters in the intensive care unit. METHODS: Complete data were evaluated for 272 catheters inserted into 230 patients (141 standard and 131 silver-integrated central venous catheters). Patient and catheter characteristics were documented for all patients. Positive catheters were detected by semi-quantitative and quantitative microbiologic techniques. Peripheral blood cultures were obtained at the time of catheter removal. RESULTS: There was no significant difference in the colonization rates and the colonization per 1000 catheter days between the standard and silver-integrated catheters. Using the Kaplan-Meier curves (long-rank test), there was a significant difference in the incidence of colonization and infections over time between standard and silver-integrated catheters (P<0.01 and P<0.05, respectively). Whereas standard catheters were first colonized 3 days after the insertion, silver-integrated catheters were first colonized 5 days after insertion. CONCLUSION: Silver-integrated central venous catheters did not prevent catheter colonization and infections in critically ill patients, but there might be a significant difference in the incidence of colonization and infections over time between standard polyurethane and silver-integrated catheters.

Cerebral salt wasting syndrome in patients with minor head trauma - two case reports.

We describe two polytrauma patients without severe head trauma who developed Cerebral Salt Wasting Syndrome (CSWS) during their stay in our ICU with natriuresis, hyponatremia and hypovolemia. Hyponatremia encountered in CSWS and the syndrome of inadequate antidiuretic hormone secretion (SIADH) is a common electrolyte finding in patients with severe head trauma, subarachnoid hemorrhage, malignancy and infections of the central nervous system. CSWS was an unexpected electrolyte finding in our patients with minor head trauma without neurological or neurosurgical problems. To rule out other causes of hyponatremia (SIADH, secondary adrenal dysfunction and thyroid dysfunction) a correct diagnosis is very important, as proper treatment of CSWS with fluid and salt replacement will decrease mortality and morbidity. In conclusion, CSWS should be suspected in any polytrauma patient with minor head trauma and hyponatremia.