Cerebral Venous Sinus Thrombosis Associated With Coronavirus Disease 2019: Case Report and Review of the Literature.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) is associated with significant risk of acute thrombosis. We present a case report of a patient with cerebral venous sinus thrombosis (CVST) associated with COVID-19 and performed a literature review of CVST associated with COVID-19 cases. CASE REPORT: A 38-year-old woman was admitted with severe headache and acute altered mental status a week after confirmed diagnosis of COVID-19. Magnetic resonance imaging brain showed diffuse venous sinus thrombosis involving the superficial and deep veins, and diffuse edema of bilateral thalami, basal ganglia and hippocampi because of venous infarction. Her neurological exam improved with anticoagulation (AC) and was subsequently discharged home. We identified 43 patients presenting with CVST associated with COVID-19 infection. 56% were male with mean age of 51.8±18.2 years old. The mean time of CVST diagnosis was 15.6±23.7 days after onset of COVID-19 symptoms. Most patients (87%) had thrombosis of multiple dural sinuses and parenchymal changes (79%). Almost 40% had deep cerebral venous system thrombosis. Laboratory findings revealed elevated mean D-dimer level (7.14/mL±12.23 mg/L) and mean fibrinogen level (4.71±1.93 g/L). Less than half of patients had prior thrombotic risk factors. Seventeen patients (52%) had good outcomes (mRS <=2). The mortality rate was 39% (13 patients). CONCLUSION: CVST should be in the differential diagnosis when patients present with acute neurological symptoms in this COVID pandemic. The mortality rate of CVST associated with COVID-19 can be very high, therefore, early diagnosis and prompt treatment are crucial to the outcomes of these patients.

Comprehensive Echocardiographic Findings in Critically Ill COVID-19 Patients With or Without Prior Cardiac Disease.

PURPOSE: Coronavirus disease 2019 (COVID-19) presents with a spectrum of disease severity, the most serious cases requiring intensive care. Echocardiography is a front-line tool in evaluating cardiovascular complications of COVID-19 in the intensive care unit (ICU); we analyzed transthoracic echocardiograms obtained from this patient population with state-of-the-art ultrasound technology. METHODS: All patients with COVID-19 requiring ICU admission on whom a transthoracic echocardiogram was obtained were included in the study. Focused transthoracic protocols were performed by experienced sonographers. Echocardiographic variables, including speckle-tracking echocardiography, were collected and analyzed. Clinical information was obtained from the electronic medical record. Patients were followed until discharge. RESULTS: Of 52 total patients (mean age: 59.9 ± 11.6 years), 59.6% were male and 15 (29%) had known prior cardiac disease. Cardiac complications identified on echocardiography were prevalent, occurring in 55.7% of patients. Patients with known prior cardiac disease were more likely to have new or worsening left ventricular dysfunction. Right ventricular dysfunction was the most common abnormality (assessed qualitatively in 18 cases and with advanced echocardiographic methods in 34 cases). Known prior cardiac disease, right ventricular enlargement, and pulmonary hypertension were significantly associated with morbidity and mortality. CONCLUSIONS: Patients requiring intensive care for COVID-19 face significant morbidity and mortality, and cardiac complications occur in the majority of patients admitted to the ICU with COVID-19. Those with known prior cardiac disease fare worse, and other echocardiographic findings (right ventricular enlargement, pulmonary hypertension) are also associated with worse outcomes. State-of-the-art echocardiography performed by experienced sonographers can be critical to identifying cardiac complications and guiding ICU strategy.

Glucose Management Technologies for the Critically Ill.

