Cumulative oxygen deficit is a novel predictor for the timing of invasive mechanical ventilation in COVID-19 patients with respiratory distress.

BACKGROUND AND OBJECTIVES: The timing of invasive mechanical ventilation (IMV) is controversial in COVID-19 patients with acute respiratory hypoxemia. The study aimed to develop a novel predictor called cumulative oxygen deficit (COD) for the risk stratification. METHODS: The study was conducted in four designated hospitals for treating COVID-19 patients in Jingmen, Wuhan, from January to March 2020. COD was defined to account for both the magnitude and duration of hypoxemia. A higher value of COD indicated more oxygen deficit. The predictive performance of COD was calculated in multivariable Cox regression models. RESULTS: A number of 111 patients including 80 in the non-IMV group and 31 in the IMV group were included. Patients with IMV had substantially lower PaO2 (62 (49, 89) vs. 90.5 (68, 125.25) mmHg; p < 0.001), and higher COD (-6.87 (-29.36, 52.38) vs. -231.68 (-1040.78, 119.83) mmHg·day) than patients without IMV. As compared to patients with COD < 0, patients with COD > 30 mmHg·day had higher risk of fatality (HR: 3.79, 95% CI [2.57-16.93]; p = 0.037), and those with COD > 50 mmHg·day were 10 times more likely to die (HR: 10.45, 95% CI [1.28-85.37]; p = 0.029). CONCLUSIONS: The study developed a novel predictor COD which considered both magnitude and duration of hypoxemia, to assist risk stratification of COVID-19 patients with acute respiratory distress.

Shp2 positively regulates cigarette smoke-induced epithelial mesenchymal transition by mediating MMP-9 production.

Cigarette smoke (CS) is a major risk factor for the development of lung cancer and chronic obstructive pulmonary disease (COPD). Epithelial-mesenchymal transition (EMT) commonly coexists in lung cancer and COPD. CS triggers many factors including matrix metalloproteinases (MMPs) production, contributing to EMT progression in the lungs. Here, how Shp2 signaling regulates the CS-induced MMP-9 production and EMT progression were investigated in mouse lungs and in pulmonary epithelial cell cultures (NCI-H292) found CS induced MMP-9 production, EMT progression (increased vimentin and α-SMA; decreased E-cadherin) and collagen deposition in lung tissues; cigarette smoke extract (CSE) induced MMP-9 production and EMT-related phenotypes in NCI-H292 cells, which were partially prevented by Shp2 KO/KD or Shp2 inhibition. The CSE exposure induced EMT phenotypes were suppressed by MMP-9 inhibition. Recombinant MMP-9 induced EMT, which was prevented by MMP-9 inhibition or Shp2 KD/inhibition. Mechanistically, CS and CSE exposure resulted in ERK1/2, JNK and Smad2/3 phosphorylation, which were suppressed by Shp2 KO/KD/inhibition. Consequentially, the CSE exposure-induced MMP-9 production and EMT progression were suppressed by ERK1/2, JNK and Smad2/3 inhibitors. Thus, CS induced MMP-9 production and EMT resulted from activation of Shp2/ERK1/2/JNK/Smad2/3 signaling pathways. Our study contributes to the underlying mechanisms of pulmonary epithelial structural changes in response to CS, which may provide novel therapeutic solutions for treating associated diseases, such as COPD and lung cancer.

A rapid response team is associated with reduced overall hospital mortality in a Chinese tertiary hospital: a 9-year cohort study.

BACKGROUND: Although the evidence for its effectiveness remains uncertainty, rapid response systems are implemented across many hospitals across the world. Increasingly, hospitals in China have recently started to adopt a medical emergency or rapid response team (RRT). Hence, we aimed to determine whether the implementation of an RRT in Chinese hospitals also improved outcomes. METHODS: Our hospital is a Joint Commission International (JCI) accredited, tertiary teaching hospital with 1,200 beds. We conducted a retrospective cohort study comparing 60 months after the implementation of the RRT (January 1, 2013, to December 31, 2017) and 36 months before implementation (January 1, 2009, to December 31, 2011). The outcomes included the overall hospital mortality and incidence of codes. RESULTS: We analyzed 144,673 non-obstetric hospital admissions and 1,269,621 patient days in the control period and 348,687 non-obstetric hospital admissions and 2,361,913 patient days after the RRT implementation. The RRT was activated 834 times (2.39 calls per 1,000 patients and 0.35 call per 1,000 patient-days). There was no difference in the code rate (0.23 vs. 0.17 per 1,000 patient days, P=0.379) between the two periods. Although the hospital mortality had remained stable around 3.0 per 1,000 patients from 2009 to 2011, there was a significant 40% decrease of overall hospital mortality from 2.95 to 1.77 per 1,000 non-obstetric patients after the implementation of RRT (P=0.001), and the annual mortality showed a consistent decrease (P=0.037 for the trend). Moreover, the increase of RRT activations was significantly correlated with the decrease of hospital mortality (P=0.025). CONCLUSIONS: RRT implementation was associated with reduced overall hospital mortality in a Chinese tertiary hospital.

