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Objectives: Assessment of the literature on the ProtekDuo cannula when used as venopulmonary (V-P) extracorporeal membrane oxygenation (ECMO) in ARDS secondary to COVID-19. Method(s): Systematic literature search in EMBASE, Medline (Pubmed) and NHS library using appropriate keywords as well as PICOS and PRISMA approach. Result(s): We found 285 publications, of which 5 publications met the search criteria and were included in this review. A total of 194 patients with COVID-19 related ARDS had a ProtekDuo placed to establish venovenous (V-V) ECMO and right ventricular (RV) support. Patients treated with the ProtekDuo cannula had survival rates between between the studies of 59 and 89%, with a significant survival compared to an invasive ventilation group or when compared to dual site V-V ECMO or other double lumen ECMO cannulas. One of the studies focused on extubation and early discontinuation of ventilator support, which the authors achieved in 100% of ProtekDuo patients. The incidence of acute kidney injury (AKI) and use of continuous renal replacement therapy (CRRT) was significantly reduced in the ProtekDuo versus other groups. Conclusion(s): The ProtekDuo displayed lower mortality rates, AKI occurrence and CRRT need as compared to other respiratory support modalities and has shown to be a game changer for ECMO support in patients suffering from COVID-19 ARDS. Many authors suggested the ProtekDuo for first line use in these patients.
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BACKGROUND: Coronavirus disease 2019 (COVID-19) patients with acute respiratory failure who experience delayed initiation of invasive mechanical ventilation have poor outcomes. The lack of objective measures to define the timing of intubation is an area of concern. We investigated the effect of timing of intubation based on respiratory rate-oxygenation (ROX) index on the outcomes of COVID-19 pneumonia. METHODS: This was a retrospective cross-sectional study performed in a tertiary care teaching hospital in Kerala, India. Patients with COVID-19 pneumonia who were intubated were grouped into early intubation (within 12 hours of ROX index <4.88) or delayed intubation (12 hours or more hours after ROX <4.88). RESULTS: A total of 58 patients was included in the study after exclusions. Among them, 20 patients were intubated early, and 38 patients were intubated 12 hours after ROX index <4.88. The mean age of the study population was 57±14 years, and 55.0% of the patients were male; diabetes mellitus (48.3%) and hypertension (50.0%) were the most common comorbidities. The early intubation group had 88.2% successful extubation, while only 11.8% of the delayed group had successful extubation (P<0.001). Survival was also significantly more frequent in the early intubation group. CONCLUSIONS: Early intubation within 12 hours of ROX index <4.88 was associated with improved extubation and survival in patients with COVID-19 pneumonia.
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BACKGROUND: Pneumonia from COVID-19 that results in ARDS may require invasive mechanical ventilation. This retrospective study assessed the characteristics and outcomes of subjects with COVID-19-associated ARDS versus ARDS (non-COVID) during the first 6 months of the COVID-19 pandemic in 2020. The primary objective was to determine whether mechanical ventilation duration differed between these cohorts and identify other potential contributory factors. METHODS: We retrospectively identified 73 subjects admitted between March 1 and August 12, 2020, with either COVID-19-associated ARDS (37) or ARDS (36) who were managed with the lung protective ventilator protocol and required > 48 h of mechanical ventilation. Exclusion criteria were the following: <18 years old or the patient required tracheostomy or interfacility transfer. Demographic and baseline clinical data were collected at ARDS onset (ARDS day 0), with subsequent data collected on ARDS days 1-3, 5, 7, 10, 14, and 21. Comparisons were made by using the Wilcoxon rank-sum test (continuous variables) and chi-square test (categorical variables) stratified by COVID-19 status. A Cox proportional hazards model assessed the cause-specific hazard ratio for extubation. RESULTS: The median (interquartile range) mechanical ventilation duration among the subjects who survived to extubation was longer in those with COVID-19-ARDS versus the subjects with non-COVID ARDS: 10 (6-20) d versus 4 (2-8) d; P < .001. Hospital mortality was not different between the two groups (22% vs 39%; P = .11). The competing risks Cox proportional hazard analysis (fit among the total sample, including non-survivors) revealed that improved compliance of the respiratory system and oxygenation were associated with the probability of extubation. Oxygenation improved at a lower rate in the subjects with COVID-19-associated ARDS than in the subjects with non-COVID ARDS. CONCLUSIONS: Mechanical ventilation duration was longer in subjects with COVID-19-associated ARDS compared with the subjects with non-COVID ARDS, which may be explained by a lower rate of improvement in oxygenation status.
