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This chapter gives a broad overview of nephrology as it affects hospitalists while also hoping to answer a few of the essential questions hospitalists may ask their nephrology colleagues. Evaluation and treatment of both acute and chronic kidney disease is constantly evolving as the small but tight-knit community of hospital-nephrologists continue to collect, review, and research data. The majority of the chapter will be focused on discussing a few new updates in the field of nephrology and how these updates could potentially change hospital care. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.
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SARS-CoV-2 is a highly contagious virus that can affect almost any system in the body. New developments in understanding its transmissibility, management, and sequelae are unfolding almost daily. However, no medical publication in 2021 would be complete without a snapshot of the current status of this pandemic. The virus continues to mutate to more contagious, and therefore more dangerous, strains. The best path forward through this pandemic is vaccination against SARS-CoV-2 for all those who are eligible. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.
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SESSION TITLE: Critical Care in Chest Infections Case Report Posters 1 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: The "common cold” is a syndrome defined by upper respiratory symptoms in addition to: rhinorrhea, fever, chills, headache, and/or malaise. Classically "colds” are thought of as a mild, self-limiting disease;however, they can cause severe respiratory symptoms in immunocompetent individuals. We present a case of severe acute respiratory distress syndrome (ARDS) caused by the Human Rhinovirus in an immunocompetent host. CASE PRESENTATION: 61-year-old gentleman with a past medical history significant for hypertension presented to an outside hospital for worsening shortness of breath, fatigue, and cough with production x 3 weeks. Social history is notable that he had a 12-pack-year history and quit smoking tobacco approximately 10 years ago. On arrival, the patient was noted to be hypoxic with percent saturation of 88% on 2 L nasal cannula. He rapidly deteriorated and required intubation 5 days after admission. The patient subsequently transferred to a tertiary care intensive care unit for further workup and management. Upon arrival at the tertiary care center, he was found to have a PaO2/FiO2 ratio of 71 and ARDS protocol was initiated. Despite pronation, paralyzation, dexamethasone, and nitric oxide, the patient continued to deteriorate. Three COVID-19 PCR's and COVID-19 antibody resulted negative. Extensive work-up including fungal, autoimmune, viral, and bacterial were negative with the exception of a positive rhinovirus PCR. MRI brain was completed due to patient's unequal pupils which demonstrated numerous recent infarcts of the bilateral cerebral and cerebellar hemispheres with mass-effect with mild leftward shift. The family ultimately decided to pursue comfort measures and the patient died. DISCUSSION: Human Rhinovirus is responsible for ? to ½ of common colds in adults making it the most common cause of "colds.” Due to its more than 100 serotypes, an average adult has approximately 2-3 Rhinovirus infections per year. Rhinovirus infections are classically thought to be self-resolving and mild, particularly in the immunocompetent. However, several recent studies have shown coinfection of the rhinovirus in patients with community acquired pneumonia;although these studies have been unable to tease out how clinically significant the rhinovirus infection was in these patients. The patient case above is an example that the Rhinovirus may be a more important culprit in community-acquired pneumonia than previously suspected. In addition to its possible respiratory conditions, studies have demonstrated an increase in risk of stroke. Currently, there are no FDA-approved antivirals for the Human Rhinovirus, treatment largely aimed to reduce symptomatology. CONCLUSIONS: The medical community, in large, thinks of the Rhinovirus as a relatively benign disease process. Though this may be the case in most patients, even immunocompetent individuals can suffer from serious complications of the virus. Reference #1: Chu HY;Englund JA;Strelitz B;Lacombe K;Jones C;Follmer K;Martin EK;Bradford M;Qin X;Kuypers J;Klein EJ;"Rhinovirus Disease in Children Seeking Care in a Tertiary Pediatric Emergency Department.” Journal of the Pediatric Infectious Diseases Society, U.S. National Library of Medicine, https://pubmed.ncbi.nlm.nih.gov/26908489/. Reference #2: JO;, Proud D;Naclerio RM;Gwaltney JM;Hendley. "Kinins Are Generated in Nasal Secretions during Natural Rhinovirus Colds.” The Journal of Infectious Diseases, U.S. National Library of Medicine, https://pubmed.ncbi.nlm.nih.gov/2295843/. Reference #3: Subramanian, A., et al. "Stroke Following Positive Biomarker for Viral Respiratory Illnesses.” B47. CRITICAL CARE: NON-PULMONARY CRITICAL CARE, 2020, https://doi.org/10.1164/ajrccm-conference.2020.201.1_meetings.a3566. DISCLOSURES: No relevant relationships by Philip Forys No relevant relationships by Brandon Pearce
