Mortality incidence among critically ill burn patients infected with multidrug-resistant organisms: A retrospective cohort study.

INTRODUCTION: Many risk factors have been reported to increase mortality among burn patients. Previously, a higher mortality incidence was reported in acute burn patients infected with multidrug-resistant organisms (MDROs) when compared to patients infected with non-MDROs. However, considering this as an independent risk factor for mortality in acute burn patients is not yet confirmed. METHODS: We conducted an observational retrospective study in Qatar. We included adult patients admitted to the surgical intensive care unit (ICU) between January 2015 and December 2017 with burn injuries involving either at least 15% of the total body surface area (TBSA) or less than 15% with facial involvement. All patients developed infection with a positive culture of either MDRO or non-MDRO. The primary outcome was in-hospital mortality. Other outcomes included days of mechanical ventilation, ICU, length of stay in hospital, and requirement of vasoactive agents. RESULTS: Fifty-eight patients were included in the final analysis: 33 patients in the MDRO group and 25 patients in the non-MDRO group. Six patients (18.2%) died in the MDRO group versus four patients (16%) in the non-MDRO group (P = 1). No significant difference was observed between the two groups with regard to the ICU length of stay. However, there was a trend towards increased median length of stay in hospital in the MDRO group: 62 days versus 45 days in the non-MDRO group (P = 0.057). No significant differences were observed in the other outcomes. CONCLUSION: In severely burned patients, infection with MDRO was not associated with increased mortality. There was a trend towards increased hospitalisation in MDRO-infected patients. Further studies with a larger sample size are needed to confirm these results. LAY SUMMARY: Many factors affect mortality in burn patients admitted to the intensive care unit, such as age, total body surface area involved in the injury, and others. In this retrospective study, we evaluated whether wound infection with a bacterial organism resistant to multiple classes of antibiotics (multidrug-resistant) is considered an independent risk factor for mortality in critically ill burn patients. We included 58 patients requiring intensive care admission with burn injuries involving 15% or more of the total body surface area or less than 15% but with facial involvement. A total of 33 patients were infected with multidrug-resistant organisms (MDROs) and 25 patients with non-MDROs. Six patients (18.2%) from the MDRO group died versus four (16%) in the non-MDRO group. The MDRO group required a longer stay in hospital and an average of one more day on a mechanical ventilator. We concluded that wound infection with MDROs might not increase mortality when compared to wound infection with non-MDROs, although other studies with a larger number of patients involved need to be conducted to validate these results.

Unfractionated heparin as a safe alternative in a case of low molecular weight heparin-induced thrombocytosis: A case report.

INTRODUCTION AND IMPORTANCE: Low molecular weight heparins are rarely associated with thrombocytosis. However, the safety of transitioning to unfractionated heparin is unknown. CASE PRESENTATION: We report a case of a 47-year-old South Asian male who presented to the hospital after ingestion of a caustic liquid. He received subcutaneous enoxaparin 40 mg once daily for prophylaxis against venous thromboembolism. His platelet count increased from the baseline of 748 × 109/L to a peak of 1213 × 109/L, after which enoxaparin was changed to unfractionated heparin. His platelet count returned to normal within seven days. The modified Naranjo scale with thrombocytosis-specific criteria was 6, indicating a probable association with enoxaparin. CLINICAL DISCUSSION: In this case, the patient developed thrombocytosis after initiation of low-molecular weight heparin and platelet count normalized after shifting to unfractionated heparin. CONCLUSION: Clinicians should suspect LMWH-induced thrombocytosis when platelet count elevation cannot be explained by other causes. Unfractionated heparin might be a safe alternative in case of low molecular weight heparin-induced thrombocytosis.

Propofol Safety in Anticoagulated and Nonanticoagulated Patients During Extracorporeal Membrane Oxygenation.

Sedation management during extracorporeal membrane oxygenation(ECMO) is a common challenge encountered by treating intensivists. Data about the safety of propofol use during ECMO has been contradictory. We aimed to investigate associated risks of propofol use on oxygenator lifespan and to explore the effect of propofol use on oxygenator membranes when therapeutic anticoagulation was omitted. Adult respiratory ECMO patients who received propofol were retrospectively compared with those who did not, and outcomes were assessed by means of duration of oxygenator functionality before requiring an exchange, and number of exchanges during propofol use and/or ECMO support. Out of the 63patients included in the analysis, 46%received propofol during ECMO as part of sedation regimen. The use of propofol was not found to be associated with an increased incidence of oxygenator failure when compared with cohorts who did not receive propofol (21% propofol arm vs. 6% control, p = 0.13). When analyzed for anticoagulation omission effects, propofol did not increase the risk of oxygenator failure (p = 0.63). The only predictor that statistically predicted the risk of oxygenator failure was development of heparin-induced thrombocytopenia (HIT) during ECMO. The results of this study further support the previously reported safety of propofol utilization during respiratory ECMO even in the absence of anticoagulation.

Effectivness of Clonidine in Treating Dexmedetomidine Withdrawal in a Patient with Co-Existing Psychiatric Illness: A Case Report.

BACKGROUND Dexmedetomidine is a sedating agent approved for use in non-intubated patients and procedural sedation due to its efficacy in conscious sedation and minimal risks of respiratory depression. Previous reports proved the effectiveness of clonidine in treatment of withdrawal symptoms, but none have discussed cases with co-existing non-controlled psychiatric illness and prolonged duration of dexmedetomidine exposure. CASE REPORT We report a case of a 40-year-old woman diagnosed with viral meningitis. Due to her complicated psychiatric illness and viral meningitis, she developed severe agitation unresponsive to standard therapy. The patient had to be placed on dexmedetomidine, to which she developed dependence. There were several attempts to gradually withdraw dexmedetomidine but these were unsuccessful despite adding multiple antipsychotic medications. Withdrawal was manifested in multiple symptoms, including severe agitation, sweating, and tachycardia. Clonidine was used and was an effective treatment option to successfully withdraw the patient from dexmedetomidine. A smaller initial dose was used due to low baseline systolic blood pressure, which was successful. CONCLUSIONS This report proves that clonidine is an effective option for treatment of dexmedetomidine dependence compared to other antipsychotic agents. The present report is the first to discuss severe psychiatric illness and prolonged dexmedetomidine duration (>7 days) in a non-intubated patient. Dexmedetomidine withdrawal must be considered in the differential diagnosis of patients with psychiatric illness, which can be easily treated with clonidine.