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BACKGROUND: Several studies have suggested that high-flow nasal cannula (HFNC) is useful for respiratory support after extubation in subjects with COVID-19 pneumonia, whereas 18.2% subsequently needed to undergo re-intubation. This study aimed to evaluate whether the breathing frequency (f)-ratio of oxygen saturation (ROX) index, which has been shown to be useful for predicting future intubation, is also useful for re-intubation in subjects with COVID-19. METHODS: We retrospectively analyzed mechanically ventilated subjects with COVID-19 who underwent HFNC therapy after extubation at 4 participating hospitals between January 2020-May 2022. We evaluated the predictive accuracy of ROX at 0, 1, and 2 h for re-intubation until ICU discharge and compared the area under the receiver operating characteristic (ROC) curve of the ROX index with those of f and SpO2 /FIO2 . RESULTS: Among the 248 subjects with COVID-19 pneumonia, 44 who underwent HFNC therapy after extubation were included. A total of 32 subjects without re-intubation were classified into the HFNC success group, and 12 with re-intubation were classified into the failure group. The overall trend that the area under the ROC curve of the ROX index was greater than that of the f and SaO2 /FIO2 was observed, although there was no statistical significance at any time point. The ROX index at 0 h, at the cutoff point of < 7.44, showed a sensitivity and specificity of 0.42 and 0.97, respectively. A trend of positive correlation between the time until re-intubation and ROX index at each time point was observed. CONCLUSIONS: The ROX index in the early phase of HFNC therapy after extubation was useful for predicting re-intubation with high accuracy in mechanically ventilated subjects with COVID-19. We may need close observation for subjects with < 7.44 ROX index just after extubation because of their high risk for re-intubation.
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Hepatitis A is a common viral infection worldwide that is transmitted via the fecal-oral route. Since the introduction of an efficient vaccine, the incidence of infection has decreased but the number of cases has risen due to widespread community outbreaks among unimmunized individuals. Classic symptoms include fever, malaise, dark urine, and jaundice, and are more common in older children and adults. People are often most infectious 14 days prior to and 7 days following the onset of jaundice. We will discuss the case of a young male patient, diagnosed with acute hepatitis A, leading to fulminant hepatitis refractory to conventional therapy and the development of subsequent kidney injury. The medical treatment through the course of hospitalization was challenging and included the use of L-ornithine-L-aspartate and prolonged intermittent hemodialysis, leading to a remarkable outcome. Hepatitis A is usually self-limited and vaccine-preventable;supportive care is often sufficient for treatment, and chronic infection or chronic liver disease rarely develops. However, fulminant hepatitis, although rare, can be very challenging to manage as in the case of our patient.Copyright © 2023 The Author(s).
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Introduction: COVID-19 pneumonia can result in significant morbidity and mortality in affected individuals. Our audit aims to study the respiratory outcomes of patients with COVID-19 pneumonia following the use of HFNC and NIV during the second wave of the pandemic. Method(s): We analysed the outcomes of 94 patients admitted to a tertiary combined HDU/ICU with severe COVID-19 pneumonia requiring non-invasive support between July and December 2021. Result(s): 94 patients were admitted during the study period. ICU mortality rate was 22% (21/94), total in-hospital mortality was 38% (36/94). HFNC was used as first line respiratory support in 58/94 cases, of which 39.6% required intubation. Of those patients who failed HFNC, time to intubation was significantly higher in those patients who passed away than those who were intubated and survived (mean 6.08 days vs 2.86 days, p < 0.05 one sided T-test). In all patients, very late intubation defined as intubation > 5d post admission to ICU, occurred in 6/41 patients, of which the mortality rate was 100%. ROX score performed at 12 h post intubation was unable to discriminate those who succeeded with HFNC and those who required intubation (mean ROX 7.24 vs 7.9, p > 0.05). NIV was used in combination with HFNC pre-intubation in 5/23 HFNC cases with 100% mortality rate. Extubation failure rates were low (5/94) and use of tracheostomy was uncommon (4/94;all 4 survived ICU stay, 3 eventually died in hospital). Conclusion(s): HFNC failure with prolonged use of HFNC and use of multiple non-invasive device strategies before intubation was associated with a high risk of mortality. Conventional measurements of HFNC failure in the form of a 12 h ROX score could not assist the clinician in predicting those patients at risk of HFNC failure.
