Causes of an elevated international normalized ratio in the intensive care unit and the implications for plasma transfusion.

BACKGROUND: The presence of an elevated international normalized ratio (INR) is common in patients in the intensive care unit (ICU), but the cause rarely determined. These patients are at risk to receive prophylactic plasma prior to invasive procedures. STUDY DESIGN AND METHODS: Samples from patients with an INR of 1.5 or greater were frozen and subsequently thawed and assayed for procoagulant and anticoagulant clotting factors and anti-Xa to determine the likely cause of the INR. Samples showing a low FVII, FX, PC, and PS were categorized as a vitamin K deficiency pattern. Samples showing a low FV, low or normal fibrinogen, and high FVIII were categorized as a liver disease pattern. Samples showing an anti-Xa >0.01 IU/ml were assayed for anti-Xa DOACs. Samples which could not be categorized were grouped as equivocal. RESULTS: A total of 48 samples were obtained over a 6-month period. Nineteen showed a Vitamin K deficiency pattern, 17 a liver disease pattern, 7 showed an anti-Xa DOAC and 5 were equivocal. High FVIII and D-dimers and reduced levels of the anticoagulant proteins were present in the majority of the samples. FVII levels correlated inversely with the INR (r = -0. 81), as did FX (r = -0.67) but not FV (r = -0.04) nor fibrinogen (r = -0.15). CONCLUSION: Transfusion of plasma to reverse an elevated INR in the ICU should be discouraged since such a practice is either avoidable by the use of vitamin K or inappropriate in the case of liver disease or an anti-Xa DOAC.

Arterial Catheter Use in the ICU: A National Survey of Antiseptic Technique and Perceived Infectious Risk.

OBJECTIVES: Recent studies have shown that the occurrence rate of bloodstream infections associated with arterial catheters is 0.9-3.4/1,000 catheter-days, which is comparable to that of central venous catheters. In 2011, the Centers for Disease Control and Prevention published new guidelines recommending the use of limited barrier precautions during arterial catheter insertion, consisting of sterile gloves, a surgical cap, a surgical mask, and a small sterile drape. The goal of this study was to assess the attitudes and current infection prevention practices used by clinicians during insertion of arterial catheters in ICUs in the United States. DESIGN: An anonymous, 22-question web-based survey of infection prevention practices during arterial catheter insertion. SETTING: Clinician members of the Society of Critical Care Medicine. SUBJECTS: Eleven thousand three hundred sixty-one physicians, nurse practitioners, physician assistants, respiratory therapists, and registered nurses who elect to receive e-mails from the Society of Critical Care Medicine. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 1,265 responses (11% response rate), with 1,029 eligible participants after exclusions were applied. Only 44% of participants reported using the Centers for Disease Control and Prevention-recommended barrier precautions during arterial catheter insertion, and only 15% reported using full barrier precautions. The mean and median estimates of the incidence density of bloodstream infections associated with arterial catheters were 0.3/1,000 catheter-days and 0.1/1,000 catheter-days, respectively. Thirty-nine percent of participants reported that they would support mandatory use of full barrier precautions during arterial catheter insertion. CONCLUSIONS: Barrier precautions are used inconsistently by critical care clinicians during arterial catheter insertion in the ICU setting. Less than half of clinicians surveyed were in compliance with current Centers for Disease Control and Prevention guidelines. Clinicians significantly underestimated the infectious risk posed by arterial catheters, and support for mandatory use of full barrier precautions was low. Further studies are warranted to determine the optimal preventive strategies for reducing bloodstream infections associated with arterial catheters.

Maternal mortality secondary to acute respiratory failure in Colombia: a population-based analysis.

PURPOSE: To estimate the mortality rate and trends of respiratory failure in the pregnant and postpartum population of Colombia. METHODS: A retrospective analysis of the national registry of mortality in Colombia was performed from 1998 to 2009. Maternal death was defined as death that occurred during pregnancy or up to 42 days postpartum. Two independent investigators reviewed maternal deaths to determine deaths caused by respiratory failure. Inter-rater agreement was assessed by kappa correlation coefficient. Causes of respiratory failure were identified according to the International Classification of Diseases (ICD-10). RESULTS: During the study period, 8,637,486 live births were reported with 6,676 maternal deaths for an overall maternal mortality rate (MMR) of 82.9 per 100,000 live births. Of these, a total of 835 cases were related to respiratory failure, with a specific MMR of 9.69 per 100,000 live births. The main causes of maternal deaths due to respiratory failure included pulmonary sepsis (284 cases, or 3.58 per 100,000 live births), pulmonary embolism (119 cases or 1.50 per 100,000 live births), and preeclampsia-related pulmonary edema (112 cases or 1.41 per 100,000 live births). All-cause maternal mortality ratio decreased yearly from 1998 to 2009 by -3.76% (95% CI -4.83 to -2.67), while the trend of mortality secondary to respiratory failure remained stable over time (P = 0.449). CONCLUSIONS: Respiratory failure is an important cause of mortality in the obstetric population in Colombia, with pulmonary sepsis as the lead cause of respiratory failure among maternal deaths. While overall maternal mortality rates have decreased in the last decade, respiratory failure-related deaths have remained stable over time.