Factors associated with outcomes of septic shock patients receiving high dose noradrenaline according to three primary infection sites.

OBJECTIVE: To identify factors associated with outcome of septic shock patients receiving high dose noradrenaline according to three primary infection sites. METHODS: This retrospective study was based on data from a publicly available ICU database (Medical Information Mart for Intensive Care [MIMIC] III. Septic shock patients receiving high dose (≥1 µg/kg per min) noradrenaline and ≥18 years were identified and their characteristics and outcomes were compared according to three primary infection sites (abdominal, respiratory and urinary tract). RESULTS: 154 septic shock patients who received high doses of noradrenaline were identified; (89 [58%] had a respiratory infection, 41 [27%] an abdominal infection and 24 [16%] a urinary infection). There were no differences among the three infection groups in duration/maximum dosage of noradrenaline, length of stay in the ICU/hospital, do not resuscitate (DNR) rates, hypertension and adequate antimicrobial therapy. Patients with urinary infections had a lower risk of death at 28-days compared with those with abdominal or respiratory infections. CONCLUSIONS: The prognosis for septic shock patients receiving high dose noradrenaline is poor. Patients with abdominal or respiratory infections are at higher risk of death compared with those with urinary infections.

Utilization of echocardiography during septic shock was associated with a decreased 28-day mortality: a propensity score-matched analysis of the MIMIC-III database.

BACKGROUND: Hemodynamic management is of paramount importance in patients with septic shock. Echocardiography has been increasingly used in assessing volume status and cardiac function. However, whether the utilization of echocardiography has an impact on prognosis is unknown. Thus, we intended to explore its effect on the outcomes of patients with septic shock. METHODS: The study was based on the Medical Information Mart for Intensive Care (MIMIC) III database. Septic shock patients were divided into two groups according to the usage of echocardiography during the onset of septic shock. The primary outcome was 28-day mortality. Secondary outcomes included the usage of inotropes, ventilation-free and norepinephrine-free time, and fluids input. Propensity-score matching was used to reduce the imbalance. RESULTS: Among 3,291 eligible patients, 1,289 patients who underwent echocardiography (Echo), and 1,289 who did not receive the Echo, had similar propensity scores and were included in the analyses. After matching, the Echo group had a significantly lower 28-day mortality (33.2% vs. 37.7%, P=0.019). More patients in the Echo group received pulmonary artery catheter (PAC) (4.2% vs. 0.2%, P<0.001) and inotropes (17.8% vs. 7.1%, P<0.001). In the survival analysis, Echo utilization was associated with improved 28-day mortality [hazard ratio (HR): 0.83; 95% confidence interval (CI), 0.73-0.95, P=0.005]. A reduced likelihood of 28-day mortality in patients with Echo vs. those without Echo was maintained either when excluding patients receiving multiple echocardiography scans (HR, 0.82; 95% CI, 0.72-0.94; P=0.004) or when excluding patients undergoing PAC or pulse index continuous cardiac output (PiCCO) (HR, 0.87; 95% CI, 0.76-0.99; P=0.034). CONCLUSIONS: Utilization of echocardiography was associated with improved 28-day outcomes in patients with septic shock.

High 28-day mortality in critically ill patients with sepsis and concomitant active cancer.