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Introduction: Patients with COVID-19-related acute respiratory distress syndrome (ARDS) require respiratory support with invasive mechanical ventilation and show varying responses to recruitment manoeuvres. In patients with ARDS not related to COVID-19, two pulmonary subphenotypes that differed in recruitability were identified using latent class analysis (LCA) of imaging and clinical respiratory parameters [1]. We aimed to validate these phenotypes and evaluate if similar subphenotypes are present in patients with COVID-19-related ARDS. Method(s): This is the retrospective analysis of mechanically ventilated patients with COVID-19-related ARDS who underwent CT scans at positive end-expiratory pressure of 10 cmH2O and after a recruitment manoeuvre at 20 cmH2O. LCA was applied to quantitative CT-derived parameters, clinical respiratory parameters, blood gas analysis and routine laboratory values before recruitment to identify subphenotypes. Result(s): 99 patients were included. Using 12 variables, a two-class LCA model was identified as best fitting. Subphenotype 2 (recruitable) was characterized by a lower PaO2/ FiO2, lower normally aerated lung volume and lower compliance as opposed to a higher nonaerated lung mass and higher mechanical power when compared to subphenotype 1 (non-recruitable) (Fig. 1). Patients with subphenotype 2 had more decrease in non-aerated lung mass in response to a standardized recruitment manoeuvre (p = 0.024) and were mechanically ventilated longer until successful extubation (adjusted SHR 0.46, 95% CI 0.23-0.91, p = 0.026), while no difference in survival was found (p = 0.814). Conclusion(s): A recruitable and non-recruitable subphenotype were identified in patients with COVID-19-related ARDS. The subphenotypes are similar to non-COVID-19-related ARDS and are promising for identification of recruitable patients in future practice as they can be classified with only few clinically available parameters before the recruitment manoeuvre.
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Outcomes: 1. Self-report the ability to use a palliative extubation simulation curriculum to teach key palliative care topics to learners across various levels. 2. Self-report the ability to mitigate communication and procedural errors associated with suboptimal palliative extubations to provide maximum comfort for patients and families at end of life. Background(s): The COVID-19 pandemic revealed gaps in the provision of end-of-life (EOL) care. In particular, the high number of mechanically ventilated patients at the EOL highlighted the need to standardize evidence-based palliative extubation (PE) amidst significant practice variation. Suboptimal PE practices can worsen symptoms, inappropriately hasten death, and add undue stress on patients, families, and healthcare staff. Effective training models are needed to standardize evidence-based PE. Simulation-based learning (SBL) has been shown to effectively improve medical knowledge, procedural proficiency, and interprofessional communication, all of which are necessary to successfully perform a PE. Unfortunately, the use of SBL in palliative care (PC) education is sparse. Method(s): An innovative educational activity using high-fidelity simulation and SBL models was created to teach key PC topics and skills within the context of a simulated PE procedure. The curriculum consists of a 1-hour didactic followed by 2 hours of simulation, divided into 4 sections. The simulation is designed to teach complex symptom management, communication strategies, and leadership skills. Each section concludes with a debrief to provide feedback and teaching points. This curriculum was piloted over multiple years among palliative medicine fellows. It will expand to include medical students this academic year with the plan to be further incorporated into medical resident education in the future. The following validated questionnaires will be used to study the efficacy of this SBL model: Student Satisfaction and Self-Confidence in Learning Scale, Simulation Design Scale, and Educational Practices Questionnaire. Participants will complete the questionnaires following the simulation. Conclusion(s): Multiple specialties have adopted SBL as an effective modality to enhance training. The use of SBL in palliative medicine education is relatively sparse. An innovative PE-simulation educational activity may provide an optimal way to teach key PC concepts across graduate and undergraduate medical education.Copyright © 2023
