ABSTRACT
BACKGROUND: One-third of pregnant women will experience worsening asthma requiring emergency hospitalization. However, no report comprehensively discussed the management of asthma attacks in pregnant women in impoverished settings. We attempt to illuminate what general practitioners can do to stabilize and improve the outcome of severe acute asthma exacerbations in primary care with resource limitations. CASE REPORT: A nulliparous 29-year-old woman in her 21st week of pregnancy presented severe acute asthma exacerbation in moderate persistent asthma with uncontrolled asthma status along with gestational hypertension, uncompensated metabolic acidosis with a high anion gap, anemia, respiratory infection, and asymptomatic bacteriuria, all of which influenced her exacerbations. This patient was admitted to our resource-limited subdistrict hospital in Indonesia during the COVID-19 pandemic for optimal stabilization. Crystalloid infusions, oxygen supplementation, nebulized beta-agonist with anticholinergic agents, inhaled corticosteroids, intravenous methylprednisolone, broad-spectrum antibiotics, subcutaneous terbutaline, mucolytics, magnesium sulphate, oral antihypertensives, and continuous positive airway pressure were used to treat her life-threatening asthma. After she was stabilized, we referred the patient to a higher-level hospital with more advanced pulmonary management under the supervision of a multidisciplinary team to anticipate the worst scenario of pregnancy termination. CONCLUSION(S): Limitations in primary care, including the lack of sophisticated intensive care units and laboratory panels, may complicate challenges in managing severe acute asthma exacerbation during pregnancy. To enhance maternal-fetal outcomes, all multidisciplinary team members should be well-informed about key asthma management strategies during pregnancy using evidence-based guidelines regarding the drug, rationale, and safety profile.Copyright © 2023 Muhammad Habiburrahman, Triya Damayanti, Mohammad Adya Firmansha Dilmy, Hariyono Winarto.
ABSTRACT
Though not common, drug-induced pericarditis is a serious condition, since pericardial tamponade, should it develop, may be life-threatening. As the number of drugs is constantly expanding, so does the proportion of those capable of causing pericarditis. The authors reviewed the relevant literature in the PubMed database and complemented it with information from the VigiBase database. In their article, the authors present current knowledge about the mechanisms of origin and level of risk of drug-induced pericarditis and discuss relevant information on individual drugs divided into 7 classes. Some medicines are associated with a high risk of developing pericarditis, a fact to be taken into account when treating patients with these agents. © 2022 Czech Society of Cardiology Z.S. All rights reserved.
ABSTRACT
SESSION TITLE: Cardiovascular Critical Care Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: The carotid sinus-arterial baroreflex is essential in maintaining blood pressure (BP) regulation. Afferent baroreflex failure (ABF) can present with labile changes in BP within seconds and can be secondary to neck surgery or radiation (RT). The prevalence and etiology of this condition remain unknown, and management of BP can be challenging. We present here the first case, to our knowledge, of ABF precipitated by thyroidectomy, in a patient (pt) with active COVID-19 pneumonia (PNA), causing difficult control of severely labile BP in a critical care unit. CASE PRESENTATION: A 74-year-old female with a history of COPD and a thyroid mass s/p an open left hemithyroidectomy & isthmusectomy, partial right thyroidectomy with drain placement who presented with dyspnea and hypoxia with COVID-19 PNA and superimposed bacterial PNA. She was immediately intubated and admitted to the ICU. Due to improved alertness and breathing, an extubation trial was done on day 2 but was unsuccessful due to a neck mass compressing the trachea, and during extubation, the pt began to develop stridor, desaturate, and was reintubated. CT head and neck showed a markedly enlarged thyroid with left tracheal deviation and the pt underwent complete thyroidectomy the following day. On the 4th day following surgery, the pt desaturated on PRVC and CXR showed new consolidation, and the PNA panel was positive for K. pneumoniae. The pt's BP began to fluctuate from the 80's/40's - 260's/190's. Titrating pressors were not effective in controlling her volatile BP. Clonidine was started to control hypertensive urgencies, but severe subsequent hypotensive episodes made it difficult to continue. A trial of Fentanyl drip did not add a benefit either. Adequate BP control was finally achieved through administering Clonidine only when SBP reached above 180mmHg and Midodrine when SBP reached below 80mmHg. DISCUSSION: Blood pressure changes can be sensed by carotid sinus stretch receptors. ABF can manifest secondary to carotid sinus nerve damage following neck surgery or radiation. The diagnosis of ABF remains ill-defined;with limited research available to guide definitive management. Critically ill patients with poor prognosis have demonstrated higher ACTH levels with a longer cortisol release, with elevated IL-8 and IL-6 concentrations, concluding potential destructive pituitary-adrenal axis response in the setting of inflammation. IL-6 in particular can manifest following hypoxic conditions. In certain cases of POTS and AD in COVID-19, there has been an improvement of symptoms with the use of B-blockers, fludrocortisone, midodrine, methyldopa, and clonidine. CONCLUSIONS: Additional research with a multidisciplinary approach is warranted to fully optimize the treatment of ABF in patients with neck surgery and or inflammatory conditions such as COVID-19. Reference #1: Biaggioni I, Shibao CA, Jordan J. Evaluation and Diagnosis of Afferent Baroreflex Failure. Hypertension. 2022 Jan;79(1):57-9. Reference #2: Dimopoulou I, Alevizopoulou P, Dafni U, Orfanos S, Livaditi O, Tzanela M, Kotanidou A, Souvatzoglou E, Kopterides P, Mavrou I, Thalassinos N. Pituitary-adrenal responses to human corticotropin-releasing hormone in critically ill patients. Intensive care medicine. 2007 Mar;33(3):454-9. Reference #3: Dani M, Dirksen A, Taraborrelli P, Torocastro M, Panagopoulos D, Sutton R, Lim PB. Autonomic dysfunction in 'long COVID': rationale, physiology and management strategies. Clinical Medicine. 2021 Jan;21(1):e63. DISCLOSURES: No relevant relationships by Wadah Akroush No relevant relationships by Shady Geris No relevant relationships by Brooke Kania No relevant relationships by Anas Mahmoud No relevant relationships by Rajapriya Manickam