Midwakh-Associated Acute Lung Injury (MALI) in a 14-Year-Old Male: A Case Report.

Midwakh is one of the most used alternative tobacco products (ATPs) in the UAE, particularly among adolescents. We report a 14-year-old adolescent male, who presented with acute lung injury within 24 hours following the first attempt at Midwakh smoking. A high-resolution computerized tomogram of the chest (HRCT) showed bilateral interstitial pneumonia and patchy consolidation. Flexible bronchoscopy revealed bilateral petechial haemorrhages with oedematous bronchial walls. Mechanical ventilation was required for two weeks. The criteria for moderate acute respiratory distress syndrome (ARDS) were met, and a good response was achieved to a high dose of steroids, and ultra-protective mechanical ventilation with the prone position. Significant clinical and radiological recovery was achieved at three months. As per the literature reviewed, this is the first case of Midwakh-associated acute lung injury reported to date. We emphasize that physicians should be well informed about the use of ATPs and their potential severe complications.

Neonatal extra corporeal membrane oxygenation.

Extracorporeal life support (ECLS) has been proven to be very useful in the neonatal period. For reversible respiratory and cardiac disorders, when maximal conventional measures have failed to provide life support, extracorporeal membrane oxygenation (ECMO) becomes the treatment of choice. The indications, contra-indications for ECMO, optimization of the care prior to embracing ECMO, cannulation techniques, daily management of ECMO from the practical standpoint, weaning and decannulation, complications, and special circumstances in neonatal period have been described. The follow-up of neonatal ECMO and various system manifestations necessitating careful review will be highlighted.

Implementation of new ECMO centers during the COVID-19 pandemic: experience and results from the Middle East and India.

PURPOSE: Extracorporeal membrane oxygenation (ECMO) use for severe coronavirus disease 2019 (COVID-19) patients has increased during the course of the pandemic. As uncertainty existed regarding patient's outcomes, early guidelines recommended against establishing new ECMO centers. We aimed to explore the epidemiology and outcomes of ECMO for COVID-19 related cardiopulmonary failure in five countries in the Middle East and India and to evaluate the results of ECMO in 5 new centers. METHODS: This is a retrospective, multicenter international, observational study conducted in 19 ECMO centers in five countries in the Middle East and India from March 1, 2020, to September 30, 2020. We included patients with COVID-19 who received ECMO for refractory hypoxemia and severe respiratory acidosis with or without circulatory failure. Data collection included demographic data, ECMO-related specific data, pre-ECMO patient condition, 24 h post-ECMO initiation data, and outcome. The primary outcome was survival to home discharge. Secondary outcomes included mortality during ECMO, survival to decannulation, and outcomes stratified by center type. RESULTS: Three hundred and seven COVID-19 patients received ECMO support during the study period, of whom 78 (25%) were treated in the new ECMO centers. The median age was 45 years (interquartile range IQR 37-52), and 81% were men. New center patients were younger, were less frequently male, had received higher PEEP, more frequently inotropes and prone positioning before ECMO and were less frequently retrieved from a peripheral center on ECMO. Survival to home discharge was 45%. In patients treated in new and established centers, survival was 55 and 41% (p = 0.03), respectively. Multivariable analysis retained only a SOFA score < 12 at ECMO initiation as associated with survival (odds ratio, OR 1.93 (95% CI 1.05-3.58), p = 0.034), but not treatment in a new center (OR 1.65 (95% CI 0.75-3.67)). CONCLUSIONS: During pandemics, ECMO may provide favorable outcomes in highly selected patients as resources allow. Newly formed ECMO centers with appropriate supervision of regional experts may have satisfactory results.

Vascular access in ECMO.

In critically ill patients, deserving extracorporeal membrane oxygenation (ECMO), choosing the right pattern of cannulation such as veno-venous (VV), veno-arterial (VA), veno-veno-arterial (VVA), and central; selecting the appropriate size cannulae; and good cannulation techniques are all pre-requisites for the successful outcome of ECMO. We are describing the selection criteria for choosing appropriate size cannulae, cannulation configurations, available cannulae, and possible complications. A brief note on anticoagulation was added.

ECMO in India, SWAAC ELSO: challenges and solutions.

The innovations leading to the development of a new technology such as extracorporeal membrane oxygenation (ECMO) and its progress over the years have been inspiring. Many great personalities were associated with the genesis and re-designing the multiple essential components of ECMO to make it more biocompatible. We discussed the brief history of cardiopulmonary bypass and ECMO. We elucidated the establishment of a commanding center, Extracorporeal Life Support Organization (ELSO) in the USA, ECMO society of India in the sub-continent and the birth of South and West Asia Chapter (SWAC) of ELSO initially, which became South and West Asia, Africa chapter (SWAAC) ELSO later after amalgamation of Africa to this sub-chapter of ELSO.

Blunt laryngeal trauma presenting as bilateral massive pneumothoraces and subcutaneous emphysema: a multidisciplinary approach to management.

A 3-year-old boy had an unwitnessed fall from a highchair. The child had no loss of consciousness, vomiting, stridor or respiratory distress but within a few minutes had significant swelling in the neck, scalp and around the eyes. He was brought immediately to the emergency room where he deteriorated rapidly and was intubated with a cuffed oral endotracheal tube. A clinical diagnosis of blunt laryngeal trauma was made. Imaging showed no laryngeal disruption, but did reveal massive bilateral pneumothoraces, that were managed with chest tube. A multidisciplinary meeting with family led to a watchful waiting approach. The patient was successfully extubated at 1 week and healed with a clear voice.

Pneumocephalus in neonatal meningitis: diffuse, necrotizing meningo-encephalitis in Citrobacter meningitis presenting with pneumatosis oculi and pneumocephalus.

UNLABELLED: OBJECTIVE/PATIENT: Gas-containing encephalitis is rarely associated with neonatal meningitis. We report a case of a 19-day-old baby who presented with a rapid onset of septic shock complicated by progressively increasing gas accumulation within the brain and anterior chamber of the eye. We describe the evolution of the clinical picture and the management. INTERVENTIONS: Ventilatory support, fluid resuscitation, and continuous venovenous hemofiltration were provided in view of multiple system failure. Despite effective antibiotic therapy and supportive management, the patient died with worsening accumulation of gas within the brain, resulting in brainstem death. RESULTS: Computed tomographic images were characteristic of diffuse necrotizing meningo-encephalitis. Postmortem examination showed friable brain tissue with venous infarction and extensive gas accumulation. Citrobacter koseri was identified from the blood and cerebrospinal fluid cultures. CONCLUSION: This case re-emphasises the importance of C. koseri as both a community-acquired and nosocomial neonatal pathogen. Radiologic evidence suggestive of diffuse necrotizing meningo-encephalitis in combination with pneumocephalus and pneumatosis oculi in Citrobacter infections has never been described before. Diagnostic imaging with computed tomographic scanning of the brain and initiation of broad-spectrum antibiotics with good penetration into cerebrospinal fluid are indicated as soon as infection with Citrobacter species is suspected clinically, with appearance of pneumatosis oculi as a rare, late finding.