Successful Outcome of Inhalation Injury, Active SARS-CoV-2 Infection, and Concomitant Pneumonia in a Patient With 27% Full-Thickness Burn: A Case Report.

Burn injuries are a major cause of morbidity and mortality. Next to the inhalation injury, TBSA and age are strong predictors of mortality in burn victims. The novel coronavirus disease 2019 (COVID-19) pandemic is associated with a fatality rate of around 3.5%. We present a case of burn victim with full-thickness burn to face, scalp, both upper extremities (27% of TBSA), inhalation injury, and active severe acute respiratory syndrome coronavirus 2 infection with concomitant pneumonia. The inhalation injury in COVID-19 positive patient was severe. A bronchoscopy revealed a diffuse erythema of the trachea and both main bronchi, the whole bronchial tree up to the distal segments was covered with carbonaceous material which could not be removed. We decided to treat the inhalation injury according to the guidelines for burns and acute respiratory distress syndrome. Accordingly, the patient did not receive any antiviral drugs or corticosteroids. The reconstruction of a full-thickness scalp defect after burn presents a challenge in large size defects and in patients with comorbidities. Double layer Integra Dermal Regeneration Template (Integra LifeSciences, Plainsboro, New Jersey) was the reconstruction method of choice. The take of dermal template and split-thickness skin graft was 100% and good scalp contour was achieved. To our knowledge this is the first case report presenting a successful treatment outcome in a burn victim with inhalation injury, active severe acute respiratory syndrome coronavirus 2 infection, and concomitant pneumonia with full-thickness burn of 27% of TBSA.

Ventriculolumbar perfusion and inhalational anesthesia with sevoflurane in an accidental intrathecal injection of tranexamic acid: unreported treatment options.

BACKGROUND: Tranexamic acid (TXA) decreases hemorrhage-related mortality in trauma patients and is increasingly being used during obstetric and orthopedic surgeries. Inadvertent intrathecal injection of TXA is a rare, potentially lethal event leading to dose-dependent cardiotoxicity and neurotoxicity. TXA enhances neuronal excitation by antagonizing inhibitory γ-aminobutyric acid type A and glycine receptors. Until now, mechanistic-based pharmacological treatments targeting multiple central nervous system receptors have been advocated for use in such cases, with no data on intrathecal TXA elimination techniques. CASE PRESENTATION: A patient scheduled for hip surgery accidentally received 350 mg of intrathecal TXA instead of levobupivacaine. The clinical picture progressed from spinal segmental myoclonus to generalized convulsions and malignant arrhythmias. The treatment consisted of ventriculolumbar perfusion with normal saline at a rate of 50 mL/hour starting 5 hours after TXA administration and inhalational sedation with sevoflurane, in addition to drugs acting on multiple receptors at different central nervous system levels. Over 2 months the neurological status improved, although it was not complete. CONCLUSIONS: For the first time, the feasibility and possible clinical efficacy of combined treatment with ventriculolumbar perfusion and inhalational sedation with sevoflurane were demonstrated. A referral to a neurosurgical facility is recommended in patients with acute TXA-induced neurotoxicity and cardiotoxicity.

Transarterial embolization of the external carotid artery in the treatment of life-threatening haemorrhage following blunt maxillofacial trauma.

