A Nationwide, Prospective Study of Tracheal Intubation in Critically Ill Adults in Spain: Management, Associated Complications, and Outcomes.

OBJECTIVES: Our aims were to explore current intubation practices in Spanish ICUs to determine the incidence and risk factors of peri-intubation complications (primary outcome measure: major adverse events), the rate and factors associated with first-pass success, and their impact on mortality as well as the changes of the intubation procedure observed in the COVID-19 pandemic. DESIGN: Prospective, observational, and cohort study. SETTING: Forty-three Spanish ICU. PATIENTS: A total of 1837 critically ill adult patients undergoing tracheal intubation. The enrollment period was six months (selected by each center from April 16, 2019, to October 31, 2020). INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: At least one major adverse peri-intubation event occurred in 40.4 % of the patients (973 major adverse events were registered) the most frequent being hemodynamic instability (26.5%) and severe hypoxemia (20.3%). The multivariate analysis identified seven variables independently associated with a major adverse event whereas the use of neuromuscular blocking agents (NMBAs) was associated with reduced odds of major adverse events. Intubation on the first attempt was achieved in 70.8% of the patients. The use of videolaryngoscopy at the first attempt was the only protective factor (odds ratio 0.43; 95% CI, 0.28-0.66; p < 0.001) for first-attempt intubation failure. During the COVID-19 pandemic, the use of videolaryngoscopy and NMBAs increased significantly. The occurrence of a major peri-intubation event was an independent risk factor for 28-day mortality. Cardiovascular collapse also posed a serious threat, constituting an independent predictor of death. CONCLUSIONS: A major adverse event occurred in up to 40% of the adults intubated in the ICU. Peri-intubation hemodynamic instability but not severe hypoxemia was identified as an independent predictor of death. The use of NMBAs was a protective factor for major adverse events, whereas the use of videolaringoscopy increases the first-pass success rate of intubation. Intubation practices changed during the COVID-19 pandemic.

Case Report: Successful Response to Intravenous Immunoglobulin and Steroid Pulses in a Renal Transplant Recipient With Severe Covid-19 Disease and Associated Acute Allograft Failure.

The impact of Covid-19 pneumonia caused by SARS-CoV-2 on transplanted populations under chronic immunosuppression seems to be greater than in normal population. Clinical management of the disease, particularly in those patients worsening after a cytokine storm, with or without allograft impairment and using available therapeutic approaches in the absence of specific drugs to fight against the virus, involves a major challenge for physicians. We herein provide evidence of the usefulness of high-dose intravenous immunoglobulin (IVIG) combined with steroid pulses to successfully treat a case of Covid-19 pneumonia in a single-kidney transplanted patient with mechanical ventilation and hemodialysis requirements in the setting of a cytokine storm. A rapid decrease in the serum level of inflammatory cytokines, particularly IL-6, IL-8, TNF-α, MCP-1 and IL-10, as well as of acute-phase reactants such as ferritin, D-dimer and C-reactive protein was observed after the IVIG infusion and methylprednisolone bolus administration with a parallel clinical improvement and progressive allograft function recovery, allowing the patient's final discharge 40 days after the treatment onset. The immunomodulatory effect of IVIG together with the anti-inflammatory and immunosuppressive potential of steroids could be an alternative strategy to treat severe cases of Covid-19 pneumonia associated with an uncontrolled inflammatory response in transplanted populations.

Efectos adversos de las tiopurinas en pacientes con enfermedad inflamatoria intestinal / Adverse events of thiopurine immunomodulators in patients with inflammatory bowel disease

Antecedentes Las tiopurinas son los inmunosupresores más utilizados para el tratamiento de la enfermedad inflamatoria intestinal.ObjetivosEvaluar la incidencia de eventos adversos (EA) en pacientes con enfermedad inflamatoria intestinal tratados con azatioprina (AZA) o con 6-mercaptopurina (MP) en nuestro hospital, las características de dichos efectos, la distribución de los factores socio-demográficos y los posibles factores predisponentes.MétodosSe incluyeron 377 pacientes con enfermedad inflamatoria intestinal que fueron diagnosticados hasta 2008 y que recibieron AZA o MP durante el curso de su enfermedad. Se recogieron retrospectivamente datos demográficos, clínicos y de laboratorio sobre su enfermedad e información detallada sobre cualquier EA.ResultadosCincuenta y un pacientes tuvieron algún tipo de EA con AZA o MP (13,5%), y el 11% suspendieron el tratamiento por toxicidad. Se observó una asociación estadísticamente significativa con la enfermedad de Crohn (p=0,008). Hubo mielotoxicidad en 18 pacientes (4,8%) con un tiempo medio de aparición de las anomalías en los análisis de laboratorio de 16 meses. Nueve pacientes presentaron toxicidad hepática secundaria a estos fármacos (2,4%), uno de ellos desarrolló hiperplasia nodular regenerativa e hipertensión portal. Diez pacientes sufrieron pancreatitis aguda (2,7%) con un tiempo medio de aparición de 27 días y una asociación estadísticamente significativa con la enfermedad de Crohn (p=0,03) y tabaquismo (p=0,01). Quince pacientes presentaron intolerancia gastrointestinal (4%), pero cinco pudieron continuar con la medicación administrada en dosis fraccionadas o tras cambiar a MP.ConclusionesLas tiopurinas presentan un porcentaje significativo de EA (13,5%), que si bien suelen ser leves, nos obligan a hacer un seguimiento de todos los casos y, en algunos incluso a suspender el tratamiento(AU)

