Continuous Infusion of Ketamine in Mechanically Ventilated Patients with SARS-CoV-2.

Background: Widespread drug shortages led to higher utilization of ketamine in our intensive care unit, especially among patients with SARS-CoV-2. Objectives: To evaluate the impact of continuous infusion of ketamine on vasopressor requirements in patients with SARS-CoV-2. Method: This was a single-center, retrospective, cohort study comparing mechanically ventilated (MV), adult patients with SARS-CoV-2 receiving either propofol or ketamine for at least 72 hours. Results: 84 patients (mean age of 61-year-old, 68% male) were analyzed. 31 patients received ketamine, and 53 patients received propofol. Mean vasopressor doses were not significantly different between ketamine and propofol groups at prespecified timepoints. However, mean arterial pressures (MAP) were higher in the ketamine group at 24 h, 48 h, and 96 h postsedative initiation. The median opioid infusion requirements were 3 vs. 12.5 mg/hr (p < 0.0001) for ketamine and propofol groups, respectively. Comparing to propofol, C-reactive protein (CRP) values were significantly lower in the ketamine group at 24 h (7.53 vs. 15.9 mg/dL, p=0.03), 48 h (5.23 vs. 14.1 mg/dL, p=0.0083), and 72 h (6.4 vs. 12.1 mg/dL, p=0.0085). Conclusion: In patients with SARS-CoV-2 on MV, there was no difference in the vasopressor requirement in patients receiving ketamine compared to propofol. Nevertheless, the use of ketamine was associated with higher MAP, reductions in CRP in select timepoints, and overall lower opioid requirements.

Effects of Dronabinol on Dyspnea and Quality of Life in Patients With COPD.

Background: Dyspnea is frequently a debilitating symptom of chronic obstructive pulmonary disease (COPD). Cannabinoid receptor agonists have the potential to alter dyspnea in these patients. Objective: Our objective was to determine if dronabinol, a pure cannabinoid, improves dyspnea and exercise tolerance in COPD. Methods: In this double-blind randomized, crossover pilot study, COPD patients received up to 20mg of oral dronabinol or placebo daily for 6 weeks with an intervening washout period. Dyspnea and fatigue were assessed using the Borg scale at rest and after an incremental shuttle walk. Functional status, mood, and depression were measured using the St George's Respiratory Questionnaire (SGRQ), the Pulmonary Functional Status and Dyspnea Questionnaire (PFSDQ), and the Geriatric Depression Scale (GDS). Results: A total of 11 participants (with mean forced expiratory volume in 1 second 50.8 ± 24.8%) completed the study with no improvement in dyspnea at rest or postexercise taking dronabinol versus placebo (Borg scale 0.27, 95% confidence interval [CI] -0.59 to 1.14 versus 0.23 points, 95% CI -0.71 to 1.07 at rest and 0.82, 95% CI -0.59 to 2.22 versus 0.36 points, 95% CI 0.13 to 2.78 post exercise; p=0.94 and p=0.69 respectively). Dronabinol compared with placebo showed no significant change in PFSDQ dyspnea scores (0.64, 95% CI -3.92 to 5.20 versus 5.0, 95% CI -6.29 to 16.29; p=0.43) or shuttle walk distances (20.7m, 95% CI -21.5 to 62.8 versus 13.7m, 95% CI -24.8 to 52.2; p=0.69). There were no significant differences in fatigue at rest and postexercise, SGRQ scores, or GDS scores. Conclusion: In this pilot study, dronabinol did not significantly improve dyspnea or exercise capacity compared with placebo.

Impact of pulmonary rehabilitation in sleep in COPD patients measured by actigraphy.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) patients have poor sleep quality, longer time to sleep onset and frequent nocturnal awakenings. Poor sleep quality in COPD is associated with poor quality of life (QoL), increased exacerbations and increased mortality. Pulmonary rehabilitation (PR) improves functional status and QoL in COPD but effects on sleep are unclear. PR improves subjective sleep quality but there is paucity of objective actigraphy data. We hypothesized that actigraphy would demonstrate subjective and objective improvement in sleep following PR. Paired comparisons (t-test or Wilcoxon-signed-rank test) were performed before and after PR data on all variables. METHODS: This retrospective study of COPD patients undergoing PR utilized actigraphy watch recordings before and after 8-weeks of PR to assess changes in sleep variables including total time in bed (TBT), total sleep time (TST), sleep onset latency (SOL), sleep efficiency (SE), wakefulness after sleep onset (WASO) and total nocturnal awakenings. A change in Pittsburg Sleep Quality Index (PSQI) was a secondary outcome. PSQI was performed before and after PR. RESULTS: Sixty-nine patients were included in the final analysis. Most participants were male (97%), non-obese (median BMI 27.5, IQR 24.3 to 32.4 kg/m2) with an average age of 69 ± 8 years and 71% had severe COPD (GOLD stage 3 or 4). Prevalence of poor sleep quality (PSQI ≥5) was 86%. Paired comparisons did not show improvement in actigraphic sleep parameters following 8-weeks PR despite improvements in 6-min-walk distance (6MWD, mean improvement 54 m, 95% CI 34 m to 74 m, p<0.0001) and St. George's Respiratory Questionnaire scores (SGRQ, mean improvement 7.7 points, 95% CI 5.2 to 10.2, p<0.0001). Stratified analysis of all sleep variables by severity of COPD, BMI, mood, mental status, 6-MWD and SGRQ did not show significant improvement after PR. In Veterans with poor sleep quality (PSQI ≥ 5), PR improved subjective sleep quality (PSQI, mean difference 0.79, 95% CI 0.07 to 1.40, p = 0.03). CONCLUSIONS: Pulmonary rehabilitation improved subjective sleep quality in Veterans who had poor sleep quality at the beginning of the PR but did not improve objective sleep parameters by actigraphy. Our findings highlight the complex interactions among COPD, sleep and exercise.

