A Case Series of Patients With Complex Airway Disease and Large Thyroid Tumors Anterior to the Trachea Precluding Tracheostomy.

BACKGROUND: This case series explores the management of respiratory failure in patients with large anterior tracheal thyroid tumors where tracheostomy is not an option. To our knowledge, this study is the first to address the challenges associated with caring for such patients. CASE SUMMARY: We present the clinical courses of four intubated adults with advanced thyroid cancer and complex airway issues that preclude surgical tracheostomy. Interventions included custom airway stents, long-term intubation, and oncological therapies. Ethical quandaries around patient autonomy and capacity emerged, exacerbated by the absence of viable exit strategies for prolonged intubation, notably the performance of a tracheostomy, causing emotional distress in patients, families, and staff. CONCLUSIONS: This study showcases the multifaceted challenges in medical, ethical, and emotional domains associated with managing intubated patients with complex disease precluding tracheotomies. We advocate for a nuanced, multidisciplinary, and personalized approach to confront unique issues in airway management, ethical considerations, and disposition.

Elevated brain natriuretic peptide in a patient with metastatic cancer without heart failure: A case study.

ABSTRACT: Brain natriuretic peptide (BNP) is a well-established biomarker for heart failure (HF). However, its diagnostic utility can be limited in patients with comorbidities that independently elevate serum BNP levels, including chronic renal failure and sepsis. We describe a rare occurrence of significantly elevated serum BNP levels in a patient with metastatic urothelial cancer without HF or obvious signs of sepsis. The report highlights the need for considering alternative causes for increased serum BNP levels, especially in the presence of malignancy.

Management of Pericardial Effusion in Patients With Solid Tumor: An Algorithmic, Multidisciplinary Approach Results in Reduced Mortality After Paradoxical Hemodynamic Instability.

OBJECTIVE: This study compared outcomes in patients with solid tumor treated for pericardial effusion with surgical drainage versus interventional radiology (IR) percutaneous drainage and compared incidence of paradoxical hemodynamic instability (PHI) between cohorts. BACKGROUND: Patients with advanced-stage solid malignancies may develop large pericardial effusions requiring intervention. PHI is a fatal and underreported complication that occurs following pericardial effusion drainage. METHODS: Clinical characteristics and outcomes were compared between patients with solid tumors who underwent s urgical drainage or IR percutaneous drainage for pericardial effusion from 2010 to 2020. RESULTS: Among 447 patients, 243 were treated with surgical drainage, of which 27 (11%) developed PHI, compared with 7 of 204 patients (3%) who were treated with IR percutaneous drainage ( P =0.002); overall incidence of PHI decreased during the study period. Rates of reintervention (30-day: 1% vs 4%; 90-day: 4% vs 6%, P =0.7) and mortality (30-day: 21% vs 17%, P =0.3; 90-day: 39% vs 37%, P =0.7) were not different between patients treated with surgical drainage and IR percutaneous drainage. For both interventions, OS was shorter among patients with PHI than among patients without PHI (surgical drainage, median [95% confidence interval] OS, 0.89 mo [0.33-2.1] vs 6.5 mo [5.0-8.9], P <0.001; IR percutaneous drainage, 3.7 mo [0.23-6.8] vs 5.0 mo [4.0-8.1], P =0.044). CONCLUSIONS: With a coordinated multidisciplinary approach focusing on prompt clinical and echocardiographic evaluation, triage with bias toward IR percutaneous drainage than surgical drainage and postintervention intensive care resulted in lower incidence of PHI and improved outcomes.

Point-of-care Ultrasound (POCUS) Program for Critical Care Nurse Practitioners and Physician Assistants in an Oncological Intensive Care Unit and Rapid Response Team.

ABSTRACT: Implementation of a comprehensive point-of-care ultrasound (POCUS) program for nurse practitioners (NPs) and physician assistants (PAs) in an intensive care unit (ICU) setting improves their diagnostic and therapeutic skills and enhances patient care. Overcoming staffing, IT infrastructure, and administrative challenges has allowed our critical care medicine service to develop a successful program that empowers NPs and PAs and boosts their professional growth. Our POCUS program underscores the necessity of institutional support, dedicated mentorship, collaboration with qualified faculty, and creation and maintenance of a curriculum that adheres to accepted national guidelines. Insights gained from our experiences can serve as a valuable resource for institutions aiming to develop their own POCUS programs.