Background Thiopurine immunomodulators are the most commonly used immunosuppressants in inflammatory bowel disease.AimsTo evaluate the incidence of adverse events (AE) in patients with inflammatory bowel disease treated with azathioprine (AZA) or 6-mercaptopurine (MP) in our hospital, the features of these effects, the distribution of socio-demographic factors, and the possible predisposing factors.MethodsWe included 377 patients with inflammatory bowel disease who were diagnosed through 2008 and who received AZA or MP during the course of their disease. We collected retrospective demographic, clinical, and laboratory data about their disease and detailed information on any AE.ResultsFifty-one patients had some form of AE with AZA or MP (13.5%) and 11% discontinued therapy because of toxicity. Statistically significant association with Crohn's disease was found (P=.008). Myelotoxicity occurred in 18 patients (4.8%) with a mean time of laboratory abnormalities appearing after 16 months. Nine patients had hepatotoxicity secondary to these drugs (2.4%); one of them developed nodular regenerative hyperplasia and portal hypertension. Ten patients had acute pancreatitis (2.7%) with a mean time occurrence of 27 days and a statistically significant association with Crohn's disease (P=.03) and smoking (P=.01). Fifteen patients had gastrointestinal intolerance (4%) but 5 were able to continue with medication given in divided doses or switching to MP.ConclusionsThiopurine immunomodulators have a significant percentage of AE (13.5%), which, although usually mild, forced us to follow up all cases and sometimes even suspend treatment(AU)

Adverse events of thiopurine immunomodulators in patients with inflammatory bowel disease.

BACKGROUND: Thiopurine immunomodulators are the most commonly used immunosuppressants in inflammatory bowel disease. AIMS: To evaluate the incidence of adverse events (AE) in patients with inflammatory bowel disease treated with azathioprine (AZA) or 6-mercaptopurine (MP) in our hospital, the features of these effects, the distribution of socio-demographic factors, and the possible predisposing factors. METHODS: We included 377 patients with inflammatory bowel disease who were diagnosed through 2008 and who received AZA or MP during the course of their disease. We collected retrospective demographic, clinical, and laboratory data about their disease and detailed information on any AE. RESULTS: Fifty-one patients had some form of AE with AZA or MP (13.5%) and 11% discontinued therapy because of toxicity. Statistically significant association with Crohn's disease was found (P = .008). Myelotoxicity occurred in 18 patients (4.8%) with a mean time of laboratory abnormalities appearing after 16 months. Nine patients had hepatotoxicity secondary to these drugs (2.4%); one of them developed nodular regenerative hyperplasia and portal hypertension. Ten patients had acute pancreatitis (2.7%) with a mean time occurrence of 27 days and a statistically significant association with Crohn's disease (P = .03) and smoking (P = .01). Fifteen patients had gastrointestinal intolerance (4%) but 5 were able to continue with medication given in divided doses or switching to MP. CONCLUSIONS: Thiopurine immunomodulators have a significant percentage of AE (13.5%), which, although usually mild, forced us to follow up all cases and sometimes even suspend treatment.

Hiperplasia nodular regenerativa: hepatotoxicidad por azatioprina en un paciente con enfermedad de Crohn / Nodular regenerative hyperplasia: azathioprine-induced hepatotoxicity in a patient with Crohn's disease

Resumen Presentamos el caso de un paciente de 53 años con enfermedad de Crohn en tratamiento con azatioprina al que se le diagnosticó de hiperplasia nodular regenerativa secundaria a este tratamiento tras detectar alteraciones analíticas en el perfil hepático y signos ecográficos y endoscópicos de hipertensión portal. El diagnóstico se estableció mediante biopsia hepática, que mostró las alteraciones de la arquitectura hepática características de esta entidad. La evolución al suspender al tratamiento fue buena, resolviéndose completamente las alteraciones analíticas al cabo de un año.ResumenEn este artículo se realiza una descripción de la incidencia y las principales características clínicas de este efecto adverso a los fármacos tiopurínicos (AU)

Abstract We report the case of a 53-year-old man with Crohn's disease who developed azathioprine-induced nodular regenerative hyperplasia of the liver. The diagnosis was suspected when abnormalities in liver function tests were observed and transabdominal ultrasonography and upper gastrointestinal endoscopy showed signs of portal hypertension. The final diagnosis was established by liver biopsy, showing the characteristic alterations in liver architecture. Outcome was favorable after treatment discontinuation, with complete normalization of liver function tests within a year. AbstractThe present article describes the incidence and the main clinical characteristics of this adverse effect to thiopurines (AU)

[Nodular regenerative hyperplasia: azathioprine-induced hepatotoxicity in a patient with Crohn's disease]. / Hiperplasia nodular regenerativa: hepatotoxicidad por azatioprina en un paciente con enfermedad de Crohn.

We report the case of a 53-year-old man with Crohn's disease who developed azathioprine-induced nodular regenerative hyperplasia of the liver. The diagnosis was suspected when abnormalities in liver function tests were observed and transabdominal ultrasonography and upper gastrointestinal endoscopy showed signs of portal hypertension. The final diagnosis was established by liver biopsy, showing the characteristic alterations in liver architecture. Outcome was favorable after treatment discontinuation, with complete normalization of liver function tests within a year. The present article describes the incidence and the main clinical characteristics of this adverse effect to thiopurines.