MRI findings at neurological onset predict neurological prognosis in hemorrhagic shock and encephalopathy syndrome.

BACKGROUND: Hemorrhagic shock and encephalopathy syndrome (HSES) is a devastating disease and has an uncertain pathogenesis. The aim of this study was to predict neurological outcomes for HSES using magnetic resonance imaging (MRI) findings at neurological onset and elucidate the pathophysiology of HSES in the acute phase from serial MRI changes. MATERIALS AND METHODS: We analyzed the MRI findings of 13 patients who underwent an initial MRI within 24 h of neurological onset. According to neurological prognosis, seven patients were included in the severe group and six in the non-severe group. All patients in the non-severe group had a follow-up MRI. We divided the whole brain into 14 regions and each region was scored according to diffusion-weighted imaging findings. We compared the total scores of each region between the two groups and between onset and follow-up MRI. RESULTS: At neurological onset, symmetrical lesions were found predominantly in the frontal, parietal, and occipital lobes in 12 of 13 patients (92%). In the severe group, the total score for onset MRI was significantly higher than those in the non-severe group (p = 0.003). The total score was significantly higher for follow-up than those of onset MRI (p = 0.036). White matter lesions that showed a bright tree appearance were observed in the follow-up MRIs of all patients. CONCLUSION: Total scores for onset MRIs are useful for predicting neurological prognosis in patients with HSES. In addition to widespread cortical involvement of predominantly watershed areas, white matter lesions may play a role in the progression of brain edema.

Intrathecal dexamethasone therapy for febrile infection-related epilepsy syndrome.

OBJECTIVE: Increasing reports suggest a role for immunological mechanisms in febrile infection-related epilepsy syndrome (FIRES). The objective of this study was to elucidate the efficacy and safety of intrathecal dexamethasone therapy (IT-DEX). METHODS: We assessed six pediatric patients with FIRES who were administered add-on IT-DEX in the acute (n = 5) and chronic (n = 1) phases. We evaluated clinical courses and prognosis. We measured cytokines/chemokines in cerebrospinal fluid (CSF) from FIRES patients at several points, including pre- and post-IT-DEX, and compared them with control patients with chronic epilepsy (n = 12, for cytokines/chemokines) or with noninflammatory neurological disease (NIND, n = 13, for neopterin). RESULTS: Anesthesia was weaned after a median of 5.5 days from IT-DEX initiation (n = 6). There was a positive correlation between the duration from the disease onset to the introduction of IT-DEX and the length of ICU stay and the duration of mechanical ventilation. No patient experienced severe adverse events. Seizure spreading and background activities on electroencephalography were improved after IT-DEX in all patients. The levels of CXCL10, CXCL9, IFN-γ, and neopterin at pre-IT-DEX were significantly elevated compared to levels in epilepsy controls, and CXCL10 and neopterin were significantly decreased post-IT-DEX, but were still higher compared to patients with chronic epilepsy. IL-6, IL-8, and IL-1ß were significantly elevated before IT-DEX compared to epilepsy controls, though there was no significant decrease post-treatment. INTERPRETATION: IT-DEX represents a therapeutic option for patients with FIRES that could shorten the duration of the critical stage of the disease. The effect of IT-DEX on FIRES might include cytokine-independent mechanisms.

Heatstroke-like symptoms in a patient with coronavirus disease pneumonia.

While there are no clear indications for body temperature control during viral infections such as COVID-19, if heat stress caused by COVID-19 leads to organ failure, then proactive body temperature regulation may be an effective treatment option.

Association Between Post-procedure Intracardiac Pressures and the Use of Temporary Epicardial Pacing Wires After Pediatric Cardiac Surgery.

The indications for using temporary epicardial pacing wires after pediatric cardiac surgery remain unclear. Post-procedure intracardiac pressure is valuable for detecting circulatory disturbances and residual lesions. This study aimed to examine the association between post-procedure intracardiac pressures and the use of temporary epicardial pacing wires. We performed a retrospective, case-control study at the pediatric intensive care unit of an urban regional tertiary hospital that included patients who had undergone congenital heart surgery between January 2015 and December 2016. We measured post-procedure intracardiac pressures, and data regarding baseline characteristics, procedures performed, and intraoperative variables were collected as covariates. Of the 186 included patients, 34 (18.3%) were treated using temporary epicardial pacing wires. The optimal cutoff values used to predict the use of pacing wires for central venous pressure, left atrial pressure, pulmonary arterial pressure/systemic blood pressure ratio, and right ventricular pressure/left ventricular pressure ratio were 11 mmHg (55.6% sensitivity, 86.2% specificity), 13 mmHg (50% sensitivity, 84.6% specificity), 0.39 (69.6% sensitivity, 78.7% specificity), and 0.51 (74.1% sensitivity, 64.2% specificity), respectively. Multivariable logistic regression analyses showed that the use of temporary epicardial pacing wires was significantly associated with left atrial pressure ≥ 11 mmHg (odds ratio 4.4; 95% confidence interval 1.01-18.9), and a pulmonary arterial pressure/systemic blood pressure ratio ≥ 0.39 (odds ratio 6.3; 95% confidence interval 1.3-31.4). High post-procedure intracardiac pressures were associated with the use of temporary epicardial pacing wires. These data can aid in the decision-making for the proper use of temporary epicardial pacing wires.