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Background SituationOn day 24 of life, a pre-term neonate (GA at birth 31+2 weeks) with achondroplasia tested SARS-CoV-2 positive on PCR. The patient was ventilated for increasing oxygen requirements, eventually necessitating transfer to the regional PICU. Meeting the clinical case definition for severe acute respiratory COVID-19, the patient was initiated on hydrocortisone 0.5 mg/kg BD as per Scottish Paediatric Consensus Guidelines for COVID-19.1 Respiratory decline, with bilateral consolidation on chest X-Ray led to oscillation on day 27 of life. An MDT was set up to consider next steps. There is a paucity of evidence for managing severe acute respiratory COVID-19 in this age group. The MDT considered unlicensed use of tocilizumab (TOC) and remdesivir (RDV) as potential therapies. Evidence on the utility of RDV in severe acute COVID-19 is conflicting.2 3 TOC use in <18 years is extrapolated from adult data, with sparse dosing information in <1 years. CRP remained below adult threshold (44). Concern regarding immunosuppressive effect of TOC was raised as secondary bacterial infection had not been excluded. On balance, the MDT concluded RDV be offered as the ‘next step' treatment option. Renal and liver function were normal pre-RDV (ALT 19, AST 57), however within 48hour (2 doses) of RDV, transaminases had increased to >5x ULN (ALT 354, AST 873). Clinical status remained otherwise stable, and no other changes to medication were identified, thus the decision was made to withdraw RDV as the likely cause. 48 hours post withdrawal transaminases has normalised. The patient clinically improved over the next 5 days and was extubated ~7 days later.Clinical ContributionPharmacy played a significant role in the MDT, and were heavily involved in all risk:benefit decision making. Initial literature searches were conducted to establish current data on both TOC and RDV in this age group. A Phase 2/3 trial protocol evaluating RDV safety, tolerability and pK in COVID-19 patients from birth-18 years was obtained to further guide decision making. Assessment of treatment eligibility based on UK CAS alert and the Phase 2/3 study was undertaken, along with assessment of baseline clinical parameters. On MDT decision to treat, Pharmacy supported in the ULM application process (internal and Gilead compassionate access scheme) and advised on dosing, administration and monitoring. Pharmacy played a pivotal role in monitoring and recognition of adverse events. On identifying rapidly developing transaminitis, a full review was undertaken to determine RDV as a likely causative agent to support the decision to withdraw treatment. A Yellow Card was completed.ConclusionDespite withdrawal of RDV after only 2 days, the patient clinically improved and was extubated and discharged a short time after, raising the question as to whether RDV offered any clinical benefit in this case. Managing severe acute COVID-19 in neonates presents a significant challenge for clinical teams. There remains a paucity of evidence in this age group.4 Treatment decisions are made on a case-by-case basis, however outcomes are rarely published. More evidence is required before significant conclusions can be drawn about the utility or safety profile of RDV in neonates.ReferencesPollock L, McLellan K. ‘Scottish Paediatric Consensus Treatment Guidelines for COVID-19 and related conditions', produced by Scottish Hyperinflammatory MDT;NHS GG&C Clinical Guidelines;2020, V3.Beigel J, Tomashek K, Dodd L, et al. Remdesivir for the treatment of COVID-19- final report. New England Journal of Medicine 2020;383:1813–1826.Hongchao P, Peto R, Henao-Restrepo AM, et al. Repurposed antiviral drugs for COVID-19 – interim WHO solidarity trail results (WHO Solidarity Trail Consortium). New England Journal of Medicine 2021;384:497–511.Swann O, Holden K, Turtle L, et al. Clinical characteristics of children and young people admitted to hospital with COVID-19 in the United Kingdom: prospective multicentre observational cohort study. BMJ 2020;370:m3249.
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Introduction: During the COVID-19 pandemic, the number of patients who required admission to the intensive care unit (ICU) and prolonged intubation (ETI) or a tracheotomy (TT) due to severe ARDS has increased. Causes of persistent dyspnea after severe COVID-19 pneumonia include diffuse lung disease and pulmonary embolism. However, other causes of persistent dyspnea need to be ruled out in COVID-19 ICU-survivors, including iatrogenic tracheal stenosis (TS). Iatrogenic TS account for 50% of the 15-20 patients evaluated every year in the laryngotracheal multidisciplinary team (MDT) of our center. The management of these patients requires an individualized and multidisciplinary assessment, including Interventional Pulmonologists, Thoracic Surgeons and Otolaryngologists. The objective of this study was to describe the cases of iatrogenic TS after severe pneumonia due to COVID-19. Material(s) and Method(s): A descriptive study of the cases of iatrogenic TS in COVID-19 ICU-survivors evaluated at our center's MDT, from the end of the first wave to present. Result(s): A total of 10 patients were included, 70% were women, with a median age of 60 years [53.5-64.5]. The median ICU stay was 58.5 days [34-91]. All patients were intubated and 9 of them (90%) required TT, in 2 cases due to extubation failure. Symptoms at diagnosis included dyspnea in 3 (30%), stridor in 6 (60%) and 1 (10%) was asymptomatic. TS location was glottic in 2 (20%) and tracheal in 8 (80%). The main cause of TS was ring fracture secondary to TT (40%). Conclusion(s): Iatrogenic TS is a rare cause of dyspnea in COVID-19 ICU-survivors, but it must be considered in these patients given the high number of patients who required prolonged ETI or TT during the COVID-19 pandemic.