OBJECTIVE: This study was performed to explore the characteristics and outcomes of patients with sepsis accompanied by active cancer who were admitted to the intensive care unit (ICU). METHODS: The baseline characteristics, infection profiles, and outcomes of patients with sepsis were retrospectively analyzed according to the presence of concomitant active cancer. The association between concomitant active cancer and 28-day mortality was explored. RESULTS: Of 23,956 patients with sepsis, 1574 (6.6%) had concomitant active cancer. The most common type was digestive (30.7%). The 28-day mortality ranged from 41.9% to 81.5%. Patients with active cancer had a significantly higher Simplified Acute Physiology Score II and significantly shorter length of ICU stay. Respiratory (32.9%), genitourinary (31.0%), and bloodstream (17.0%) infections were most common. Escherichia coli was the most frequent gram-negative pathogenic bacteria. The 28-day mortality rate was significantly higher in patients with than without active cancer. Concomitant active cancer was associated with increased 28-day mortality in patients with sepsis. Hematological malignancy was associated with a significantly higher risk of death than solid tumors. CONCLUSIONS: Concomitant active cancer was associated with higher 28-day mortality in patients with sepsis requiring ICU admission. Hematological malignancy was associated with a higher risk of death than solid tumors.

High Serum Iron level is Associated with Increased Mortality in Patients with Sepsis.

Iron is an essential nutrient for bacterial survival and thus higher iron levels may precipitate bacterial infections. We investigated the association between the serum iron level and prognosis in patients with sepsis by using the single-centre Medical Information Mart for Intensive Care III (MIMIC-III) database. Sepsis patients with iron parameters measured on ICU admission were included and stratified according to quartiles of serum iron levels. A total of 1,891 patients diagnosed with sepsis according to the Sepsis-3 criteria were included in this study, 324 of whom were septic shock. After adjusting for confounding variables, higher iron quartile was associated with an increase in 90-day mortality in the Cox regression analysis. Moreover, a stepwise increase in the risk of 90-day mortality was observed as the quartiles of serum iron levels increased in the patients with sepsis. In conclusion, higher serum iron levels were independently associated with increased 90-day mortality in this large cohort of patients with sepsis.

Comparison of the predictive value of scoring systems on the prognosis of cirrhotic patients with suspected infection.

Cirrhotic patients with infection are prone to develop sepsis or even septic shock rendering poorer prognosis. However, few methods are available to predict the prognosis of cirrhotic patients with infection although there are some scoring systems can be used to predict general patients with cirrhosis. Therefore, we aimed to explore the predictive value of scoring systems in determining the outcome of critically ill cirrhotic patients with suspected infection.This was a retrospective cohort study based on a single-center database. The prognostic accuracy of the systemic inflammatory response syndrome (SIRS) criteria, quick Sequential Organ Failure Assessment (qSOFA), chronic liver failure (CLIF)-SOFA, quick CLIF-SOFA (qCLIF-SOFA), CLIF-consortium organ failure (CLIF-C OF), Model for End-Stage Liver Disease (MELD), and Simplified Acute Physiology Score (SAPS) II were compared by using area under the receiver operating characteristic (AUROC) curve and net benefit with decision curve analysis. The primary endpoint was in-hospital mortality while the secondary endpoints were duration of hospital and intensive care unit (ICU) stay and ICU mortality.A total of 1438 cirrhotic patients with suspected infection were included in the study. Nearly half the patients (50.2%) were admitted to the ICU due to hepatic encephalopathy and the overall in-hospital mortality was 32.0%. Hospital and ICU mortality increased as the score of each scoring system increased (P < .05 for all trends). The AUROC of CLIF-SOFA (AUROC, 0.742; 95% confidence interval, CI, 0.714-0.770), CLIF-C OF (AUROC, 0.741; 95% CI, 0.713-0.769), and SAPS II (AUROC, 0.759; 95% CI, 0.733-0.786) were significantly higher than SIRS criteria (AUROC, 0.618; 95% CI, 0.590-0.647), qSOFA (AUROC, 0.612; 95% CI, 0.584-0.640), MELD (AUROC, 0.632; 95% CI, 0.601-0.662), or qCLIF-SOFA (AUROC, 0.680; 95% CI, 0.650-0.710) (P < .05 for all). In the decision curve analysis, the net benefit of implementing CLIF-SOFA and CLIF-C OF to predict the prognosis of cirrhotic patients with suspected infection were higher compared with SIRS, qSOFA, MELD, or qCLIF-SOFA.CLIF-SOFA and CLIF-C OF scores, as well as SAPS II were better tools than SIRS, qSOFA, MELD, or qCLIF-SOFA to evaluate the prognosis of critically ill cirrhotic patients with suspected infection.

Two-tube method for treatment of spontaneous esophageal rupture and concomitant mediastinal infection.