Cardiac arrest caused by rapidly increasing ascites in a patient with TAFRO syndrome: a case report.

Case: Thrombocytopenia, anasarca, fever, renal insufficiency, and organomegaly (TAFRO) syndrome is a newly defined systemic inflammatory disorder with gradual progression of symptoms. A 59-year-old man with fever and ascites of unknown cause developed sudden-onset shock and respiratory failure in the general ward. Cardiac arrest immediately followed. Although he was resuscitated, frequent administration of adrenaline was required to maintain his blood pressure. His circulation was most effectively stabilized by drainage of fluid from his distended abdomen. The volume of discharged ascites reached 4,000 mL at that time, and several liters continued to be discharged for >1 month. The diagnosis of TAFRO syndrome was based on the clinical features and laboratory and histological findings. Outcome: The ascites volume and concentrations of inflammatory parameters decreased with treatment using several immunosuppressive agents. Conclusion: The newly defined TAFRO syndrome may be life-threatening. Patients should be monitored for progression to shock and cardiac arrest, especially those with rapidly increasing ascites.

Impact of mobilisation therapy on the haemodynamic and respiratory status of elderly intubated patients in an intensive care unit: A retrospective analysis.

OBJECTIVES: This study identified respiratory and haemodynamic parameters affected by limited mobilisation therapy in elderly, critically ill, intubated patients in an intensive care unit. METHODS: Over 18 months, we retrospectively assessed physiological changes during 43 mobilisation therapy sessions in 23 patients requiring mechanical ventilation for >48h. We compared heart rate, mean arterial blood pressure, respiratory rate, partial pressure of oxygen in arterial blood/inspired fraction of oxygen and lactate before and after mobilisation therapy, which entailed sitting on the edge of a hospital bed without back support. We analysed baseline characteristics and therapy duration. RESULTS: Patients' median age was 75 (interquartile range: 65-79) years, and the median Acute Physiology and Chronic Health Evaluation II score was 27 (26-31). Average therapy duration was 1h (0.5-2h). Therapy did not significantly modify heart rate or arterial blood pressure but increased the partial pressure of oxygen in arterial blood/inspired fraction of oxygen ratio significantly, from 218.8 (135.4-271.7) to 237.3 (167.2-284.9; p=0.007), indicating improved lung function. CONCLUSION: In this retrospective review, mobilisation therapy had no adverse effect on elderly, critically ill, intubated patients' haemodynamic status and appeared to improve the PaO2/FIO2 ratio; further research is required to confirm this finding.

Dexmedetomidine sedation for pediatric post-Fontan procedure patients.

OBJECTIVE: The hemodynamic, respiratory, and sedative effects of dexmedetomidine (DEX) for pediatric patients post-Fontan surgery. DESIGN: Retrospective. SETTING: Single institutional intensive care unit. PARTICIPANTS: Fourteen patients undergoing Fontan-type surgery. RESULT: A retrospective review was conducted on 14 pediatric patients who had undergone a Fontan procedure for congenital heart disease. A vital component of postoperative management of these patients is to prevent an increase in pulmonary vascular resistance (PVR) that may lead to a serious reduction in cardiac output. DEX an alpha-2 adrenergic receptor agonist might offer an advantage over current sedation methods in preventing a rise in PVR. Nine patients received sedation with DEX and five patients in a control group were administered standard regimens of sedation and analgesia. The DEX group exhibited no evidence of an increased partial pressure of arterial carbon dioxide postoperatively as opposed to the control group. This lack of respiratory depression made the DEX group less likely to increase their PVR. However, the DEX group did experience a significant incidence of bradycardia that required the use of a cardiac pacemaker. CONCLUSIONS: The results of this retrospective review of the role of DEX in the management of the post-Fontan surgical pediatric patient indicate some potential advantages.