The impact of protocol-based high-intensity pharmacological thromboprophylaxis on thrombotic events in critically ill COVID-19 patients.

The reported incidence rate of venous and arterial thrombotic events in critically ill patients with COVID-19 infections is high, ranging from 20% to 60%. We adopted a patient-tailored thromboprophylaxis protocol based on clinical and laboratory presentations for these patients in our institution. We hypothesised that patients who received high-intensity thromboprophylaxis treatment would experience fewer thrombotic events. The aims of our study were to explore the incidence of thrombotic events in this population; to assess independent factors associated with thrombotic events and to evaluate the incidence of haemorrhagic events. A retrospective review of all adult patients with confirmed SARS-CoV-2 infection admitted to the intensive care unit (ICU) between 1 March and 29 May 2020 was performed. The primary outcome was a composite of venous and arterial thrombotic events diagnosed during the ICU stay. Multivariable logistic regression was used to identify the independent factors associated with thrombotic events. A total of 188 patients met the inclusion criteria. All received some type of thromboprophylaxis treatment except for six patients who did not receive any prophylaxis. Of the 182 patients who received thromboprophylaxis, 75 (40%) received high-intensity thromboprophylaxis and 24 (12.8%) were treated with therapeutic anticoagulation. Twenty-one patients (11.2%) experienced 23 thrombotic events (incidence rate of 12.2% (95%CI 7.9-17.8)), including 12 deep venous thromboses, 9 pulmonary emboli and 2 peripheral arterial thromboses. The multivariable logistic regression analysis showed that only D-dimer (OR 2.80, p = 0.002) and high-intensity thromboprophylaxis regimen (OR 0.20, p = 0.01) were independently associated with thrombotic events. Thirty-one patients (16.5%) experienced haemorrhagic events; among them, 13 were classified as major bleeding according to the International Society on Thrombosis and Haemostasis criteria. Therapeutic anticoagulation, but not the high-intensity thromboprophylaxis regimen, was associated with major bleeding. A proactive approach to the management of thromboembolism in critically ill COVID-19 patients utilising a high-intensity thromboprophylaxis regimen in appropriately selected patients may result in lower thrombotic events without increasing the risk of bleeding.

The obesity supine death syndrome (OSDS).

The obesity supine death syndrome refers to a catastrophic cascade of cardiorespiratory complications resulting from the supine positioning of a morbidly obese subject which can ultimately lead to death. It was first described in 1977 in two massively obese patients who were forced to lie down for medical procedures. But surprisingly, despite the current worldwide epidemic of obesity, very few cases have been reported yet. It can be assumed that the syndrome is poorly recognized in clinical practice and may participate in the high rate of unexplained death in morbidly obese patients. Based on the previously published cases and on those we met, this review aims at helping clinicians to early detect at-risk patients, to correctly diagnose this dramatic syndrome and to understand the underlying pathophysiology. More importantly, the main objective is to convince the attending clinicians that they have to do everything in their power to prevent obesity supine death syndrome occurrence by maintaining morbidly obese patients in the sitting or upright position whenever possible. When the syndrome unfortunately occurs, the best therapeutic approach is based on the immediate return to sitting position.

Decrease in pulse pressure and stroke volume variations after mini-fluid challenge accurately predicts fluid responsiveness†.

