Transient Diabetes Insipidus After Vasopressin Discontinuation.

Vasopressin infusion is commonly used in intensive care settings during states of advanced vasodilatory shock for its vasoconstrictive properties. Vasopressin also acts on renal tubular cell receptors in the collecting ducts of kidneys to allow for water reabsorption. The sudden discontinuation of vasopressin infusion can lead to the development of transient diabetes insipidus (DI) with classic findings of polyuria, dilute urine, and hypernatremia. We report the case of a 59-year-old male who underwent an emergent bedside cricothyrotomy procedure secondary to papillary carcinoma of the thyroid and subsequently developed septic shock requiring initiation of vasopressin infusion for hemodynamic support. He remained on vasopressin for five days before the infusion was discontinued after clinical improvement. Within 12 hours of vasopressin discontinuation, the patient developed polyuria (> 3 L/day urine output) with volumes as high as 1 L per hour. His serum sodium levels increased more than 10 mmol/L from 137 to 149 mmol/L. This case is unique from prior reports, as our patient was without any neurological or neurosurgical comorbidities that would predispose him to an organic central cause of DI. Furthermore, the patient's large-volume diuresis and serum abnormalities spontaneously self-improved within 24 hours without significant medical intervention. In conclusion, this case adds to a growing number of reports of transient DI following vasopressin withdrawal, demonstrating the need to formally recognize this occurrence as a potential consequence of vasopressin use in intensive care settings.

Causes of Death Among Medical ICU Patients With Pneumonia Due to COVID-19 in a Safety-Net Hospital.

We sought to identify the primary causes of death of adult patients admitted to the medical ICU with symptomatic COVID-19 who ultimately suffered in-hospital mortality over the span of three major waves of COVID-19: Wild-type, alpha/epsilon, and delta. DESIGN: Retrospective single-center cohort study from March 2020 to December 2021. SETTING: One medical ICU in a 600-bed Tertiary Care Hospital in Los Angeles, CA. PATIENTS: Adult (n = 306) ICU patients admitted with symptomatic COVID-19 who suffered in-hospital mortality. INTERVENTIONS: None. MAIN RESULTS: Of the 306 patients with COVID-19 who died in the hospital, 86.3% were Hispanic/Latino. The leading cause of death was respiratory failure, occurring in 57.8% of patients. There was no significant change in the rate of pulmonary deaths across the three waves of COVID-19 in our study period. The mean time from symptom onset to admission was 6.5 days, with an average hospital length of stay of 18 days. This did not differ between pulmonary and other causes of death. Sepsis was the second most common cause of death at 23.9% with a significant decrease from the wild-type wave to the delta wave. Among patients with sepsis as the cause of death, 22% (n = 16) were associated with fungemia. There was no significant association between steroid administration and cause of death. Lastly, the alpha/epsilon wave from December 2020 to May 2021 had the highest mortality rate when compared with wild-type or delta waves. CONCLUSIONS: We found the primary cause of death in ICU patients with COVID-19 was acute respiratory failure, without significant changes over the span of three waves of COVID-19. This finding contrasts with reported causes of death for patients with non-COVID-19 acute respiratory distress syndrome, in which respiratory failure is an uncommon cause of death. In addition, we identified a subset of patients (5%) who died primarily due to fungemia, providing an area for further investigation.

Spontaneous hemothorax in a 48-year-old man with COVID-19 acute respiratory distress syndrome.

A 48-year-old man presented with gradually worsening dyspnea three days after testing positive for COVID-19. He was admitted to the intensive care unit on maximum high flow nasal cannula settings and subsequently intubated for hypoxic respiratory failure due to COVID-19 pneumonia. Two weeks into the patient's hospital course, he unexpectedly developed worsening hypotension with multiple vasopressor requirements. Labs revealed an unexpected hemoglobin drop from 12.5 to 7.9 g/dL. Chest radiograph showed near complete opacification of the right hemithorax concerning for hemothorax. This case presentation describes a rare phenomenon of spontaneous hemothorax in a patient with COVID-19.

Critical iron deficiency anemia with record low hemoglobin: a case report.