Objective Spontaneous esophageal rupture (SER) is a rare but life-threatening condition with high mortality. The prognosis of patients with SER treated with surgical intervention or the traditional "three-tube" method is controversial. Thus, the aim of this study was to evaluate the clinical efficacy, feasibility, and safety of a new "two-tube" method involving a trans-fistula drainage tube and a three-lumen jejunal feeding tube for the treatment of SER without concomitant pleural rupture. Methods From January 2007 to June 2016, patients with SER and managed with the "two-tube" method or other methods were retrospectively analyzed. Data collected included initial presentation, procedure time, duration of treatment, numbers of patients with eventual healing of leaks, and complications. Results The average procedure time for the "two-tube" method was 22.1 ± 5.5 minutes. In comparison with the control method, the "two-tube" method had a similar diagnosis time (3.6 ± 1.4 vs. 3.4 ± 1.4 days) but a significantly higher successful closure rate (94.4% vs. 63.6%) and shorter treatment time (38.2 ± 5.6 vs. 53.6 ± 16.9 days). No complications associated with performance of the "two-tube" method occurred. Conclusion The "two-tube" method is an effective and safe approach for patients with SER.

Diaphragmatic dysfunction in sepsis due to severe acute pancreatitis complicated by intra-abdominal hypertension.

Objective This study aimed to examine the mechanism of diaphragmatic dysfunction in sepsis due to severe acute pancreatitis (SAP) with intra-abdominal hypertension (IAH) in a rat model. Methods The rats were assigned at random to four groups: (1) control (n = 5), (2) SAP (n = 5), (3) SAP+IAH (n = 5), and (4) SAP+IAH+SS-31 (n = 5). Length and force output of the diaphragm were analysed in vivo. Histopathological examinations were performed by haematoxylin-eosin. Oxidative stress levels related to protease in diaphragmatic mitochondria were detected with a colorimetric technique. Results In the septic rat model due to SAP complicated by IAH, myofibres were increased. Muscle contractile function was significantly lower in the SAP+IAH group compared with the SAP and control groups. Glutathione peroxidase and superoxide dismutase levels were significantly lower and malondialdehyde levels were higher in the SAP and SAP+IAH groups compared with the control group. Notably, SS-31 could reverse atrophy of myofibres in SAP+IAH rats, as well as contractile dysfunction and mitochondrial dysfunction in the diaphragm. Conclusions Diaphragmatic structure and biomechanics are altered in septic rats due to SAP and IAH. This finding is mainly due to an increase in release of mitochondrial reactive oxygen species.

Intensive blood pressure control in patients with acute type B aortic dissection (RAID): study protocol for randomized controlled trial.

BACKGROUND: Blood pressure control is an essential therapy for patients with acute type B aortic dissection (ABAD) and should be maintained throughout the entire treatment. Thus, vast majority current guidelines recommend control the blood pressure to lower than 140/90 mmHg. Theoretically, a much lower target may further decrease the risk of propagation of dissection. However, some argued that too lower blood pressure would compromise the organ perfusion. Thus, there is no unanimous optimal target for blood pressure in patients with ABAD so far. The present study aimed to investigate the optimal blood pressure target for patients with ABAD, in the hope that the result would optimize the treatment of aortic dissection (AD). METHODS: The study is a multi-center randomized controlled clinical trial. Study population will include patients with new diagnosed ABAD and hypertension. Blocked randomization was performed where intensive blood pressure control (<120 mmHg) with conventional blood pressure control (<140 mmHg) were allocated at random in a ratio of 1:1 in blocks of sizes 4, 6, 8, and 10 to 360 subjects. Interim analysis will be performed. The primary outcome is a composite in-hospital adverse outcome, including death, permanent paraplegia or semi- paralysis during the hospitalization, and renal failure requiring hemodialysis at discharge. While the secondary outcomes include the aortic size, lower extremity or visceral ischemia, retrograde propagation into aortic arch or ascending aorta, mortality in 6 months and 1 year, intensive care unit (ICU) length of stay, total length of hospital stay, creatinine level, and surgical or endovascular intervention. ETHICS AND DISSEMINATION: The study was approved by the institutional review board of Sir Run Run Shaw Hospital (approval number: 20160920-9). Informed consent will be obtained from participants or their next-of-kin. The results will be published in a peer-reviewed journal and shared with the worldwide medical community. TRIAL REGISTRATION: NCT03001739 (https://register.clinicaltrials.gov/).

Attitudes toward the American nutrition guidelines for the critically ill patients of Chinese intensive care physicians.