Background Severe bleeding after blunt maxillofacial trauma is a rare but life-threatening event. Non-responders to conventional treatment options with surgically inaccessible bleeding points can be treated by transarterial embolization (TAE) of the external carotid artery (ECA) or its branches. Case series on such embolizations are small; considering the relatively high incidence of maxillofacial trauma, the ECA TAE procedure has been hypothesized either underused or underreported. In addition, the literature on the ECA TAE using novel non-adhesive liquid embolization agents is remarkably scarce. Patients and methods PubMed review was performed to identify the ECA TAE literature in the context of blunt maxillofacial trauma. If available, the location of the ECA injury, the location of embolization, the chosen embolization agent, and efficacy and safety of the TAE were noted for each case. Survival prognostic factors were also reviewed. Additionally, we present an illustrative TAE case using a precipitating hydrophobic injectable liquid (PHIL) to safely and effectively control a massive bleeding originating bilaterally in the ECA territories. Results and conclusions Based on a review of 205 cases, the efficacy of TAE was 79.4-100%, while the rate of major complications was about 2-4%. Successful TAE haemostasis, Glasgow Coma Scale score ≥ 8 at presentation, injury severity score ≤ 32, shock index ≤ 1.1 before TAE and ≤ 0.8 after TAE were significantly correlated with higher survival rate. PHIL allowed for fast yet punctilious application, thus saving invaluable time in life-threatening situations while simultaneously diminishing the possibility of inadvertent injection into the ECA-internal carotid artery (ICA) anastomoses.

Optic nerve ultrasound for fluid status assessment in patients with severe preeclampsia.

Background There are no data on usefulness of optic nerve sheath diameter (ONSD) as a marker of patient's fluid status in preeclampsia. The objective was to examine potential correlation between ONSD and lung ultrasound estimates of extravascular lung water in severe preeclampsia. Patients and methods Thirty patients with severe preeclampsia were included. Optic and lung ultrasound were performed within 24 hours from delivery. ONSD was measured 3 mm behind the globe. Lung ultrasound Echo Comet Score (ECS) was obtained summing B-lines ("comet tails") in parasternal intercostal spaces bilaterally. Pearson's correlation analysis was used to assess the relationship between ONSD and ECS (p < 0.05 significant). Results Median ONSD was 5.7 mm (range 3.8-7.5 mm). Median ECS value was 19 (range 0-24). Statistically significant correlation was found between ONSD and ECS (r2 = 0.464; p < 0.001). Conclusions Significant correlation between ONSD and ECS suggests optic ultrasound could be used for assessing fluid status and guiding peripartum fluid therapy in patients with severe preeclampsia.

Effect of pre-gravid body mass index on outcomes of pregnancies following in vitro fertilization.

PURPOSE: To examine the effect of pre-gravid body mass index (BMI) on perinatal outcomes in in vitro fertilization (IVF) singleton pregnancies. METHODS: Retrospective population-based cohort study. All singleton pregnancies delivered at ≥ 22 weeks' in Slovenia between 2002 and 2015 were included. Logistic regression analysis was used to examine the relationship between BMI category and outcomes, controlling for potential confounding variables. Interaction term was included to evaluate whether effects of obesity on perinatal outcomes differ in IVF vs. non-IVF pregnancies. We counted the frequencies of hypertensive disorders of pregnancy, gestational diabetes, cesarean delivery, preterm births, and small as well as large for gestational age neonates, neonatal respiratory distress syndrome, neonatal intraventricular hemorrhage, and perinatal deaths. RESULTS: Pre-gravid overweight and obesity were associated with higher rates of hypertensive disorders, gestational diabetes, and cesarean deliveries in both IVF and non-IVF pregnancies. Pre-gravid underweight was associated with small for gestational age neonates in IVF and non-IVF pregnancies. There was a significantly lower effect of pre-gravid obesity on the incidence of hypertensive disorders (odds ratio (OR) 0.7; 95% confidence interval (CI) 0.5-0.9) and cesarean delivery (OR 0.8; 95% CI 0.7-0.99) in IVF vs. non-IVF pregnancies. The effect of pre-gravid obesity on neonatal mortality was significantly greater in IVF compared to non-IVF pregnancies (OR 4.6; 95% CI 1.4-15.8). CONCLUSIONS: Pre-gravid BMI has an important effect on perinatal outcomes in pregnancies following IVF.

Prophylactic versus clinically-driven antibiotics in comatose survivors of out-of-hospital cardiac arrest-A randomized pilot study.

