Assessment of Inspiratory Effort in Spontaneously Breathing COVID-19 ARDS Patients Undergoing Helmet CPAP: A Comparison between Esophageal, Transdiaphragmatic and Central Venous Pressure Swing.

INTRODUCTION: The clinical features of COVID-19 are highly variable. It has been speculated that the progression across COVID-19 may be triggered by excessive inspiratory drive activation. The aim of the present study was to assess whether the tidal swing in central venous pressure (ΔCVP) is a reliable estimate of inspiratory effort. METHODS: Thirty critically ill patients with COVID-19 ARDS underwent a PEEP trial (0-5-10 cmH2O) during helmet CPAP. Esophageal (ΔPes) and transdiaphragmatic (ΔPdi) pressure swings were measured as indices of inspiratory effort. ΔCVP was assessed via a standard venous catheter. A low and a high inspiratory effort were defined as ΔPes ≤ 10 and >15 cmH2O, respectively. RESULTS: During the PEEP trial, no significant changes in ΔPes (11 [6-16] vs. 11 [7-15] vs. 12 [8-16] cmH2O, p = 0.652) and in ΔCVP (12 [7-17] vs. 11.5 [7-16] vs. 11.5 [8-15] cmH2O, p = 0.918) were detected. ΔCVP was significantly associated with ΔPes (marginal R2 0.87, p < 0.001). ΔCVP recognized both low (AUC-ROC curve 0.89 [0.84-0.96]) and high inspiratory efforts (AUC-ROC curve 0.98 [0.96-1]). CONCLUSIONS: ΔCVP is an easily available a reliable surrogate of ΔPes and can detect a low or a high inspiratory effort. This study provides a useful bedside tool to monitor the inspiratory effort of spontaneously breathing COVID-19 patients.

Relationship between positive end-expiratory pressure levels, central venous pressure, systemic inflammation and acute renal failure in critically ill ventilated COVID-19 patients: a monocenter retrospective study in France.

BACKGROUND: The role of positive pressure ventilation, central venous pressure (CVP) and inflammation on the occurrence of acute kidney injury (AKI) have been poorly described in mechanically ventilated patient secondary to coronavirus disease 2019 (COVID-19). METHODS: This was a monocenter retrospective cohort study of consecutive ventilated COVID-19 patients admitted in a French surgical intensive care unit between March 2020 and July 2020. Worsening renal function (WRF) was defined as development of a new AKI or a persistent AKI during the 5 days after mechanical ventilation initiation. We studied the association between WRF and ventilatory parameters including positive end-expiratory pressure (PEEP), CVP, and leukocytes count. RESULTS: Fifty-seven patients were included, 12 (21%) presented WRF. Daily PEEP, 5 days mean PEEP and daily CVP values were not associated with occurrence of WRF. 5 days mean CVP was higher in the WRF group compared to patients without WRF (median [IQR], 12 mm Hg [11-13] vs. 10 mm Hg [9-12]; P=0.03). Multivariate models with adjustment on leukocytes and Simplified Acute Physiology Score (SAPS) II confirmed the association between CVP value and risk of WRF (odd ratio, 1.97; 95% confidence interval, 1.12-4.33). Leukocytes count was also associated with occurrence of WRF in the WRF group (14 G/L [11-18]) and the no-WRF group (9 G/L [8-11]) (P=0.002). CONCLUSIONS: In mechanically ventilated COVID-19 patients, PEEP levels did not appear to influence occurrence of WRF. High CVP levels and leukocytes count are associated with risk of WRF.

SEVERE MYOCARDITIS WITH CARDIOGENIC SHOCK IN ADULT-ONSET STILL'S DISEASE AFTER mRNA COVID-19 VACCINATION: A CASE OF ATYPICAL PRESENTATION