Massive intravascular hemolysis from Clostridium perfringens septicemia: a review.

We describe the case of a patient with hemolysis-associated Clostridium perfringens septicemia and review all similar cases published in the literature since 1990, with specific focus on the relationship between treatment strategy and survival. We searched PubMed for all published cases of C. perfringens-associated hemolysis, using the medical subject terms "clostridia," "clostridial sepsis," and/or "hemolysis." All case reports, case series, review articles, and other relevant references published in the English literature since 1990 were included in this study. There were no exclusion criteria. Each case was examined with respect to presenting features of illness, antibiotic regimen, time-to-antibiotic therapy, additional interventions, complications, and patient survival. These variables were entered into a data set and then systematically analyzed with the aid of a statistician, using serial t tests and chi-square analyses. Since 1990, 50 patients of C. perfringens septicemia with hemolysis have been reported. Median age was 61 years (range 31-84), and 58% were male. Mortality was 74%, with a median time to death of 9.7 hours (range 0-96 hours). Of the patients, 35 (70%) were treated medically, while 15 (30%) received antibiotics and surgery. Surgical intervention was associated with significantly improved survival (risk ratio [RR] 0.23, 95% confidence interval [CI] 0.10, 0.53) as was the use of a combination of penicillin and clindamycin (RR of death 0.46, 95% CI 0.25, 0.83). Four patients utilizing hyperbaric oxygen therapy (HBOT) have been reported, and all patients survived. In cases of clostridial sepsis with hemolysis, strong predictors of survival include early initiation of appropriate antibiotics as well as surgical removal of infected foci. The HBOT may also be associated with survival. The disease often progresses rapidly to death, so rapid recognition is critical for the patient survival.

Spontaneous Pneumothorax in a Healthy Young Woman: Discussion About Treatment Options.

A spontaneous pneumothorax, a potentially life-threatening condition, is a disease process in which air enters the space between the visceral and parietal pleural of the lung, thus increasing the pressures in that space. It can be diagnosed by both physical exam and radiographic testing. In this case, we present a 21-year-old, otherwise healthy woman who presented with sudden, sharp shoulder pain and chest tightness and was diagnosed with her first, spontaneous pneumothorax. We further discuss the diagnosis and treatment options for a first-time spontaneous pneumothorax.

Perspectives on Using Race in Pulmonary Function Testing: A National Survey Fellows and Program Directors.

BACKGROUND: Pulmonary function tests (PFTs) have historically used race-specific prediction equations. The recent American Thoracic Society guidelines recommend the use of a race-neutral approach in prediction equations. There are limited studies centering the opinions of practicing pulmonologists on the use of race in spirometry. Provider opinion will impact adoption of the new guideline. The aim of this study was to ascertain the beliefs of academic pulmonary and critical care providers regarding the use of race as a variable in spirometry prediction equations. METHODS: We report data from 151 open-ended responses from a voluntary, nationwide survey (distributed by the Association of Pulmonary Critical Care Medicine Program Directors) of academic pulmonary and critical care providers regarding the use of race in PFT prediction equations. Responses were coded using inductive and deductive methods, and a thematic content analysis was conducted. RESULTS: There was a balanced distribution of opinions among respondents supporting, opposing, or being unsure about the incorporation of race in spirometry prediction equations. Responses demonstrated a wide array of understanding related to the concept and definition of race and its relationship to physiology. CONCLUSIONS: There was no consensus among providers regarding the use of race in spirometry prediction equations. Concepts of race having biologic implications persist among pulmonary providers and will likely affect the uptake of the Global Lung Function Initiative per the American Thoracic Society guidelines.

Mechanical Thrombectomy for a Clot in Transit With Adherence to the Tricuspid Valve.