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Background Prolonged periods of ventilation can be associated with significant physical and psychological short- and longterm effects, research supports early rehabilitation in adult icu, however little evidence is available in PICU and potential benefits. Method An early mobility guideline was implemented into PICU in November 2020, focusing on early rehabilitation, mobilizing patients more frequently, and reducing levels of sedation through regular assessment of COMFORT and Delirium scoring. Baseline data from November 2019- February 2020- was obtained to compare ventilation hours of patients with respiratory aetiology to patients post early mobility implementation from November 2020- February 2021. Patients from birth to 18 years with respiratory aetiology, requiring invasive ventilation were screened, and retrospective data was obtained from electronic notes, anonymised and entered into SPSS. Results Findings identified Before Early mobility group to have a mean ventilation time of 68.90 hours and After early mobility group 69.25 hours. No significant differences were identified between the two groups. Patients had a diagnosis of respiratory aetiology, however the COVID 19 pandemic altered respiratory pathogens seen within PICU, changing the cohort of patients seen in both groups. However, further analysis highlighted reductions in patients requiring NIV after extubation, 46.5% Before and 23.7% After Early Mobility cohort, and risks of accidental extubation Before Early mobility group 1% accidental extubation and After group 2 5.3%, identifying no significant risk. Conclusion PICU early mobility studies are limited (Johnston et al 2019) and behind the wealth of studies available within AICU (Cameron et al 2015). However critically ill children are at risk of co-morbidities and early mobility within PICU is vital. The service evaluation identified no significant change in ventilation hours After Early mobility guideline implementation, or risks of accidental intubation. However, highlighted a reduction of the use of NIV, highlighting the need for further research within PICU.
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Introduction: coughing is a physiological response to protect the airway, it produces aerosols that are identified by imaging reaching a speed of up to 8 meters per second. Extubation produces cough, hypertension, tachycardia, apnea and laryngospasm, there are methods to minimize its occurrence. Due to the COVID-19 pandemic, intravenous lidocaine and superior laryngeal nerve block have been used as cough reflex prophylaxis. The aim was to compare them in cough inhibition. Material and methods: patients aged 18-60 years, elective surgery with balanced general anesthesia, ASA 1-3, with intubation less than 3 hours, were selected. A total of 90 patients were randomized, 45 in each group. A total of 10 patients were eliminated because they presented hemodynamic instability at the end of surgery, and because the intravenous dose of lidocaine was not administered within the established time. Results: there was no statistically significant difference in the number of patients who presented cough in both groups (13 vs 10, p = 0.4684), of these there was a statistically significant difference in the number of decibels in favor of the block group (75.6 vs 67, p < 0.001). Conclusions: block presents less aerolization than intravenous lidocaine in extubation. (English) [ FROM AUTHOR] Introducción: la tos es una respuesta fisiológica de protección de la vía aérea, produce aerosoles que se identifican por imagen y alcanza una velocidad de hasta ocho metros por segundo. La extubación produce tos, hipertensión, taquicardia, apnea y laringoespasmo, existen métodos para minimizar su aparición. Debido a la pandemia de COVID-19 se han utilizado como profilaxis del reflejo tusígeno, la lidocaína intravenosa y el bloqueo del nervio laríngeo superior. El objetivo fue compararlos en la inhibición de la tos. Material y métodos: se seleccionaron pacientes entre 18-60 años, cirugía electiva con anestesia general balanceada, ASA 1-3, con intubación menor a tres horas. Se aleatorizó un total de 90 pacientes, 45 en cada grupo, se eliminó un total de 10 pacientes por presentar inestabilidad hemodinámica al final de la cirugía o por no administrar dosis intravenosa de lidocaína en el tiempo establecido. Resultados: no hubo diferencia estadísticamente significativa en el número de pacientes que presentaron tos en ambos grupos (13 vs 10, p = 0.4684), de éstos se obtuvo una diferencia estadísticamente significativa en el número de decibeles a favor del grupo de bloqueo (75.6 vs 67, p < 0.001). Conclusiones: el bloqueo (selectivo) presenta menos aerolización que la lidocaína intravenosa en la extubación. (Spanish) [ FROM AUTHOR] Copyright of Revista Mexicana de Anestesiologia is the property of Colegio Mexicano de Anestesiologia 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.)