AIM: To investigate benefits of prophylactic antibiotics in comatose survivors of out-of-hospital cardiac arrest (OHCA). METHODS: Patients without evidence of tracheobronchial aspiration on admission bronchoscopy were randomized to prophylactic Amoxicillin-Clavulanic acid 1.2g every 8h (P) or clinically-driven antibiotics (C) administered if signs of infection developed during initial 7days of intensive care unit (ICU) stay. RESULTS: Among 83 patients enrolled between September 2013 and February 2015, tracheobronchial aspiration was documented in 23 (28%). Accordingly, 60 patients were randomized. Percentage of patients on antibiotics between days 1-5 was significantly greater in P group. White blood count, C-reactive protein, procalcitonin (PCT) and CD 64 significantly increased during the postresuscitation phase. Except for lower CRP and PCT in group P on day 6 (p<0.05), there was no significant differences. Mini BAL on day 3 was less often positive in group P (7% vs. 42%; p<0.01). There was no significant difference in other microbiological samples and X-ray signs of pneumonia cumulatively documented in 50% in both groups. Use of vasopressors/inotropes (93% in both groups), duration of mechanical ventilation (5.4±3.7 vs. 5.2±3.1 days), tracheal intubation (6.5±4.6 vs. 5.9±4.3 days), ICU stay (7.7±5.2 vs. 6.9±4.5 days), survival (73% vs. 73%) and survival with good neurological outcome (50% vs. 40%) were also comparable between P and C groups. CONCLUSION: Bronchoscopy on admission documented tracheobronchial aspiration in 28% of comatose survivors of OHCA. In the absence of aspiration, prophylactic antibiotics did not significantly alter systemic inflammatory response, postresuscitation pneumonia, ICU treatment and outcome (ClinicalTrials.gov Identifier: NCT02899507).

Repetitive magnetic stimulation of the phrenic nerves for diaphragm conditioning: a normative study of feasibility and optimal settings.

Electrical stimulation can enhance muscle function. We applied repetitive cervical magnetic phrenic stimulation (rCMS) to induce diaphragm contractions in 7 healthy subjects (800 ms trains; transdiaphragmatic pressure (Pdi) measurements; tolerance ratings). Each rCMS train produced a sustained diaphragm contraction. Sixty-five percent of the maximal available output at 15 Hz proved the best compromise between Pdi and discomfort with nonfatiguing contractions. rCMS appears feasible and should be investigated for diaphragm conditioning in appropriate clinical populations.

Tracheal pressure regulated volume assist ventilation in acute respiratory failure.

PURPOSE: Proportional assist ventilation (PAV) uses volume assist (VAV) and flow assist ventilation (FAV) to reduce elastic and resistive effort, respectively. Proportional assist ventilation may be difficult to apply clinically, particularly due to FAV related considerations. It was hypothesized that regulating tracheal (Ptr) rather than airway opening pressure (Pao), to overcome endotracheal tube related resistive effort, during VAV would provide an effective alternative method of ventilation. We therefore compared the effects of Pao and Ptr regulated VAV on breathing pattern and inspiratory effort. METHODS: In seven intubated patients, flow, volume, Pao, Ptr, esophageal and transdiaphragmatic pressure were measured during VAV (0-80% respiratory system elastance) using Pao vs Ptr to regulate ventilator applied pressure. Breathing pattern and the pressure-time integral of the inspiratory muscles (integralP(mus) . dt) and diaphragm (integralP(di) . dt) were determined. RESULTS: Compared to spontaneous breathing, the respiratory rate to tidal volume ratio, or rapid shallow breathing index (RSBI), improved progressively with increasing VAV (130 +/- 64 vs 70 +/- 35, VAV 0 vs 80%; P < 0.05) while inspiratory effort fell (integralP(mus) . dt = 39.6 +/- 7.5 vs 28.5 +/- 7.2 cm H(2)O.sec.L(-1), integralP(di) . dt, = 35.4 +/- 7.8 vs 24.2 +/- 5.9 cm H(2)O.sec.L(-1), VAV 0 vs 80%; P < 0.05) due to a decrease in elastic related effort. At any given level of support, there was further reduction in RSBI, integralP(mus) . dt, and integralP(di) . dt (which averaged 23.6 +/- 2.7, 33.7 +/- 4.4, and 38.5 +/- 5.1%, respectively; P < 0.05) for Ptr compared to Pao regulated VAV due to a decrease in resistive effort. CONCLUSIONS: Tracheal pressure regulated VAV can be a simple and effective method of partial ventilatory support in acute respiratory failure. Further work will be needed to determine its efficacy and potential benefit relative to PAV and other modes of ventilation in routine clinical practice.