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TYPE: Case Report TOPIC: Procedures INTRODUCTION: With the emergence of COVID-19, our institution has seen an increase in the number of tracheostomies performed. We describe a case of a bedside percutaneous tracheostomy complicated by injury to an innominate artery that prompted multidisciplinary discussions on best practices for preoperative evaluation. CASE PRESENTATION: A 63-year-old lady presented with acute metabolic encephalopathy after suffering a seizure the day prior. She was intubated for airway protection but failed to extubate despite her chief complaint resolving. The decision was made to perform a bedside percutaneous tracheostomy on day thirteen of ventilator support. The procedure was complicated by an incidental injury to a high-riding innominate artery. The patient was emergently taken to the operating room where she underwent a sternotomy and coronary artery bypass with repair to the innominate artery. She was then transferred to the cardiovascular transplant unit in critical condition. DISCUSSION: Bedside tracheostomies are becoming more frequent due to convenience, lower cost, and lower infection rates. There are no official recommendations to perform imaging prior to performing a bedside tracheostomy to evaluate for vascular structures that could be damaged and lead to significant morbidity and mortality unless palpated pulses are present. Portable ultrasonography has the ability to lower the frequency of hemorrhagic complications by detecting pre-tracheal vessels. CONCLUSIONS: As bedside tracehsomties increase in prevalence, there should be a standardized preoperative assessment that includes portable ultrasound prior to tracheostomies to decrease hemorrhagic complications. DISCLOSURE: Nothing to declare. KEYWORD: tracheostomy
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TOPIC: Procedures TYPE: Medical Student/Resident Case Reports INTRODUCTION: It is estimated that approximately 33% of ICU patients require a central venous catheter (CVC). More than 15% of these patients have complications. The use of ultrasound guidance significantly decreases the risk of complications during catheter placement when compared with the standard landmark placement technique. We describe a case of a CVC that was placed and subsequently used in the carotid artery;a complication that could have been avoided with proper ultrasound-guided technique. CASE PRESENTATION: A 67 year-old gentleman with a significant past medical history of coronary artery disease, hyperlipidemia, and diabetes mellitus was admitted to an outside hospital for acute hypoxic respiratory failure secondary to COVID-19. A right internal jugular central line was placed due to poor peripheral access. Chest X-ray (CXR) reported "right IJ catheter tip overlies SVC ” and thus the central line was used for medication administration. The following morning, he exhibited expressive aphasia and altered mentation;head CT demonstrated acute right posterior cerebral artery infarction. The patient was transferred to a hospital with specialized neurological care. Upon arrival, it was noted that blood aspirated from the catheter appeared arterial. The catheter was placed on arterial pressure monitoring which revealed an arterial waveform with a MAP of 94 and partial pressure of oxygen of the blood aspirated from the catheter was 98. Computer tomography of the chest demonstrated the venous catheter was in the carotid artery and deviation of the heart to the right. The patient ultimately developed uncal and subfalcine hernia secondary to hemorrhagic transformation of the infarct and passed away. DISCUSSION: The case above illustrates the importance of proper ultrasound-guided technique when placing central venous catheters. On CXR imaging, anatomical variation gave the illusion that the CVC was located in the superior vena cava when in fact it was located in the ascending aorta. In addition to aiding in the proper placement of the CVC, utilization of the ultrasound would also allow the operator to confirm the location of the CVC prior to its use, avoiding this devastating complication. CONCLUSIONS: The placement of CVC's will always come with complication risks;however, using proper ultrasound technique can reduce the frequency of these complications. REFERENCE #1: Gershengorn, Hayley B, et al. "Variation of Arterial and Central Venous Catheter Use in United States Intensive Care Units.” Anesthesiology, U.S. National Library of Medicine, Mar. 2014, www.ncbi.nlm.nih.gov/pmc/articles/PMC4145875/#:~:text=Rates%20of%20AC%20use%20have, in%20certain%20ICU%20patient%20subgroups.&text=Reported%20rates%20of%20CVC%20usage, to%2091%25%20for%20ICU%20patients. REFERENCE #2: McGee, David C., et al. "Preventing Complications of Central Venous Catheterization: NEJM.” New England Journal of Medicine, 26 June 2003, www.nejm.org/doi/10.1056/NEJMra011883?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%2B%2B0www.ncbi.nlm.nih.gov. REFERENCE #3: MK;, McGee DC;Gould. "Preventing Complications of Central Venous Catheterization.” The New England Journal of Medicine, U.S. National Library of Medicine, pubmed.ncbi.nlm.nih.gov/12646670/. DISCLOSURES: No relevant relationships by Brandon Pearce, source=Web Response No relevant relationships by Elise Porter, source=Web Response No relevant relationships by Thomas Preston, source=Web Response