BACKGROUND: Anemia is a serious global health problem that affects individuals of all ages but particularly women of reproductive age. Iron deficiency anemia is one of the most common causes of anemia seen in women, with menstruation being one of the leading causes. Excessive, prolonged, and irregular uterine bleeding, also known as menometrorrhagia, can lead to severe anemia. In this case report, we present a case of a premenopausal woman with menometrorrhagia leading to severe iron deficiency anemia with record low hemoglobin. CASE PRESENTATION: A 42-year-old Hispanic woman with no known past medical history presented with a chief complaint of increasing fatigue and dizziness for 2 weeks. Initial vitals revealed temperature of 36.1 °C, blood pressure 107/47 mmHg, heart rate 87 beats/minute, respiratory rate 17 breaths/minute, and oxygen saturation 100% on room air. She was fully alert and oriented without any neurological deficits. Physical examination was otherwise notable for findings typical of anemia, including: marked pallor with pale mucous membranes and conjunctiva, a systolic flow murmur, and koilonychia of her fingernails. Her initial laboratory results showed a critically low hemoglobin of 1.4 g/dL and severe iron deficiency. After further diagnostic workup, her profound anemia was likely attributed to a long history of menometrorrhagia, and her remarkably stable presentation was due to impressive, years-long compensation. Over the course of her hospital stay, she received blood transfusions and intravenous iron repletion. Her symptoms of fatigue and dizziness resolved by the end of her hospital course, and she returned to her baseline ambulatory and activity level upon discharge. CONCLUSIONS: Critically low hemoglobin levels are typically associated with significant symptoms, physical examination findings, and hemodynamic instability. To our knowledge, this is the lowest recorded hemoglobin in a hemodynamically stable patient not requiring cardiac or supplemental oxygen support.

A Nationwide Survey Study on Medical Student Experience in Acute Care Surgery.

BACKGROUND: There is little known about medical student education in acute care surgery (ACS)-how much and what type of exposure students receive in the specialty. The aim of this study was to investigate the current status of ACS education provided to students in U.S. medical schools. MATERIALS AND METHODS: We created an online survey tool covering the surgical clerkship and ACS curriculum and distributed this survey to the official email list of the Association for Surgical Education Committee on Clerkship Directors. RESULTS: A total of 57 of 294 (19.4%) responses were received. All respondents reported that at least some of their major teaching hospitals are affiliated with an ACS service and have a level 1 or 2 trauma center. Although almost two-thirds (61.8%) of respondents believe that medical students should have formal ACS education in the form of a clinical rotation, an ACS rotation is mandatory at only 16.4% of programs and is optional at 69.1% of programs as part of the surgical clerkship curriculum. The duration of ACS rotations ranges from 1 to 6 wk, and half of programs require students to take overnight call (most often 1-2 nights/wk). The most common pathologies that students see on ACS include appendicitis, biliary disease and cholecystitis, intestinal obstruction, and trauma. CONCLUSIONS: Medical students across the nation have varying exposure to ACS during their clinical training. With the continued growth of the ACS specialty, further study is warranted to examine the impact of undergraduate ACS education on student career planning.

Acute Care Surgery Education in US Medical Schools: A Systematic Review of the Current Literature and Report of a Medical Student Experience.

OBJECTIVE: There is currently little known about acute care surgery (ACS) education in US medical schools. The purpose of this paper was to systematically review the state of the literature describing ACS training at the medical school level and introduce an ACS education model provided to medical students at our institution. DESIGN: We conducted a comprehensive literature review using the PubMed database to identify all articles related to ACS (trauma surgery, emergency general surgery, and surgical critical care) and undergraduate medical education. PARTICIPANTS: A total of 376 articles were captured with our search strategy. The articles were reviewed for eligibility by 2 separate reviewers. RESULTS: We identified 3 relevant articles for our literature review. All studies were performed at level 1 trauma centers. The duration of ACS rotations ranges from 1 to 4 weeks with variable night call schedules. While several curricular changes have improved student perceptions on ACS education, none of the studies have thoroughly evaluated the impact on students' readiness or career choices for their postgraduate training. CONCLUSIONS: The current lack of information on ACS education in medical school has left us with a need to better understand this area in order to improve students' experience and exposure to the specialty. Future efforts should be placed on addressing current issues in ACS education and evaluating its impact on career choice of medical students.