This case report investigates the management of a clot in transit (CIT), a rare but possibly life-threatening condition discovered in a small percentage of pulmonary embolism (PE) cases. CITs are thrombi lodged within the right-side heart chambers or the major veins, and there are currently no universal guidelines for their management though the literature has shown reduced mortality with reperfusion therapy compared to anticoagulation alone. In this case, a 96-year-old male who presented with a submassive PE was initially stabilized with anticoagulation and was then discovered to have a CIT with adherence to the tricuspid valve. The patient underwent a successful mechanical thrombectomy using the Inari FlowTriever (Inari Medical, Irvine, CA), an FDA-approved device for CIT removal. Overall, this manuscript supports this percutaneous intervention in intermediate to high-risk PE patients with concomitant CIT, offering an alternative to thrombolysis and cardiothoracic surgery, which carry their own risks. Furthermore, the unique characteristic of the CIT in this patient suggests a potential for further investigation into the diversity of CIT morphology and its significance.

Patient With Prior COVID-19 Infection Presenting With Acute Upper Airway Obstruction: A Case Report.

New clinical manifestations of coronavirus disease 2019 (COVID-19) have been emerging throughout the pandemic and are being reported to the medical community. There have been limited reports that the virus can cause acute airway compromise. Here, we describe a young patient with a recent COVID-19 infection now presenting with acute airway compromise, presumed to be pharyngitis, and their clinical course during their hospitalization. The purpose of this case presentation was to shed light on a newly reported, presumed, presentation of COVID-19 that can be life-threatening in people of all ages. Though there have been limited reported cases, it is important to include this virus in the differential diagnosis of virus-induced airway compromise.

In-Hospital Cardiac Arrest Outcomes During the Early COVID-19 Pandemic in RI: A Qualitative Analysis.

Throughout the COVID-19 pandemic, there has been growing but limited data describing the poor mortality outcomes in COVID-19 patients who experienced In-Hospital Cardiac Arrest (IHCA). This study evaluated the baseline characteristics and outcomes of COVID-19 patients who underwent cardiopulmonary resuscitation (CPR) during hospitalization in the early phases of the pandemic and compared them to that of several national and international centers. A list of all the IHCA events in the Lifespan hospital network from March 2020 to April 2021 was generated, and data, including de-identified patient characteristics, comorbidities, and details of the IHCA event, were examined. The primary outcome of all-cause mortality was then calculated. Forty-three patients with COVID-19 who experienced an IHCA event and underwent CPR were identified. Return of spontaneous circulation (ROSC) was achieved in 23 (53%) patients, and all-cause in-hospital mortality was 97.67%, with only one patient surviving until discharge. During the early pandemic, experiencing an IHCA event while admitted with COVID-19 carried an extremely poor prognosis, even if ROSC was achieved. This outcome likely reflects the lack of clear management guidelines or established therapeutic agents and the prevalence of the Delta strain during this time period.

Baricitinib in hospitalised patients with COVID-19: A meta-analysis of randomised controlled trials.

Background: To date, only dexamethasone and tocilizumab have been shown to reduce mortality in patients with COVID-19. Baricitinib is a Janus kinase 1/2 inhibitor with known anti-inflammatory and anti-viral properties. We performed a meta-analysis of RCTs assessing the role of baricitinib in hospitalised patients with COVID-19. Methods: Electronic databases such as MEDLINE, EMBASE, and Cochrane Central were searched up until March 31, 2022, for RCTs evaluating the efficacy of baricitinib in hospitalised patients with COVID-19. The outcomes assessed were 28-day mortality, progression to invasive mechanical ventilation (IMV) or ECMO, progression to respiratory failure needing positive pressure ventilation, IMV or death, duration of hospitalisation and time to discharge. The meta-analysis was registered in the PROSPERO database (CRD42022314579). Findings: Four studies (with 10,815 patients) were included in the analysis. Pooled analysis using random-effects model showed a statistically significant reduction in 28-day mortality (OR 0.69, 95% CI 0.50-0.94; p=0.04, I2=65%) and composite outcome of progression to severe disease needing positive pressure ventilation, IMV or death (OR 0.89, 95% CI 0.80-0.99, p= 0.03, I2=0%). There was a favorable trend towards reduced progression to IMV or ECMO (OR 0.76, 95% CI 0.58-1.01; p=0.06, I2=49%) in the baricitinib arm compared to standard therapy, even though it was not statistically significant. Statistical significance was achieved for all outcomes with fixed-effects model analysis. Interpretation: In hospitalised patients with COVID-19, baricitinib was associated with reduced 28-day mortality although there was not a statistically significant reduction in progression to IMV or ECMO. Baricitinib used in conjunction with standard of care treatments is associated with improved mortality in hospitalised patients with COVID-19 disease. Funding: None.