Minimally invasive aortic valve replacement under thoracic epidural anesthesia in a conscious patient: case report.

Cardiopulmonary bypass and full median sternotomy have been recognized as major morbidity factors in cardiac surgery. Additional morbidity factors are general anesthesia and endotracheal intubation. Over the past several years high-thoracic epidural anesthesia (hTEA) has emerged as a potentially beneficial supplement to general anesthesia in the care of patients undergoing cardiac surgery. We report a case of ministernotomy aortic valve replacement performed with hTEA. The procedure was not converted to general anesthesia or to a conventional operation and was performed without adverse incidents. The patient was discharged from the hospital on the 2nd postoperative day. There were no complications within 30 days after surgery. This case demonstrates that thoracic epidural anesthesia without endotracheal intubation used for aortic valve replacement performed through ministernotomy is feasible. Further experience is necessary to determine the safety of this method and the effect on outcome.

Acute effects of hyperoxia on dyspnea in hypoxemia patients with chronic airway obstruction at rest.

STUDY OBJECTIVES: Supplemental oxygen is used in hypoxemic patients with chronic airways obstruction (CAO) because it reduces pulmonary artery pressure and prolongs life. The purpose of this study was to assess at rest the effects of 30% oxygen inhalation on dyspnea, breathing pattern, neuromuscular inspiratory drive based on measurement of mouth occlusion pressure (P(0.1)), and dynamic hyperinflation (DH), as reflected by changes in inspiratory capacity (IC). METHODS: Ten patients with stable CAO receiving long-term oxygen were studied at rest, before and after 5, 15, and 25 min of oxygen administration. Severity of dyspnea was rated using the visual analog scale (VAS). Breathing pattern parameters, P(0.1), IC, and tidal expiratory flow limitation (EFL), were measured sequentially. RESULTS: Eight patients exhibited EFL under baseline condition. During 30% oxygen breathing, the VAS score significantly decreased, associated with a concurrent increase of IC (11%). There was also a significant reduction of minute ventilation and tidal volume (11% and 12%, respectively), which was due to a significant decrease of mean inspiratory flow. Although not significantly, P(0.1) decreased by 13%. Finally, two patients reverted from EFL to no EFL. CONCLUSION: Patients with CAO receiving long-term oxygen may benefit from hyperoxic breathing at rest, since it decreases the ventilation and the degree of DH, with concurrent improvement of dyspnea sensation.

Minilaparotomy for aortoiliac occlusive disease: preliminary results.

This prospective study was designed to establish the feasibility of minilaparotomy for aortobifemoral bypass, and its effect on intraoperative and postoperative variables. A minilaparotomy has potential benefits for the patient, including smaller size of the surgical wound, reduced risk of infection, shorter postoperative intubation, decreased postoperative pain, earlier discharge, and a smaller, aesthetically more acceptable postoperative scar. Moreover, reoperation is less hazardous, because the peritoneum is not completely dissected. From the beginning of June 1999 through the end of September 2001, we used a minilaparotomy in 33 patients with aortoiliac occlusive disease. Obesity and prior abdominal surgery were regarded as contraindications to the operation. One patient required conversion to a full laparotomy because of intraoperative bleeding. Another patient developed wound infection. There were no deaths. The technique has proved safe, effective, and aesthetically acceptable to the patient. To date, no study has compared a median laparotomy with a minimally invasive alternative for the surgical treatment of aortoiliac occlusive disease. Prospective randomized trials are needed to determine whether minilaparotomy is the superior technique for treatment of aorto-occlusive disease.