Outcomes of Noninvasive Ventilation in Obese Patients With Acute Asthma Exacerbations.

BACKGROUND: The role of noninvasive positive pressure ventilation (NIPPV) in acute asthma exacerbation is controversial. However, the outcome of NIPPV in obese patients with asthma during such exacerbation has not been well studied despite well-established relationship between obesity and asthma. STUDY QUESTION: Does body mass index (BMI) play a role in the outcome of NIPPV during an acute exacerbation and does it predict of the success or failure of NIPPV? STUDY DESIGN: The study was a retrospective analysis by design. The purpose of the study was to assess factors predicting the success or failure of NIPPV. The entire cohort was divided into 2 groups: patients who failed NIPPV and patients who did not. Univariate and multivariate regression analysis was used to predict the variables. Stepwise selection method was used to select variables for final regression model. RESULTS: A total 96 patients were included in the study. Of those, 18 patients (18.9%) failed NIPPV and required endotracheal intubation (group 1). Rest (78.1%) did not fail NIPPV (group 2). Mean age of the study population was 48.8 years and 53% of patients were female. In the univariate analysis, the group that did not fail NIPPV (group 2) had significantly higher number of obese patients (47.9% versus 22.2%; P 0.013). Multivariate analysis showed significant association between BMI categories (BMI of 30 or more) and failure of NIPPV (odds ratio 0.26, 95% confidence interval, 0.08-0.85; P-value 0.017). Forced introduction of smoking status as a risk factor did not change the significance of association. CONCLUSION: Despite the limitations of the study design and the sample size, our analysis showed that patients with high BMI (obese) fared well with NIPPV during acute asthma exacerbation. Because there are controversies on use of NIPPV during asthma exacerbation, larger-scale prospective studies are needed to better understand the role of NIPPV in obese patients with asthma during acute exacerbation.

Cardiac involvement in myotonic dystrophy.

BACKGROUND: Myotonic dystrophy (DM) is an inherited progressive muscle disorder caused by defects in muscle proteins. As the incidence of this condition is low, not many are familiar with the multisystem involvement. At times, cardiac disease may even be the predominant manifestation in the form of arrhythmias, conduction defects, and cardiomyopathies. The progression of the disease can lead to sudden, unpredictable death. Thus, it is important to identify this subgroup and treat accordingly. OBJECTIVE: To identify patients with DM and assess their risk for sudden cardiac death. METHODS: Nine patients previously diagnosed with muscular dystrophy were evaluated by cardiologists for various reasons, from a general follow-up to cardiac arrest. All of them had electrocardiograms (EKG) and 2-D echocardiograms, and seven of them had further electrophysiological (EP) studies. RESULTS: Of the nine patients with DM, eight had EKG evidence of conduction abnormalities ranging from first-degree heart block to complete heart block. Of the seven who had EP studies, five had inducible ventricular tachycardia requiring immediate cardioversion and implantable cardioverter defibrillator (ICD) implant. Two of them underwent permanent pacemaker placement due to complete heart block and infra-Hissian block. The remaining two patients opted for a conservative approach with yearly EKG monitoring. CONCLUSION: Because one-third of the cardiac deaths in patients with DM are sudden, there is a strong need to identify these patients and intervene in those at high risk. Prophylactic pacemaker placement is recommended even in those with minimal conduction system abnormality. However, the common practice is to identify patients at high risk of conduction abnormalities by EP studies and then provide them with prophylactic invasive strategies.

Recurrent acute coronary events in a young adult.

Acute myocardial infarction (MI) in young adults is rare. Clinicopathological conditions such as nephrotic syndrome, antiphospholipid syndrome, spontaneous coronary artery spasms or embolism can be attributed to such events. In this case report, we present a 30-year-old male who had his first MI at the age of 20 years. He received percutaneous intervention as initial treatment. Despite aggressive risk factor management, he continued to have acute coronary events and was later diagnosed with antiphospholipid syndrome (APS). At the same time, he was diagnosed with severe chronic thromboembolic pulmonary hypertension and severe tricuspid regurgitation. He underwent pulmonary endartererectomy, tricuspid annuloplasty and radial artery bypass graft to the first obtuse marginal artery. Warfarin therapy was initiated upon the diagnosis of APS. Despite being therapeutic on warfarin and aggressive risk factor management, he had yet another MI. Coronary angiogram at this time showed fresh occlusion of the right coronary artery at the mid-segment, and the patient received two overlapping stents that achieved a good effect. This case emphasizes the importance of awareness, early recognition and aggressive management of patients with APS presenting chest pain or acute coronary events. Despite appropriate treatment, such as risk factor management and percutaneous interventions, recurrence of an acute coronary event is high. The presentation of younger patients with recurrent coronary events but no significant risk factors of atherosclerosis should evoke the suspicion of APS-related coronary artery disease, and all risk factors should be aggressively managed.