BACKGROUND: Dynamic indices, such as pulse pressure variation (PPV), are inaccurate predictors of fluid responsiveness in mechanically ventilated patients with low tidal volume. This study aimed to test whether changes in continuous cardiac index (CCI), PPV, and stroke volume variation (SVV) after a mini-fluid challenge (100 ml of fluid during 1 min) could predict fluid responsiveness in these patients. METHODS: We prospectively studied 49 critically ill, deeply sedated, and mechanically ventilated patients (tidal volume <8 ml kg(-1) of ideal body weight) without cardiac arrhythmias, in whom a fluid challenge was indicated because of circulatory failure. The CCI, SVV (PiCCO™; Pulsion), and PPV (MP70™; Philips) were measured before and after 100 ml of colloid infusion during 1 min, and then after the additional infusion of 400 ml during 14 min. Responders were defined as subjects with a ≥15% increase in cardiac index (transpulmonary thermodilution) after the full (500 ml) fluid challenge. Areas under the receiver operating characteristic curves (AUCs) and the grey zones were determined for changes in CCI (ΔCCI100), SVV (ΔSVV100), and PPV (ΔPPV100) after 100 ml fluid challenge. RESULTS: Twenty-two subjects were responders. The ΔCCI100 predicted fluid responsiveness with an AUC of 0.78. The grey zone was large and included 67% of subjects. The ΔSVV100 and ΔPPV100 predicted fluid responsiveness with AUCs of 0.91 and 0.92, respectively. Grey zones were small, including ≤12% of subjects for both indices. CONCLUSIONS: The ΔSVV100 and ΔPPV100 predict fluid responsiveness accurately and better than ΔCCI100 (PiCCO™; Pulsion) in patients with circulatory failure and ventilated with low volumes.

Difference in venous-arterial carbon dioxide in septic shock.

Determining the venous-to-arterial PCO2 difference (PCO2gap) during resuscitation of septic shock patients might be useful when deciding when to continue resuscitation despite a ScvO2>70% associated with hyperlacticemia. Because hyperlacticemia is not a discriminatory factor in defining the cause of that stress, a PCO2gap>6 mmHg could be used to identify global tissue hypoperfusion. Monitoring the "Gap" could be a useful complementary tool after optimization of O2-derived parameters was achieved to evaluate the adequacy of blood flow to global metabolic demand. In this regard it can help to titrate inotropes in order to adapt O2 delivery to CO2 production, or to choose between haemoglobin correction or fluid/inotrope infusion in patients with a too low ScvO2 related to metabolic demand.

Mathematical coupling of data between global-end diastolic volume index and cardiac index calculated by the PiCCO device: myth or reality?

BACKGROUND: Aim of the study was to investigate whether cardiac index (CI) and global end diastolic volume index (GEDVi) determined from the same thermodilution curve are mathematically coupled during the infusion of an inotropic agent in critically ill patients. METHODS: Seventeen patients were prospectively studied. CI and GEDVi were evaluated in triplicate by the transpulmonary thermodilution technique with the PiCCO system before and 20 to 30 minutes after increases in dobutamine infusion rate. Mixed linear model was used to determine the within-subject correlation coefficient between changes in CI and GEDVi induced by changes in dobutamine infusion rate. RESULTS: Dobutamine administration significantly increased CI by 48±35%, whereas the average increase in GEDVi was only 8.2±12.3% but statistically significant (P<0.0001). The increase of GEDVi in response to dobutamine infusion was unexpected given that dobutamine has no recognized effect on right and left ventricular dimensions. Intriguingly, we observed a significant correlation coefficient, in individual patients, between changes in CI and GEDVi (r=0.58, P=0.002). CONCLUSION: Our study provides evidence that changes in GEDVi are mathematically coupled to changes in CI during dobutamine infusion. Therefore, clinicians using PiCCO device to evaluate GEDVi must be aware of the underlying formula to avoid placing undue reliance on artifactual correlations due to mathematical coupling.

Goitre and difficulty of tracheal intubation.