Celiac Artery Compression Syndrome Presenting As Recurrent Diabetic Ketoacidosis: A Diagnostic Challenge.

Celiac artery compression syndrome (CACS), also known as median arcuate ligament syndrome, can sometimes represent a diagnostic challenge. Here, we present the case of a 29-year-old man who presented with recurrent diabetic ketoacidosis (DKA), abdominal pain, and vomiting thought to be due to cyclical vomiting syndrome. However, the lack of a clear precipitant for DKA, the presence of chronic gastrointestinal symptoms, and a revealing physical examination of abdominal bruit led to clinical suspicion of CACS and its diagnosis after appropriate investigations. While angiography has traditionally been considered the gold standard diagnostic test, hemodynamic and geometric ultrasound criteria can, however, be diagnostic. The patient was managed by releasing the celiac artery through robotic surgery and serial monitoring as an outpatient revealed resolution of his symptoms and no further readmissions for DKA. This case highlights how a presumptive and erroneous diagnosis (cyclical vomiting syndrome) can misguide clinicians, especially when dealing with a rare diagnosis of exclusion.

A Rare Case of 4 Ps: Bilateral Pneumothoraces and Pneumomediastinum in Pneumocystis Pneumonia.

We report a case of Pneumocystis jirovecii pneumonia (PCP) complicated by bilateral pneumothoraces and pneumomediastinum in a non-human immunodeficiency virus (HIV)- infected patient. This unusual presentation exemplifies the differences in clinical course and presentation in non-HIV versus HIV-infected individuals, and the poor prognosis associated with PCP complicated by pneumothorax or pneumomediastinum. Providers should be aware of the high mortality in patients who develop one, and especially both complications.

A Case of Interstitial Pneumonia with Features of Autoimmunity.

We present a case of a 61-year-old woman with several months of gradually worsening shortness of breath, requiring multiple hospitalizations with acute hypoxemic respiratory failure. She was initially treated for eosinophilic pneumonia presumed to be secondary to medications or rheumatoid lung without much improvement. Her subsequent chest CT showed honeycombing and diffuse ground-glass opacities, and she was found to have elevated rheumatoid factor (RF) and anti-CCP antibody titers without extrathoracic features of rheumatoid arthritis. This clinical scenario was suggestive of an interstitial lung disease (ILD) due to occult underlying connective tissue disorder (CTD), along the lines of the recently proposed entity interstitial pneumonia with autoimmune features (IPAF). She continued to deteriorate rapidly and passed away after experiencing recurrent exacerbations. As there is limited evidence to explain the clinical course of such patients, there is a need for prospective research to develop tailored regimens to prevent progression or even reverse the disease process.

A Case of Vaping-Associated Lung Injury in Rhode Island.

The Centers for Disease Control and Prevention (CDC) is currently investigating a nationwide outbreak of e- cigarette, or vaping, associated lung injury (EVALI). The objective of this case report is to review a suspected case of EVALI in Rhode Island and discuss how to identify and manage this condition.

Intensive care unit rounding checklists to reduce catheter-associated urinary tract infections.

OBJECTIVE: To assess whether the implementation of an intensive care unit (ICU) rounding checklist reduces the number of catheter-associated urinary tract infections (CAUTIs). DESIGN: Retrospective before-and-after study that took place between March 2013 and February 2017. SETTING: An academic community hospital 16-bed, mixed surgical, cardiac, medical ICU. PATIENTS: Participants were all patients admitted to the adult mixed ICU and had a diagnosis of CAUTI. INTERVENTION: Initiation of an ICU rounding checklist that prompts physicians to address any use of urinary catheters with analysis comparing the preintervention period before roll out of the rounding checklist versus the postintervention periods. RESULTS: There were 19 CAUTIs and 9,288 urinary catheter days (2.04 CAUTIs per 1,000 catheter days). The catheter utilization ratio increased in the first year after the intervention (0.67 vs 0.60; P = .0079), then decreased in the second year after the intervention (0.53 vs 0.60; P = .0992) and in the third year after the intervention (0.53 vs 0.60; P = .0224). The rate of CAUTI (ie, CAUTI per 1,000 urinary catheter days) decreased from 4.62 before the checklist was implemented to 2.12 in the first year after the intervention (P = .2104). The CAUTI rate was 0.45 in the second year (P = .0275) and 0.96 in the third year (P = .0532). CONCLUSIONS: Our study suggests that utilization of a daily rounding checklist is associated with a decrease in the rates of CAUTI in ICU patients. Incorporating a rounding checklist is feasible in the ICU.

Red Blood Cell Transfusions in the ICU.