Nutrition therapy is essential for the management of critically ill patients. Some guidelines have been published to standardize and optimize the nutrition therapy. However, there are still many controversies in nutrition practice and there is a gap between guidelines and clinical nutrition therapy for patients in intensive care units (ICUs). This study aimed to assess attitudes and beliefs toward nutrition therapy of Chinese intensive care physicians by using the American guidelines as a surrogate. A questionnaire was sent to 45 adult ICUs in China, in which surveyed physicians were asked to rate their attitudes toward the American guidelines. A total of 162 physicians from 45 ICUs returned the questionnaires. Physicians were categorized into groups according to their professional seniority, hospital levels and whether they were members of Chinese Society for Parenteral and Enteral Nutrition (CSPEN). Overall, 94% of the respondents thought that nutrition therapy for critically ill patients was very important, and 80% mentioned that they used the American guidelines. There was diversity of opinion on the recommendations pertaining to nutrition assessment, supplemental parenteral nutrition and cutoff values for gastric residual volume, negative or neutral attitudes about these recommendations were 43%, 59% and 41%, respectively. Members of CSPEN were more likely to select a greater strength of recommendation than non-members. In conclusion, the overall attitudes of Chinese intensive care physicians toward the American guidelines were positive. Nevertheless, given the great guideline-practice gap, nutrition-focused education is warranted for many intensive care physicians in China.

Clinical and microbiological characteristics of Klebsiella pneumoniae liver abscess in East China.

BACKGROUND: Klebsiella pneumoniae has been the dominant pathogen for liver abscesses in several Asian countries. Although the prevalence of K. pneumoniae liver abscess (KLA) in mainland China is increasing recently, the clinical and microbiological characteristics of KLA in China have not been elucidated. METHODS: Clinical and microbiology characteristics of 45 consecutive patients with KLA from a tertiary teaching hospital in China between June 2008 and June 2012 were retrospectively evaluated. RESULTS: Vast majority of the strains were susceptible to main antimicrobial agents. Most of K. pneumoniae strains from pyogenic liver abscess patients belonged to K1/K2 serotype (68.9% for K1 serotype and 20% for K2 serotype). All K. pneumoniae strains were rmpA positive, and 68.9% of these strains were magA positive. Overall, 57.8% (26/45) of K. pneumoniae strains belonged to ST23. Twenty-five of 26 ST23 K. pneumoniae isolates (96.2%) from KLA patients were magA-positive and K1 serotype. Only 28.9% (13/45) of KLA isolates exhibited hypermucoviscous phenotype, which is clinically used as the characteristic of hypervirulent K. pneumoniae (hvKP). Liver abscess sizes in patients infected with hvKP were tend to be larger than those in patients infected with cKP. There was no significant association between the microbiological and clinical characteristics including serotypes, magA and rmpA genotypes, and STs with the metastatic infection and prognosis of KLA. CONCLUSIONS: Neither the serotypes, magA and rmpA genotypes, nor the STs of K. pneumoniae were associated with the metastatic infection and prognosis of KLA. However, further studies with larger sample are needed in the future.

Delayed admission to ICU does not increase the mortality of patients post neurosurgery.

Increasing shortage of intensive care resources is a worldwide problem. While routine postoperative admission to the intensive care unit (ICU) of patients undergoing neurosurgery is a long established practice for many hospitals. Therefore, some neurosurgical patients have to be cared in post anesthesia care unit (PACU) before ICU admission during high ICU occupancy. The aim of this study was to compare the outcome of neurosurgical patients immediately admitted to the ICU post operation with those who were required to wait for ICU bed in PACU and managed by anesthesiologists before ICU admission. All adult neurosurgical patients admitted to our ICU between January 2010 and July 2013 were retrospectively analyzed. Recorded data included demographic data, surgical categories, end time of operation, operation hours, postoperative complication, hospital/ICU length of stay and cost, Glasgow coma score (GCS) on ICU discharge and ICU mortality. A total of 989 neurosurgical patients were evaluated. Nine hundred thirty-seven (94.7%) patients were immediately admitted and 52 (5.3%) patients had delayed ICU admission. Median PACU waiting hours was 4.3 h (interquartile range: 2.0-10.2 h). Delayed ICU admission post neurosurgery was highly associated with the end time of operation (p = 0.019) and high ICU occupancy (p < 0.0001). Average GCS on ICU discharge was higher in immediately admitted group (13.0 ± 3.5 vs. 11.4 ± 4.5, p = 0.012). However, delayed admission to ICU post neurosurgery was not associated with prolonged ICU length of stay, increased ICU mortality, increased postoperative complication and hospital/ICU cost (all p > 0.05). Thus, an algorithm for appropriate disposition of neurosurgical patients is warranted so as to balance the quality of care and control of scarce intensive resources.

