The Intensivist's Perspective of Shock, Volume Management, and Hemodynamic Monitoring.

One of the primary reasons for intensive care admission is shock. Identifying the underlying cause of shock (hypovolemic, distributive, cardiogenic, and obstructive) may lead to entirely different clinical pathways for management. Among patients with hypovolemic and distributive shock, fluid therapy is one of the leading management strategies. Although an appropriate amount of fluid administration might save a patient's life, inadequate (or excessive) fluid use could lead to more complications, including organ failure and mortality due to either hypovolemia or volume overload. Currently, intensivists have access to a wide variety of information sources and tools to monitor the underlying hemodynamic status, including medical history, physical examination, and specific hemodynamic monitoring devices. Although appropriate and timely assessment and interpretation of this information can promote adequate fluid resuscitation, misinterpretation of these data can also lead to additional mortality and morbidity. This article provides a narrative review of the most commonly used hemodynamic monitoring approaches to assessing fluid responsiveness and fluid tolerance. In addition, we describe the benefits and disadvantages of these tools.

Assessment of Anti-VEGFs in Treating Diabetic Macular Edema in Alfaisal Eye Center, Khartoum, Sudan, 2019.

Background: Anti-vascular endothelial growth factor (anti-VEGF) medicines have revolutionized DME and DR treatment. Despite the worldwide use of anti-VEGFs, their use remains limited in Sudan. This study aimed to assess the impact of anti-VEGF (ranibizumab and bevacizumab) injections in patients with diabetic macular oedema in Khartoum, Sudan. Methods: An analytical comparative cross-sectional study was implemented in Alfaisal referral eye centre. A Standard questionnaire was used to collect the variables related to the research objectives. Thirty-four patients were recruited; 16 patients under ranibizumab (Lucentis) and 18 under bevacizumab (Avastin). Data were analyzed through SPSS 23, best-corrected visual acuity (BCVA) and central retinal thickness (CRT) measurements were considered as main outcomes to evaluate the treatment effectiveness. Results: Among the 34 participants, 64.7% were males and 35.3% were females, with an average age of 62 years and 13 years of long standing diabetes. A total of 54 eyes received an average of 2.3 injections in an average of 7 months' period. The mean BCVA before and after treatment for both drugs respectively 0.19 min and 0.21 min was statistically correlated (p = 0.000). For patients under Lucentis, the mean BCVA before and after medication was 0.20 min-0.24 min and 0.19-0.19 min for those who used Avastin. The mean central retinal thickness (CRT), before and after treatment for both drugs, was 492.22µm-422.89µm, respectively, with a significant correlation (p = 0.003). For patients under Lucentis, the mean CRT decreased from 536.30 µm to 425.19 µm; it dropped from 453.16µm to 421.18µm for patients under Avastin. About 79.4% (27/34) of the participants reported that injections were not affordable and 14.7% (5/34) complained from shortage of one dose, regardless of which type of treatment. Glycaemia control, duration of treatment, type and frequency of injections used were found to be the most contributing factors to the effectiveness of anti-VEGF medications. Conclusion: Both anti-VEGF medications are effective in treating DME, Lucentis showed better improvements in BCVA and macular thickness than Avastin. Policymakers in Sudan require urgent alternative strategies to increase access to these medications.

Satisfaction with Care and Satisfaction with Decision Making are Similar Regardless of Staffing Model in a Neurocritical Care Unit.

INTRODUCTION: Patient-centered care, particularly shared medical decision making, is difficult to measure in critically ill patients where decisions are often made by a designated surrogate, often receiving information from multiple providers with varying degrees of training. The purpose of this study was to compare short-term satisfaction with care and decision making in patients or surrogates between two neurocritical care units [one staffed by a neurocritical care attending and advanced practice providers (APPs) and one staffed by a neurocritical care attending and resident/fellow trainees] using the Family Satisfaction in the ICU (FS-ICU) survey. METHODS: Over a 6-month period, the FS-ICU was administered on a tablet device to patients or surrogates at least 24 h after admission and stored on REDCap database. RESULTS: One hundred and thirty-four patients or surrogates completed the FS-ICU. The response rates were 59.97% and 46.58% in the APP and trainee units, respectively. There were no differences in patient age, sex, ventilator days or ICU length of stay. Overall, there were no differences in satisfaction with care or perceived shared medical making between the units. Respondents who identified their relationship with the patient as "other" (not a spouse, parent, nor a sibling) were less satisfied with care. Additionally, surrogates who identified as parents of the patient were more satisfied with degree of shared medical decision making. CONCLUSION: This study showed that: (1) collecting FS-ICU in a neurocritical care unit is feasible, (2) overall there is no difference in short-term satisfaction with care or shared decision making between a NICU staffed with trainees compared to one staffed with APPs, and (3) parents of patients have a higher short-term satisfaction with degree of shared medical decision making.

False-Negative Platelet Factor 4 Antibodies and Serotonin Release Assay and the Utility of Repeat Testing in the Diagnosis of Heparin-Induced Thrombocytopenia and Thrombosis.

OBJECTIVE: To report a case of false-negative serological tests in the diagnosis of heparin-induced thrombocytopenia (HIT) followed by a brief review of the literature on this topic. CASE PRESENTATION: A 75-year-old Caucasian female patient was admitted with a traumatic right ankle fracture that required open reduction and internal fixation. Despite postoperative subcutaneous heparin chemoprophylaxis, she developed deep vein thrombosis (DVT) and pulmonary embolism (PE) on day 4 and subsequently started on continuous heparin infusion. On day 5, she suffered a stroke from a complete occlusion of the right common carotid artery with tandem occlusion of the right middle cerebral artery. She underwent successful thrombectomy of both arteries. The proposed stroke mechanism was paradoxical embolism through a patent foramen ovale. Over the next few days, thrombocytopenia was noted, the heparin drip was stopped, and HIT antibodies (antibodies targeting the complex of platelet factor 4 and heparin; PF4-H AB) and serotonin release assay (SRA) tests were sent. Because of the suspicion for HIT, she was started on bivalirudin with subsequent improvement in platelet count. Initial PF4-H AB and SRA tests were negative, bivalirudin was stopped, and heparin was restarted. Subsequently, her platelets trended down, again raising clinical suspicion of HIT. Repeat PF4-H AB and SRA testing resulted positive. CONCLUSIONS: A positive SRA in the appropriate context is considered for the diagnosis of heparin-induced thrombocytopenia. This case report highlights that false-negative serological evaluation is possible early in the course of the disease. Repeat testing is recommended in patients with high clinical suspicion.