Background/Aims Adult-onset Still's disease is a systemic inflammatory disease of unknown aetiology. Post-COVID-19 vaccine adult-onset Still's disease has been reported and was associated with only mild myocarditis. Here we report the first case of adult-onset Still's disease after mRNA COVID-19 vaccination presenting with severe myocarditis with acute heart failure and cardiogenic shock. Methods We described the case history of the patient. Results A 72-year-old Chinese woman developed gradual onset of fever, shortness of breath, sore throat, generalised arthralgia, malaise and poor appetite 15 days after receiving the first dose of BNT162b2 mRNA COVID-19 vaccine. Physical examination revealed fever, bilateral ankle oedema and elevated jugular venous pressure. Significant investigation results are shown in Table 1. Extensive viral panel tests (including enterovirus, influenza and cytomegalovirus) were all negative. Echocardiography showed severely reduced left ventricular ejection fraction of 20%. The acute heart failure was complicated by cardiogenic shock requiring intensive care unit admission. Myocarditis was later diagnosed. Although the heart condition subsequently improved, there were persistent fever and arthralgia, as well as the development of generalised maculopapular skin rash. In view of that, series of investigations were performed, which revealed persistent neutrophilic leucocytosis, hyper-ferritinaemia and liver function derangement, while autoimmune panel was grossly unremarkable and septic/viral workup was negative (Table 1). Contrast PET-CT scan showed no features of malignancy. Adult-onset Still's disease was diagnosed, and the patient was treated with oral prednisolone 40mg daily. The patient's condition responded to the treatment;the fever subsided and the leucocyte count and inflammatory markers were normalised, and she was subsequently discharged. Three months after discharge, the patient was clinically well with prednisolone tapered down to 5mg daily. Reassessment echocardiogram showed full recovery with LVEF 60%. Conclusion Severe myocarditis with acute heart failure and cardiogenic shock is a possible initial presentation of adult-onset Still's disease after mRNA COVID-19 vaccination. After exclusion of more common aetiologies, it is important to consider adult-onset Still's disease as one of the differential diagnoses in the presence of compatible features following COVID-19 vaccination, such that appropriate and timely workup and treatment can be offered. (Table Presented).

The diagnosis of spontaneous secondary tension pneumothorax following apparentrecovery from COVID19 pneumonitis

Background: Coronavirus disease 19 has been associated with a plethora of different manifestations of systems affected (including pulmonary, gastro-intestinal, and thrombotic disease) and time to presentation of complications. Pneumothorax has been established as a complication in the literature. However, tension pneumothorax remains a rare presentation with higher mortality. We report a case of secondary tension pneumothorax in a patient following apparent recovery from COVID-19 pneumonitis. Case presentation: Eight days after resolution of COVID-19 pneumonitis symptoms a 51-year-old Caucasian man with no pre-existing pulmonary disease was brought into the emergency department following 48 hours of progressive shortness of breath. Further clinical assessment revealed reduced breath sounds in the right lung, BP was 116/95 mmHg and jugular venous pressure was not elevated. Chest x-ray showed right-sided tension pneumothorax with mediastinal shift. Insertion of a chest drain led to rapid resolution of symptoms and the patient was discharged following full re-expansion of the lung. Conclusion(s): The period of recovery from COVID-19 is variable. Clinicians should consider tension pneumothorax as a possible complication of COVID-19 pneumonitis in patients presenting with type 1 respiratory failure, even after resolution of pneumonitis symptoms and a considerable time period following initial contraction of COVID-19.

The effect of positive pressure ventilation on Acute Kidney Injury (AKI) in COVID-19 Acute Respiratory Distress Syndrome (ARDS). An observational study

