Pragmatic study of a thromboprophylaxis algorithm in critically ill patients with SARS-COV-2 infection.

The optimal thromboprophylactic strategy for patients affected by Coronavirus disease 2019 (COVID-19) has been debated among experts. This study evaluated the safety and efficacy of a thromboprophylaxis algorithm. This was a retrospective, single-center study in critically ill patients admitted to the intensive care unit (University affiliated Hospital) for acute respiratory failure due to Severe Acute Respiratory Syndrome-Coronavirus 2 (SARS-CoV-2). From March 16 to April 9, 2020, thromboprophylaxis was adjusted according to weight (control group, n = 19) and after this date, thromboprophylaxis depended on an algorithm based on thrombotic and hemorrhagic risk factors (protocol group, n = 13). With regard to safety (number of major bleeding events and blood transfusions), the groups were not significantly different. With regard to efficacy, the number of thrombotic events decreased from 37 to 0%, p = 0.025 after implementation of the algorithm. Also, peak fibrinogen dropped from 8.6 (7.2-9.3) to 6.5 (4.6-8.4) g/L, p = 0.041 and D-dimers from 2194 (1464-3763) to 1486 (900-2582) ng/mL, p = 0.0001. In addition, length of stay declined from 19 (10-31) to 5 (3-19) days, p = 0.009. In conclusion, a tailored thromboprophylaxis algorithm (risk stratification based on clinical parameters and biological markers) reduce thrombotic phenomena in critically ill COVID-19 patients without increasing major bleeding.

Continuous mixed venous and central venous oxygen saturation in cardiac surgery with cardiopulmonary bypass.

BACKGROUND AND OBJECTIVE: Replacing mixed venous oxygen saturation (SvO2) monitoring by central venous oxygen saturation (ScvO2) monitoring in order to avoid the use of a pulmonary artery catheter and its related complications is still controversial in the setting of cardiac surgery. The influence of surgery, cardiopulmonary bypass and anaesthesia drugs on the relationship between SvO2 and ScvO2 has never been studied. METHODS: Fifteen patients scheduled for cardiac surgery with cardiopulmonary bypass were included in the study. SvO2 (from the pulmonary artery) and ScvO2 (from the superior vena cava) were continuously measured with fibre-optic catheters from induction of anaesthesia to 24 h postoperatively. RESULTS: A total of 9267 pairs of measurements were recorded. Mean bias between SvO2 and ScvO2 was 4.4% with limits of agreement of -13.6 and +22.5%, respectively. Trends of SvO2 and ScvO2 values followed very different patterns for some patients. Surgery, cardiopulmonary bypass and anaesthesia drugs did not influence the relationship between the two methods. CONCLUSION: Because of the large interindividual variability in the difference between SvO2 and ScvO2, the measure of ScvO2 should not replace the measure of SvO2 with a pulmonary artery catheter for the management of patients undergoing cardiac surgery with cardiopulmonary bypass.

The Double-Trunk Mask Improves Oxygenation During High-Flow Nasal Cannula Therapy for Acute Hypoxemic Respiratory Failure.

BACKGROUND: High-flow nasal cannula (HFNC) oxygen therapy is used to deliver an FIO2 from 0.21 to 1.0. The double-trunk mask (DTM) is a device designed to increase the FIO2 in patients with a high inspiratory flow demand. The aim of our study was to evaluate the effect of DTM in hypoxemic subjects already receiving HFNC. METHODS: We report a prospective multi-center crossover pilot study including 15 subjects treated with HFNC for acute hypoxemic respiratory failure. Measurements were performed at the end of 30-min periods with HFNC only, with HFNC + DTM, and again with HFNC only. RESULTS: Compared with HFNC alone, HFNC + DTM increased PaO2 from 68 ± 14 mm Hg to 85 ± 22 mm Hg (P < .001) and did not affect PaCO2 (P = .18). In the 11 responders, the PaO2 increased from 63 ± 12 mm Hg to 88 ± 23 mm Hg (P < .001). No complications were reported during DTM use. CONCLUSION: In subjects receiving oxygen via HFNC, the addition of the DTM over the HFNC increased PaO2 without changing the PaCO2 .

Metabolic acidosis and 5-oxoprolinuria induced by flucloxacillin and acetaminophen: a case report.

BACKGROUND: Frequent causes of high anion gap metabolic acidosis are well known: ethanol, methanol, and ethylene glycol intoxication; hyperglycemia; lactic or D-lactic acidosis; and impaired renal function. There are other causes, less frequent but also important. This report illustrates a rare case of a patient with increased anion gap metabolic acidosis due to a deficit of the γ-glutamyl cycle that led to 5-oxoproline (acid pyroglutamic) accumulation. CASE PRESENTATION: An 82-year-old white woman was admitted to our intensive care unit because of septic shock caused by right knee methicillin-sensitive Staphylococcus aureus-induced arthritis. She was treated for 10 days with flucloxacillin and rifampicin and developed metabolic acidosis with high anion gap. Her test results for methanol, ethanol, ethylene glycol, and acetylsalicylic acid were negative. Her glycemia, lactate level, and renal function were normal. However, the result of a urinary assay for pyroglutamate was positive. We concluded that the patient had metabolic acidosis induced by accumulation of 5-oxoproline. We modified her antibiotic treatment, administered acetylcysteine, and her acidosis resolved. CONCLUSIONS: 5-Oxoprolinuria (pyroglutamic acid accumulation) is a rare, probably underdiagnosed cause of transient metabolic acidosis with increased anion gap.

Relationship between CRP and hypofibrinolysis: Is this a possible mechanism to explain the association between CRP and outcome in critically ill patients?

BACKGROUND-: Endothelial cell dysfunction may be implicated in the development of multiple organ failure (MOF) by a number of mechanisms. Among these, altered fibrinolysis promotes fibrin deposition, which may create microvascular alterations during inflammation. Elevated concentrations of C-reactive protein (CRP), especially when these persist over time, are correlated with an increased risk of MOF and death. CRP may inhibit fibrinolysis by inducing plasminogen activator inhibitor-1 (PAI-1) release from human aortic endothelial cells. Moreover, the administration of recombinant CRP in volunteers may increase circulating PAI-1 levels.In this study, we tested the hypothesis that CRP is associated with hypofibrinolysis in intensive care patients with and without sepsis. METHODS-: We studied the association of inflammation and abnormal fibrinolysis in intensive care unit (ICU) patients with (n = 11) and without (n = 21) sepsis. The inflammatory response was assessed by serum concentration of C-reactive protein (CRP), a marker of the acute phase reaction, which increase rapidly in the inflammatory response, and the plasma fibrinolytic capacity was evaluated by the Euglobulin Clot Lysis Time (ECLT), determined by a new semi-automatic method. RESULTS-: ECLT was significantly higher in septic than non-septic patients (1104 +/- 439 vs 665 +/- 275 min; p = 0.002) and was significantly correlated with CRP concentration (R2 = 0.45; p < 0.001). In a multivariate analysis, CRP was the strongest predictor of ECLT (R2 = 0.51, F = 25.6, p < 0.001). In addition, the overall ICU length of stay was significantly correlated with CRP (R2 = 0.264, p = 0.003) and ECLT (R2 = 0.259, p = 0.003). CONCLUSION-: In critically ill patients a significant correlation thus exists between plasma fibrinolytic capacity and serum CRP levels. Our data were obtained in the first 24 hours of ICU admission or of sepsis, thus, the relation between CRP and hypofibrinolysis appeared very quickly. This finding is compatible with a link between inflammation and abnormal fibrinolysis, and may explain the negative prognostic value of CRP in critically ill patients.