Impact of ketamine as an adjunct sedative in acute respiratory distress syndrome due to COVID-19 Pneumonia.

PURPOSE: Deep sedation is sometimes needed in acute respiratory distress syndrome. Ketamine is a sedative that has been shown to have analgesic and sedating properties without having a detrimental impact on hemodynamics. This pharmacological profile makes ketamine an attractive sedative, potentially reducing the necessity for other sedatives and vasopressors, but there are no studies evaluating its effect on these medications in patients requiring deep sedation for acute respiratory distress syndrome. MATERIALS AND METHODS: This is a retrospective, observational study in a single center, quaternary care hospital in southeast Texas. We looked at adults with COVID-19 requiring mechanical ventilation from March 2020 to September 2020. RESULTS: We found that patients had less propofol requirements at 72 h after ketamine initiation when compared to 24 h (median 34.2 vs 54.7 mg/kg, p = 0.003). Norepinephrine equivalents were also significantly lower at 48 h than 24 h after ketamine initiation (median 38 vs 62.8 mcg/kg, p = 0.028). There was an increase in hydromorphone infusion rates at all three time points after ketamine was introduced. CONCLUSIONS: In this cohort of patients with COVID-19 ARDS who required mechanical ventilation receiving ketamine we found propofol sparing effects and vasopressor requirements were reduced, while opioid infusions were not.

Septic pulmonary emboli causing recurrent bilateral pneumothoraces in a patient with right sided endocarditis: A case report and review of literature.

Patients with a history of drug abuse and right sided endocarditis are prone to develop septic pulmonary emboli. Pneumothorax is a rare complication of septic pulmonary emboli reported in the literature, likely due to the rupture of thin-walled septic cavitary lesions resembling pneumatoceles into the pleural space. Only seven cases (including our case) of pneumothorax from septic pulmonary emboli due to right sided endocarditis have been described in the literature. Our patient is the first reported case of recurrent bilateral pneumothorax due to septic pulmonary emboli and tricuspid valve endocarditis.

Intensive care unit complications and outcomes of adult patients with hemophagocytic lymphohistiocytosis: A retrospective study of 16 cases.

AIM: To study the management, complications and outcomes of adult patients admitted with hemophagocytic lymphohistiocytosis (HLH) in the intensive care unit (ICU). METHODS: We performed a retrospective observational study of adult patients with the diagnosis of "HLH" admitted to the two academic medical ICUs of Baylor College of Medicine between 01/01/2013 to 06/30/2017. HLH was diagnosed using the HLH-2004 criteria proposed by the Histiocyte Society. RESULTS: Sixteen adult cases of HLH were admitted to the medical ICUs over 4 years. Median age of presentation was 49 years and 10 (63%) were males. Median Sequential Organ Failure Assessment (SOFA) score at the time of ICU admission was 10. Median ICU length of stay (LOS) was 11.5 d and median hospital LOS was 29 d. Septic shock and acute respiratory failure accounted for majority of diagnoses necessitating ICU admission. Septic shock was the most common ICU complication seen in (88%) patients, followed by acute kidney injury (81%) and acute respiratory failure requiring mechanical ventilation (75%). Nine patients (56%) developed disseminated intravascular coagulation and eight (50%) had acute liver failure. 10 episodes of clinically significant bleeding were observed. Multi system organ failure was the most common cause of death seen in 12 (75%) patients. The 30 d mortality was 37% (6 cases) and 90 d mortality was 81% (13 cases). There was no difference in mortality based on age (above or less than 50 years), SOFA score on ICU admission (more than or less than 10), immunosuppression, time to diagnose HLH or direct ICU admission versus floor transfer. CONCLUSION: HLH is a devastating disease associated with poor outcomes in ICU. Intensivists need to have a high degree of clinical suspicion for HLH in patients with septic shock/multi system organ failure and progressive bi/pancytopenia who are not responding to standard management in ICU.

"Sacred Pause" in the ICU: Evaluation of a Ritual and Intervention to Lower Distress and Burnout.

BACKGROUND: Increased exposure to deaths in the intensive care unit (ICU) generate grief among ICU staff, which remains unresolved most of the time. Unresolved grief becomes cumulative and presents a risk factor for burnout. "sacred pause" is a ritual performed at patient's death to honor the lost life and recognize the efforts of the health-care team. OBJECTIVE: To study the impact of the ritual of sacred pause on the attitudes and behaviors of the ICU physicians and nurses. METHODS: Ten-question online anonymous survey was sent to ICU physicians and nurses in the medical ICU of a tertiary care hospital in July 2017. RESULTS: Thirty-four ICU team members completed the survey including 12 physicians and 22 nurses. Seventy sacred pause rituals were performed from July 2016 to June 2017. Seventy-nine percent respondents believed that the ritual brought closure and helped them overcome the feelings of disappointment, grief, distress, and failure after the death of their patient in ICU. Seventy-three percent agreed that the ritual has instilled and encouraged a sense of team effort. Eighty-two percent responded that the ritual makes their efforts feel appreciated. Many felt that the ritual should be a universal phenomenon in all ICUs. Only 55% respondents felt that the practice has a potential to decrease ICU burnout, many of them (42%) were undecided. CONCLUSION: Sacred pause brings closure, prevents cumulative grief and distress, builds resilience, promotes team effort, and improves professional satisfaction of ICU team. It may lower burnout syndrome in ICU, but further studies are warranted.

Proteome analysis of bell pepper (Capsicum annuum L.) chromoplasts.

We report a comprehensive proteome analysis of chromoplasts from bell pepper (Capsicum annuum L.). The combination of a novel strategy for database-independent detection of proteins from tandem mass spectrometry (MS/MS) data with standard database searches allowed us to identify 151 proteins with a high level of confidence. These include several well-known plastid proteins but also novel proteins that were not previously reported from other plastid proteome studies. The majority of the identified proteins are active in plastid carbohydrate and amino acid metabolism. Among the most abundant individual proteins are capsanthin/capsorubin synthase and fibrillin, which are involved in the synthesis and storage of carotenoids that accumulate to high levels in chromoplasts. The relative abundances of the identified chromoplast proteins differ remarkably compared with their abundances in other plastid types, suggesting a chromoplast-specific metabolic network. Our results provide an overview of the major metabolic pathways active in chromoplasts and extend existing knowledge about prevalent metabolic activities of different plastid types.