Hyperglycemia is common in the intensive care unit (ICU) both in patients with and without a previous diagnosis of diabetes. The optimal glucose range in the ICU population is still a matter of debate. Given the risk of hypoglycemia associated with intensive insulin therapy, current recommendations include treating hyperglycemia after two consecutive glucose >180 mg/dL with target levels of 140-180 mg/dL for most patients. The optimal method of sampling glucose and delivery of insulin in critically ill patients remains elusive. While point of care glucose meters are not consistently accurate and have to be used with caution, continuous glucose monitoring (CGM) is not standard of care, nor is it generally recommended for inpatient use. Intravenous insulin therapy using paper or electronic protocols remains the preferred approach for critically ill patients. The advent of new technologies, such as electronic glucose management, CGM, and closed-loop systems, promises to improve inpatient glycemic control in the critically ill with lower rates of hypoglycemia.

A rare cause of postoperative hypotension.

A 62-year-old woman presented with a 3-month history of abdominal distension and decreased exercise tolerance. A chest radiograph showed a probable left pleural effusion (Fig 1). A CT scan of the abdomen revealed a solid ovarian mass with omental caking and a large volume of ascites; there was also confirmation of a left pleural effusion. Three days before surgery a CT pulmonary angiogram (CTPA) showed no evidence of pulmonary thromboembolism (PTE). The patient had some improvement in her symptoms after paracentesis and thoracentesis with drainage of 2,000 mL and 250 mL of fluid, respectively. She underwent total abdominal hysterectomy, bilateral oophorectomy, and partial sigmoid resection with an estimated blood loss of 850 mL. During the operation, she received 5 L of crystalloid and required phenylephrine at 40 to 80 µg/min to maintain a mean arterial pressure > 65 mm Hg. She was extubated after surgery, but immediately after extubation, she became markedly hypotensive and hypoxemic with a BP of 50/20 mm Hg and an oxygen saturation of 70%. An ECG showed T-wave inversions from V1 to V5 and an S1Q3T3 pattern (Fig 2). A bedside echocardiogram showed an enlarged right ventricle (RV), septal dyskinesia, and obliteration of the left ventricle, all consistent with systolic and diastolic RV overload (Fig 3).

Effect of Protocolized Sedation on Clinical Outcomes in Mechanically Ventilated Intensive Care Unit Patients: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

OBJECTIVE: To assess the effects of protocolized sedation (algorithm or daily interruption) compared with usual care without protocolized sedation on clinical outcomes in mechanically ventilated adult intensive care unit (ICU) patients via a systematic review and meta-analysis of randomized controlled trials (RCTs). METHODS: We searched Ovid MEDLINE, EMBASE, Cochrane CENTRAL, Web of Science, and ClinicalTrials.gov from their inception to February 28, 2013. A random-effects model was used to synthesize risk ratios (RRs) and weighted mean differences (WMDs). RESULTS: Of 4782 records screened, 6 RCTs including 1243 patients met the inclusion criteria. Protocolized sedation was associated with significant reductions in overall mortality (RR, 0.85; 95% CI, 0.74 to 0.97; P=.02; number needed to treat, 20; P=.11), ICU length of stay (WMD, -1.73 days; 95% CI, -3.32 to -0.14 days; P=.03), hospital length of stay (WMD, -3.55 days; 95% CI, -5.98 to -1.12 days; P=.004), and tracheostomy (RR, 0.69; 95% CI, 0.50 to 0.96; P=.03; number needed to treat, 16.6; P=.04; 5 RCTs) compared with usual care. Protocolized sedation produced no significant differences in duration of mechanical ventilation (WMD, -1.04 days; 95% CI, -2.54 to 0.47 days; P=.18), reintubation (RR, 0.78; 95% CI, 0.52 to 1.15; P=.21; 3 RCTs), and self-extubation (RR, 1.49; 95% CI, 0.46 to 4.82; P=.51; 4 RCTs) compared with usual care. Included studies did not report delirium incidence. CONCLUSION: In mechanically ventilated adults in closed, nonspecialty ICUs, protocolized sedation seems to decrease overall mortality (15%), ICU and hospital lengths of stay (1.73 and 3.55 days, respectively), and tracheostomy (31%) compared with usual care without protocolized sedation.