The carina is approximately 1-2 cm above the pericardial reflection among Chinese patients.

BACKGROUND: Central venous catheters (CVCs) and central venous pressure (CVP) monitor is essential in fluid resuscitation and management for critically ill patients. Accuracy of the CVP is mainly dependent on the proper position of the catheter tip. Although the X-ray visible carina was generally recommended as the alternative of pericardial reflection (PR) to guide the placement of CVCs, few data was available with respect to the distance between the carina and PR among Chinese patients. The purpose of this study was to explore the topographic relationship between the trachea carina and PR among Chinese patients by using computed tomography (CT) images. METHODS: CT images of 172 patients who underwent CT pulmonary angiogram or CT angiogram for aorta from January 1, 2013 to November 30, 2013 were retrospectively reviewed. Distances between upper margin of the right clavicular notch, trachea carina, PR and atriocaval junction (ACJ) were calculated using the table positions on axial images. RESULTS: The mean length of extrapericardial superior vena cava (SVC) was 2.5 cm. For all patients, the PR was lower than the carina by average 1.6 cm. CONCLUSIONS: Given the PR was average 1.6 cm lower than the carina among Chinese patients, placing the CVCs tip approximate 1.6 cm lower the carina among Chinese patients would be more likely to result in a satisfactory placement.

Antihypertensive therapy with nicardipine for patients with aortic disease is associated with more esmolol usage than urapidil.

BACKGROUND: Acute aortic disease is a common but challenging entity in clinical practice. Titration the blood pressure and heart rate to a target level is of paramount importance in the acute phase regardless of whether the patient will undergo a surgery or not eventually. In addition to the initially intravenous ß-blockers, parenteral infusion of nicardipine and urapidil are the most common used antihypertensive therapy currently in mainland China. However, few empirical data was available with respect to the different effect on patients' outcome of the two antihypertensive strategies. Specifically given the deleterious reflex tachycardia of vasodilators which may increase force of ventricular contraction and potentially worsen aortic disease. Therefore, this study was aimed to evaluate the difference of the abovementioned two antihypertensive strategies on the outcome of patients with aortic disease. METHODS: All patients with new diagnosed aortic diseases presented to our hospitals from January 1, 2013 to June 30, 2014 were retrospectively reviewed. The antihypertensive strategies and their association with patients' outcomes were evaluated with logistics regression. RESULTS: A total of 120 patients with new diagnosed aortic disease were included in the study. Of them, 47 patients received urapidil while 73 patients received nicardipine antihypertensive therapy. Patients with nicardipine were more quickly to reach the target blood pressure level than those treated with urapidil (median, 18 vs. 35 min, P=0.024). After adjustment for patient demographics, co-morbidity, involved extend of aorta, interventional strategies, antihypertensive therapy with nicardipine (with urapidil as reference) for patients with aortic disease was significantly associated with high esmolol cost [odds ratio (OR): 6.2, 95% confidence interval (CI), 1.8-21.6, P=0.004] and longer ICU length of stay (LOS) (OR: 3.9, 95% CI, 1.5-10.3, P=0.006). However, there was no significant correlation between nicardipine use and ICU mortality (OR: 0.3; 95% CI, 0.1-1.4, P=0.123). CONCLUSIONS: Although nicardipine achieved the target blood pressure level more quickly than urapidil for patients with aortic disease, it was associated with more esmolol use and longer ICU LOS.

Good neurological recovery after rescue thrombolysis of presumed pulmonary embolism despite prior 100 minutes CPR.

We reported the case of a 70-year-old man who was admitted to neurologic wards for recurrent syncope for 3 years. Unfortunately, just 2 hours after his admission, he suddenly collapsed and failed to return of spontaneous circulation (ROSC) after a 100-minute standard cardiopulmonary resuscitation (CPR). Fortunately, he was timely suspected to have pulmonary embolism (PE) based on his sedentary lifestyle, elevated D-dimer and markedly enlarged right ventricle chamber on bedside echocardiography. After a rescue thrombolytic alteplase therapy, he was successfully resuscitated and good neurological recovery was achieved.