OBJECTIVES: To assess the difficulty in both laryngoscopy and tracheal intubation related to goitre and to identify factors predictive of difficult intubation due to this condition. STUDY DESIGN: Prospective observational. METHODS: We used the Intubation Difficulty Scale (IDS) in 80 consecutive patients with large goitre (defined by the inability to palpate the cricoid cartilage, the presence of endothoracic goitre, tracheal deviation of more than 1cm or tracheal stenosis on the chest x-ray) and 77 control patients. RESULTS: Cormack grades 3-4 were more frequent at initial laryngoscopy in patients with goitre (23/80 vs. 9/77; p<0.05), but the difference was no longer significant after application of an external laryngeal pressure (8/80 vs. 5/77). IDS scores (median [25th-75th percentiles]) were higher in the goitre group (1 [0 - 4]) than in the control group (0 [0 - 1]; p=0.001), corresponding to an increase in slightly difficult intubation (IDS 1-5: 36/80 vs. 15/77; p<0.05). However, incidence of moderate to major difficulty in intubation (IDS>5: 8/80 vs. 7/77) as well as time to completion of intubation were similar in both groups. Tracheal stenosis (> or =30%) and reduced mouth opening (<4.4cm) were the only significant predictors of increased difficulty in intubation in patients with a goitre. CONCLUSION: Large goitres are usually associated with slight difficulty in intubation only. Increased difficulty should be expected when severe tracheal stenosis is present on chest x-ray, especially when associated with a reduced mouth opening.

[Postoperative mortality a university Department of General Surgery: incidence of cardiac-related deaths]. / Mortalité postopératoire dans un service universitaire de chirurgie générale: incidence des décès d'origine cardiaque.

OBJECTIVES: To evaluate the incidence of cardiac deaths following noncardiac nonvascular surgery. STUDY DESIGN: Retrospective survey. PATIENTS: All patients undergoing mainly endocrinous and digestive surgery in a University department of general surgery between 1991 and 1996. METHODS: Analysis of all deaths occurring intra- and postoperatively, until discharge of the patients. Demographic and medical data, including patent myocardial ischaemia and risk factors for coronary artery disease, were recorded and compared with a control group including all patients undergoing surgery from January to September 1996. RESULTS: In the 8,700 patients who underwent mainly endocrine neck surgery (66%), or intra-abdominal surgery (31%), the mortality rate (n = 96) was 1.1% (95% confidence interval [95% CI] = 0.9-1.3%). Patent myocardial ischaemia or high risk factors for coronary artery disease were existing in 24% of patients with neck surgery, 31% of those with intra-abdominal surgery, and in 60% of the deceased patients (P < 0.01 vs control group). Those who died were older, were in a higher ASA physical class, and had undergone an emergency procedure more often than patients of the control group (P < 0.002 for each parameter). Two cardiac deaths, in patients with a patent cardiopathy, were recorded (cardiac mortality: 0.02%; 95% CI = 0.003-0.08%). The main cause of death was infection (n = 46), followed by haemorrhage (n = 12). Seven deaths remained unexplained. CONCLUSION: This study suggests that cardiac morbidity is a rare cause of death after noncardiac nonvascular surgery.

Badriye's story. Women's forum.

PIP: Badriye is a 40-year-old woman who lives in a remote village in Lebanon. Following the death of her husband due to AIDS, Badriye and the youngest of her two sons were overwhelmingly rejected by the community. People would no longer even pass in front of their house. The eldest son took to carrying a certificate which attested to the HIV-seronegative status of he and his brother. That Badriye's husband was infected with HIV and died due to AIDS was determined only after he died. An HIV test found Badriye to also be HIV positive. Badriye decided to make her HIV serostatus public on national television in an effort to explain her grief and subsequent banishment from the community as well as the facts about HIV/AIDS. A television show was produced in which Badriye, her doctor, the village chief, and the entire community were invited to participate in open discussion before the cameras. People in the community greeted and kissed Badriye immediately after the filming. The national broadcast of the program 2 weeks later produced empathy for Badriye's plight and admiration of her courage. One year later, Badriye has reconciled with the community, but not her in-laws, and now faces the challenge of securing treatment for her infection in a country with no social security system. Also over the period, the numbers of HIV and AIDS cases in Lebanon increased rapidly and the government mandated premarital HIV testing. Anonymous free testing has never been available in the country. The author argues in the wake of this experience that journalism in Lebanon can do little to effect positive change with regard to the prevention of HIV/AIDS in the country because, unlike in other countries, there is no infrastructure currently in place which is capable of responding to public pressure for action.^ieng