Hemodynamic, Biochemical, and Ventilatory Parameters are Independently Associated with Outcome after Cardiac Arrest.

BACKGROUND: Hypotension, hyperglycemia, dysoxia, and dyscarbia may contribute to reperfusion injury, and each is independently associated with poor outcome (PO) after cardiac arrest. We investigated whether the combined effects of these physiological derangements are associated with cardiac arrest outcomes. METHODS: This institutional review board-approved retrospective cohort study included consecutive resuscitated cardiac arrest patients that received targeted temperature management at Maine Medical Center from 2013 to 2015. We abstracted demographics, intra-arrest factors, and physiological parameters. The primary outcome was dichotomized cerebral performance category (CPC 1-2 vs 3-5) at hospital discharge. After comparing demographics, clinical factors, and persistent post-arrest physiological derangements in patients with good and PO, we constructed a logistic regression model comprised of clinical and demographic factors separately associated with severity, and physiology variables, attempting to evaluate the independent effects of persistent physiological derangements on outcome. RESULTS: Sixty-eight of 222 (31%) patients had CPC 1-2 (good outcome [GO]) at discharge. In bivariate analysis, factors associated with PO included increased time from collapse to resuscitation, non-shockable rhythm, and age-combined Charlson comorbidity index. In multivariate analysis, each persistent physiological derangement incrementally decreased the likelihood of GO [OR GO per derangement 0.71 (interquartile range [IQR] 0.51-0.99), p = 0.042, area under the curve (AUC) for final model 0.769]. CONCLUSIONS: Uncorrected physiological derangements in the first 24 h after cardiac arrest are independently associated with PO. Although causality cannot be established, these findings support preclinical models suggesting that aggressive normalization of physiology after resuscitation may be a reasonable strategy to decrease reperfusion injury.

Coccidioides Immitis Infection with Involvement of the Airway.

Coccidioides immitis is a fungus endemic to the southwest United States and can present as an asymptomatic infection, acute pneumonia, chronic progressive pneumonia, or disseminated extrapulmonary infection which most commonly involves the skin, lymph nodes, bones, joints, or meninges. Diagnosis can be made by serologic testing or by biopsy or culture of affected tissue. Acute pneumonia due to fungi cannot be readily distinguished from bacterial pneumonia without specific diagnostic testing. Occasionally, endobronchial/tracheal lesions can be found on bronchoscopy in patients with fungal pneumonia, and when present, should raise suspicion for this entity. We present a case of acute pneumonia due to C. immitis in a non-endemic region thatwas rapidly diagnosed by biopsy of an endobronchial excrescence. We discuss previous reports of airway involvement in fungal infections and the importance of direct discussion with a pathologist when attempting to identify regionally uncommon organisms.