Background: Acute kidney injury (AKI) is a common complication of COVID-19 ARDS and is associated with greater risk of mortality (1)). In addition to the direct tubular injury mediated by the virus, indirect mechanisms play a role in AKI development. Positive pressure ventilation, by increasing intrathoracic pressure, leads to a decreased venous return to the heart and to a reduced cardiac output (2). In addition, elevated central venous pressure (CVP) may result in elevated tubular hydrostatic pressure in the encapsulated kidney, which reduces glomerular filtration rate and oxygen delivery (3). We hypothesized that elevated intrathoracic pressure, determined by positive pressure ventilation is associated with an increased risk of AKI. The aim of the study is to assess the association between hemodynamics and ventilatory parameters set during mechanical ventilation and AKI in patients with COVID-19 ARDS. Method(s): This is single center retrospective observational study performed at Papa Giovanni XXIII Hospital Bergamo (Italy). Consecutive patients were enrolled with a diagnosis of COVID-19 and ARDS managed with invasive mechanical ventilation. If patients developed AKI (defined according to KDIGO definition) within 14 days of ICU stay were included in "AKI group", otherwise were classified in "non-AKI group". Demographic characteristics, lab tests and hemodynamic [mean arterial pressure (MAP) and central venous pressure (CVP), fluid balance] and ventilatory parameters [positive end-expiratory pressure (PEEP), plateau pressure (PPlat)] were compared between group using Mann Whitney test. Data are presented as median and 95% CI. Only data registered until the day of the AKI occurrence, in patients in AKI group, or until the day corresponding to the median days between ICU admission and the AKI occurrence calculated before for patients in non-AKI group, were considered for the statistical analysis. Result(s): Among the 140 patients included in the analysis, AKI occurred in 70 (48%) patients and 27 (19%) required continuous renal replacement therapy (CRRT). Table 1 shows comparison between the two groups. Patients in AKI group were older, had higher prevalence of obesity, hypertension and diabetes, had lower MAP and received a greater amount of fluid and furosemide compared to patients in non-AKI group (p<0.05). Only a trend toward a greater CVP was observed in patients with AKI, without reaching a significant difference. Both PEEP and Pplat were set higher in patients with AKI, while the severity of lung disease, measured by PaO2/FiO2 were not different between the two groups. Conclusion(s): In our cohort, higher pressure ventilation was associated with an increased risk of AKI.

Lower central venous pressure target contributes to higher survival among COVID-19 patients

Central venous pressure (CVP) is one of the simplest parameters in limited facilities that are used to assess the potential for fluid overload and even right heart failure. By lowering the CVP target to close to 0-4 mmHg, significant survival results were obtained in COVID-19 patients. Increased pulmonary vascular pressure has been associated with failure of ventilation and oxygenation in the event of respiratory distress due to COVID-19. The small sample size and potential bias of some unrecorded variables such as patient comorbidities, thrombosis, and inflammatory mediators are shortcomings of this study. However, CVP still has the potential to be a convenient tool for assessing the potential increases in the pulmonary vasculature.

Multisystem Inflammatory Syndrome in Children: A Diagnostic Conundrum in a Young Kenyan Boy, October 2021

Introduction/ Background: Multisystem inflammatory syndrome in children is a severe manifestation of COVID-19 infection in children and adolescents. It causes a significant hyper inflammatory response in children and is related to SARS-CoV-2 infection. There is paucity of data on this subject, especially in Sub-Saharan Africa, leading to challenges and delays in diagnosis. Methods: A case of a 17-year Kenyan boy who presented to a tertiary-level facility in Nairobi with abdominal pain and diarrhea for five days, difficulty in breathing and conjunctival injection for 1 day. Three weeks prior to this he had a dry cough and associated sore throat. He hadn't received Covid-19 vaccination. There had been a COVID-19 outbreak at school. Examination at admission revealed he was hypotensive, tachycardic, tachypnoeic, afebrile with normal oxygen saturations. He had distended neck veins with hyperactive precordium and elevated jugular venous pressure, a distended abdomen, tender in the right upper quadrant and a hepatomegaly of 16cm. Results: Investigations revealed multiple organ dysfunction (MOD) including heart failure with reduced ejection fraction (LVEF-30%), acute kidney injury, acute congestive hepatopathy, coagulopathy, elevated inflammation markers and positive SARS-CoV-2 IgG and IgM and a negative COVID 19 PCR test. He received IV antibiotics, daily hemodialysis sessions, inotropic support, high dose steroid therapy and Tocilizumab. He succumbed 8 days after admission. A postmortem revealed necrosis of the glomeruli and tubules, acute hemorrhagic necrosis of hepatocytes with fatty change, hyaline covering alveoli sac inkeeping with acute respiratory distress syndrome. Impact: MIS-C presents a diagnostic challenge and is often mistaken for other medical conditions. This often leads to inappropriate or delayed treatment, hence poor outcomes. A high index of suspicion is warranted. This may present a wakeup call for consideration of extending vaccination to the pediatric age group. Conclusion: Multi-system inflammatory syndrome is a rare COVID 19 complication affecting children and adolescents. It presents difficulty in diagnosis in Kenya considering most adolescents are managed as adults. This case hopes to increase vigilance among health care workers and that more preventive interventions can be implemented to reduce infection in children.