Red blood cells are commonly administered to critically ill patients, yet the desired benefit of improving oxygen delivery and overall outcome may not be achieved in many scenarios. In addition, blood products are of limited supply and there are clear risks associated with blood transfusion. Despite this, studies show that almost half of all ICU patients receiving blood transfusions do so in the setting of stable anemia, suggesting that many critically ill patients in the ICU may receive unnecessary transfusions. Critical illnesses can lead to increased rates of anemia, even without active blood loss. The benefits of transfusion in these situations are unclear. Clear indications for blood transfusions, including uncontrolled hemorrhage, symptomatic anemia, and possibly acute coronary syndrome, are met in the minority of patients receiving red blood cell transfusions. This review discusses current evidence regarding the use of red blood cell transfusions in the ICU. Two major categories are examined, transfusion in patients noted to be anemic, but not clearly actively bleeding or symptomatic, and patients with aggressive bleeding who are critically ill or require massive transfusions.

The impact of errors on healthcare professionals in the critical care setting.

PURPOSE: Medical errors occur at high rates in intensive care units (ICUs) and have great consequences. The impact of errors on healthcare professionals is rarely discussed. We hypothesized that issues regarding blame and guilt following errors in the ICU exist and may be dependent on type of practitioner, level of experience, and error type. MATERIALS AND METHODS: An online survey was conducted of members of a large critical care medical society addressing three clinical scenarios of procedural, diagnostic and treatment errors. RESULTS: Nine hundred one practitioners responded. In all scenarios, negative feeling after medical errors occurred in all practitioners regardless of experience or field. Surgeons and anesthesiologists showed higher negative responses after procedural errors while internal medicine and emergency medicine practitioners had higher negative responses after diagnostic errors. Survey respondents identified multiple ways to address these adverse feelings, including debriefing with the medical team (68%), talking with colleagues (68%) and discussing with patients and families (36%). CONCLUSIONS: In critical care, blame and guilt after medical errors are common and affect all providers. Critical care practitioners have identified methods which may help mitigate adverse feeling after medical errors, including debriefing and talking with colleagues. Hospitals may benefit from developing these types of strategies after medical errors.

A case of legionella pneumonia caused by home use of continuous positive airway pressure.

A 67-year-old woman with morbid obesity and severe obstructive sleep apnea presented to the emergency department with 2 days of productive cough, fever, shortness of breath and loose stools. A chest x-ray showed extensive bilateral infiltrates, and she was quickly intubated for acute hypoxic respiratory failure. A urine legionella antigen test was positive, and she was admitted to the intensive care unit with a diagnosis of severe legionella pneumonia. She improved over the next week with a course of levofloxacin. Once improved, the state health department visited her home and interviewed her husband and determined that she had not been cleaning her continuous positive pressure mask, tubing and humidifier appropriately. They concluded that the legionella likely came from her continuous positive airway pressure equipment. Cases of legionella pneumonia have frequently been reported through infected water supplies and even respiratory equipment. It is crucial that the mask and tubing used with these devices are cleaned appropriately to minimize the risk of infection.

Cardiogenic shock from coronary vasculitis in granulomatosis with polyangiitis.

Granulomatosis with polyangiitis (GPA) is a systemic vasculitis characterised by necrotising inflammatory changes in small-sized and medium-sized vessels and granuloma formation. It most commonly involves the kidneys and respiratory tract, but it can present with widespread manifestations involving any organ system. Rarely, it causes coronary vasculitis which can precipitate a severe cardiomyopathy. Here, we report a patient who presented in cardiogenic shock requiring vasopressors and was found to have extensive myocardial ischaemia secondary to coronary vasculitis. Further investigation led to a diagnosis of GPA, and he responded to treatment with corticosteroids, cyclophosphamide and plasmapheresis.

Lithium toxicity after Roux-en-Y bariatric surgery.

A 61-year-old woman with medical history significant for morbid obesity, type II diabetes mellitus, nephrogenic diabetes insipidus and bipolar disorder, had been stable on lithium carbonate therapy for several years. She had undergone a Roux-en-Y bypass surgery and, at the time of her surgery, her lithium level was found to be 0.61 mEq/L on a maintenance dose of 600 mg orally twice per day. She was discharged 8 days postoperatively on the same lithium dose, but presented to the emergency department 12 days postoperatively with signs of lithium toxicity. Her lithium level was elevated to 1.51 mEq/L and she was treated for lithium toxicity with supportive care and, ultimately, reduction of her lithium dose. Clinicians should be aware that dramatic and poorly understood changes in drug absorption may occur after bariatric surgery.