The state of acute care postgraduate training: Faculty observations.

ABSTRACT: The benefits to postgraduate training programs (PTPs) for nurse practitioners (NPs) in all populations are being well established in the literature. As health care systems and teams evolve, acute care NPs (neonatal, pediatric, and adult-gerontology) are providing more specialized care to increasingly complex patients. As educators and clinicians, we recognize that acute care PTPs are playing an important role in preparing NPs to work to the top of their scope and training. This article provides our perspectives on the merits of PTPs for adult-gerontology acute care NPs and provides guidance for counseling NPs who are interested in acute care PTPs.

Intracardiac Thrombus in Transit Detected by Point-of-Care Ultrasound.

Pulmonary embolism (PE) is a condition with a high rate of morbidity and mortality if it is not recognized and treated in a timely fashion. Point-of-care ultrasound (POCUS) is a useful tool that can help clinicians make prompt diagnosis. We present a case where we diagnosed massive PE through visualizing an intracardiac thrombus in transit, and we highlight some important ultrasonographic features.

A Tale of Two Pulmonary Artery Catheters.

Innovative catheter-based therapies are increasingly being used for the treatment of patients with submassive pulmonary embolism. These patients may be monitored in the intensive care unit following insertion of specialized pulmonary artery catheters. However, the infusion catheters utilized in catheter-based therapies differ greatly from traditional pulmonary artery catheters designed for hemodynamic monitoring. As such, the critical care team will have to be familiar with the monitoring and management of these novel catheters. Important distinctions between the catheters are illustrated using a clinical case report.

The fog of war in the battle against COVID-19.

The fog of war is a major obstacle for a fighting force trying to accomplish a goal, and it has been a significant barrier in the fight against COVID-19. This article discusses the factors that compounded a sense of confusion and created chaos in an already stressed healthcare system during the early stages of the COVID-19 pandemic.

Necrotizing fasciitis: A comprehensive review.

Necrotizing soft-tissue infections (NSTIs) are rare but rapidly progressive, life-threatening bacterial infections with high morbidity and mortality. NSTIs include necrotizing forms of fasciitis, myositis, and cellulitis. This article focuses on necrotizing fasciitis (NF) and discusses NF classifications, clinical features, diagnostic approaches, evidence-based treatments, and nursing interventions.

Standardized adult-gerontology acute care nurse practitioner point-of-care ultrasound training: A new perspective in the age of a pandemic.

Our health care landscape is rapidly changing. With the aging population and seemingly increasing outbreak of communicable diseases, it is expected that there will be a continued demand for inpatient/critical care providers. The current COVID-19 pandemic provides a glimpse of a health care system in severe provider shortage. Adult-gerontology acute nurse practitioners (GACNPs) can play a vital part in relieving that shortage. But with the increased role, there is an increased responsibility and need for expansion of AGACNP skill set. This includes the training and utilization of point-of-care ultrasound (POCUS). The case reports and data available from countries that have already combated COVID-19 outbreak show POCUS can play a key part in managing critically ill patients on isolation precautions. This article provides my perspective on POCUS training and competency achievement for AGACNPPs.

Necrotizing fasciitis associated with malignancy.

Necrotizing fasciitis (NF) is a rare soft-tissue condition with a high mortality rate even with treatment. Diagnosis is challenging due to an absence of specific symptoms at the early stages of clinical presentation. NF is typically associated with traumatic injuries, superficial skin breakdown, and surgical procedures. Diabetes mellitus and immunosuppression also increase the risk of developing NF. NF predominantly occurs in the lower extremities, the peritoneum, and the perineum. Treatments include antimicrobials, supportive care, and surgical source control. It is important for clinicians to recognize the association of spontaneous atraumatic NF caused by Clostridium septicum with malignancy, so they can maintain a high index of suspicion and provide timely interventions to optimize patient outcomes.

An Uncommon Cause of Chest Pain: Hypertriglyceridemia-Induced Pancreatitis.

Chest pain is a common and high-risk chief complaint in the emergency department. There is an array of cardiac and non-cardiac-related conditions that could lead to this symptom. It is important for the clinician to have a broad perspective when treating patients complaining of chest pain so that dangerous and potentially life-threatening conditions are not overlooked. Here, we present one such cause of chest pain that can be detrimental if the clinician fails to correctly identify the underlying condition. A brief review of hypertriglyceridemia-induced acute pancreatitis is provided, and challenges faced by the treatment team are discussed.