TRANSESOPHAGEAL ECHOCARDIOGRAM GUIDED PULMONARY ARTERY CANNULATION FOR VENO-PULMONARY ARTERY EXTRACORPOREAL MEMBRANE OXYGENATION

Background: Pulmonary arterial (PA) cannulation for veno-pulmonary artery extracorporeal membrane oxygenation (V-Pa ECMO) is a treatment for critically ill patients in respiratory and right ventricular (RV) failure. Conventional fluoroscopic guided PA cannulation does not provide direct visualization of the catheter, PA and pulmonic valve. Complications of sub-optimal catheter placement include PA perforation and inadequate hemodynamic support. The following case study uses transesophageal echocardiogram (TEE) and right heat catheterization to simultaneously assess hemodynamics and directly visualize PA catheter placement to optimize support. Case: A 28 year old male with COVID acute respiratory distress syndrome and multisystem organ failure was placed on venovenous ECMO. He subsequently developed RV dysfunction necessitating PA cannulation for RV support via V-Pa ECMO. Right heart catheterization demonstrated an elevated central venous pressure (CVP), normal pulmonary capillary wedge pressure (PCWP) and elevated CVP/PCWP ratio consistent with RV dysfunction. A Protek Duo catheter was placed with fluoroscopic and TEE guidance. Decision-making:. Conclusion: The TEE clearly demonstrated the outflow cannula was in the main PA and proximal to the PA bifurcation. Fenestrations were observed distal to the pulmonic valve and mechanical flow was observed at the distal tip of the catheter (figure 1). Pulsatile pulmonic regurgitation without mechanical regurgitation was also observed. [Formula presented]

REassessment Campaign On VEterinary Resuscitation: Has the time come for horses?

9 Hoehne, S.N., Hopper, K. and Epstein, S.E. (2019) Prospective evaluation of cardiopulmonary resuscitation performed in dogs and cats according to the RECOVER guidelines. Keywords: horse;cardiopulmonary arrest;CPR;international guidelines;RECOVER EN horse cardiopulmonary arrest CPR international guidelines RECOVER 117 119 3 02/09/22 20220301 NES 220301 It is disconcerting that equine anaesthetic-related fatalities for elective procedures are nearly 10- to 20-fold more frequent than their small animal counterparts, and between 100- and 1000-fold more likely than human anaesthesia-associated fatalities (Brodbelt I et al i . 2008;Li I et al i . 2009;Dugdale I et al i . 2016;Laurenza I et al i . 2019). The RECOVER guidelines, published in the summer of 2012, aimed to systematically review the body of literature on CPR from a veterinary standpoint and to generate practical consensus guidelines to be used in dogs and cats. Horse, CPR, RECOVER, cardiopulmonary arrest, international guidelines. [Extracted from the article] Copyright of Equine Veterinary Education is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

A Novel Non-Invasive Device for the Assessment of Central Venous Pressure in Hospital, Office and Home.

BACKGROUND: Venous congestion can be quantified by central venous pressure (CVP) and its monitoring is crucial to understand and follow the hemodynamic status of patients with cardio-respiratory diseases. The standard technique for CVP measurement is invasive, requiring the insertion of a catheter into a jugular vein, with potential complications. On the other hand, the current non-invasive methods, mainly based on ultrasounds, remain operator-dependent and are unsuitable for use in the home environment. In this paper, we will introduce a novel, non-invasive device for the hospital, office and home assessment of CVP. METHODS: After describing the measurement concept, we will report a preliminary experimental study enrolling 5 voluntary healthy subjects to evaluate the VenCoM measurements' repeatability, and the system's capability in measuring small elicited venous pressure variations (2 mmHg), as well as an induced venous hypertension within a pathological range (12÷20 mmHg). RESULTS: The experimental measurements showed a repeatability of ±1mmHg. The VenCoM device was able to reliably detect the elicited venous pressure variations and the simulated congestive status. DISCUSSION AND CONCLUSION: The proposed non-invasive VenCoM device is able to provide a fast and repeatable CVP estimate, having a wide spectrum of potential clinical applications, including the monitoring of venous congestion in heart failure patients and in subjects with renal and hepatic dysfunction, as well as pulmonary hypertension (PH) that can be extended to pneumonia COVID-19 patients even after recovery. The device needs to be tested further on a large sample size of both healthy and pathological subjects, to systematically validate its reliability and impact in clinical setting.