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The coronavirus disease 2019 (COVID-19) pandemic is a challenge for all health care providers (HCPs). Anesthesiologists are vulnerable to acquiring the disease during aerosol-generating procedures in operating theater and intensive care units. High index of suspicion, detailed history including travel history, strict hand hygiene, use of face masks, and appropriate personal protective equipment are some ways to minimize the risk of exposure to disease. Neurologic manifestations of COVID-19, modification of anesthesia regimen based on the procedure performed, and HCP safety are some implications relevant to a neuroanesthesiologist. National and international guidelines, recommendations, and position statements help in risk stratification, prioritization, and scheduling of neurosurgery and neurointervention procedures. Institutional protocols can be formulated based on the guidelines wherein each HCP has a definite role in this ever-changing scenario. Mental and physical well-being of HCPs is an integral part of successful management of patients. We present our experience in managing 143 patients during the lockdown period in India.Copyright © 2020 Wolters Kluwer Medknow Publications. All rights reserved.
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Introduction: Postintubation tracheal stenosis (PITS) is a rare complication of mechanical ventilation (MV). Risk factors for PITS include prolonged MV, reintubation and poor endotracheal tube cuff management, all of which are common in severe COVID19 patients during pandemic surges. Aims and objectives: to describe the patient characteristics and outcomes of PITS after MV for COVID19. Method(s): we conducted a retrospective review of all patients referred to our tertiary teaching hospital for endoscopic PITS treatment after COVID19 during 2021. Result(s): 60% of the 15 referred patients were female with a mean age of 60.1 years. Median duration of MV was 11.5 (8.5 - 16) days. 13.3% of patients were reintubated and 26.7% required tracheostomy during their ICU stay. 86.7% presented with stridor after a median of 32 (16.5-60) days after extubation with a further delay of 14 (2-42) days until the diagnosis of PITS. 73.3% had simple PITS with a mean diameter of 5.73+/-1.53 mm. 12 patients were successfully treated endoscopically with serial dilatation and electrocautery. Restenosis after treatment was observed in 66.7% of patients after a median of 30 (22.5-35) days. 5 patients required surgery while 2 patients required further endoscopic dilatation after surgery. Interestingly, 13 of the 15 patients were referred from a single tertiary hospital, after treatment in the same ICU. Conclusion(s): We observed an increase in referrals for PITS treatment during the study period with a cluster of patients from a single ICU. The high restenosis rate emphasizes the importance of multidisciplinary management as well as the prevention of PITS with high quality ICU care during the COVID19 pandemic.
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Coronavirus 19 (COVID-19) may cause a cytokine release syndrome inducing the severity of the disease. Various immune modulating agents are suggested due to the lack of definitive treatment and vaccine. In this case report, we aimed to share the clinical course of a Covid 19 patient who was given tocilizumab (TCZ) for severe ARDS on the 5th day of hospitalization. Although, the patient was extubated 12 days after TCZ treatment with a rapid recovery, we believe that more cases are needed to determine the efficiency and timing of TCZ treatment.Copyright © 2020 Necati Ozpinar. All rights reserved.
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Toxic epidermal necrolysis (TEN), is an acute, life-threatening emergent disease involving the skin and mucous membranes with serious systemic complications. It is characterized by widespread epidermal sloughing. Drugs are the most common triggers of TEN, but infection, vaccination, radiation therapy and malignant neoplasms can all induce it in susceptible patients. We report two cases in whom a hair dye and a COVID-19 vaccine (BioNTech, Pfizer) were believed to be the causative agents. These patients have to undergo repeated debridements of the necrotic tissue. In this manuscript the anesthetic management of TEN patients is discussed. Detailed preoperative evaluation, aggressive fluid and electrolyte replacement, avoidance of hypothermia during debridement, minimizing anesthetic agents and limiting traumatic procedures are key points in the management.Copyright © 2023 Faculty of Anaesthesia, Pain and Intensive Care, AFMS. All rights reserved.