Sedation Usage in COVID-19 Acute Respiratory Distress Syndrome: A Multicenter Study.

BACKGROUND: Patients with COVID-19 acute respiratory distress syndrome (ARDS) have been shown to have high sedation requirements. OBJECTIVE: The purpose of this study was to compare sedative use between patients with COVID-19 ARDS and non-COVID-19 ARDS. METHODS: This was a retrospective study of patients with COVID-19 ARDS compared with historical controls of non-COVID-19 ARDS who were admitted to 2 hospitals from March 1, 2020, to April 30, 2020, and April 1, 2018, to December 31, 2019, respectively. The primary outcome was median cumulative dose of propofol (µg/kg) at 24 hours after intubation. RESULTS: There were 92 patients with COVID-19 ARDS and 37 patients with non-COVID-19 ARDS included. Within the first 24 hours of intubation, patients with COVID-19 ARDS required higher total median doses of propofol: 51 045 µg/kg (interquartile range, 26 150-62 365 µg/kg) versus 33 350 µg/kg (9632-51 455 µg/kg; P = 0.004). COVID-19 patients were more likely receive intravenous lorazepam (37% vs 14%; P = 0.02) and higher cumulative median doses of midazolam by days 5 (14 vs 4 mg; P = 0.04) and 7 of intubation (89 vs 4 mg; P = 0.03) to achieve the same median Richmond Analgesia-Sedation Scale scores. COVID-19 ARDS patients required more ventilator days (10 vs 6 days; P = 0.02). There was no difference in 30-day mortality. CONCLUSION AND RELEVANCE: Patients with COVID-19 ARDS required higher doses of propofol and benzodiazepines than patients with non-COVID-19 ARDS to achieve the same median levels of sedation.

Homemade cardiac and vein cannulation ultrasound phantoms for trauma management training in resource-limited settings.

Ultrasound has become an essential skill for trauma management in resource-limited areas. Prohibitive costs of commercial ultrasound phantoms limit the abilities of many hospitals to adequately train health-care providers. We assessed the utility of homemade phantoms in a wartime setting. Thirty physicians and technicians enrolled in a medical training course, sponsored by the Syrian American Medical Society (SAMS). Ultrasound simulation models were created onsite by using psyllium, gelatin, a hotel coffee maker, and Pyrex dishes. Lamb hearts were used to teach visual diagnosis and subsequent drainage of pericardial effusions. Penrose drains were used to teach vein identification and cannulation under dynamic ultrasound guidance. Two phantoms with a total of 14 penrose drains were created, serving 30 health-care providers. Feedback from participants was positive and within one month of the course, two cases of pericardial tamponade were diagnosed and surgically treated in the largest trauma hospital operated by SAMS. CONTEXT: In resource-limited environments, ultrasound phantoms (models) are cost-prohibitive. AIMS: We assessed the utility of homemade phantoms in a resource-limited wartime setting to train Syrian physicians and technicians in vein cannulation and limited cardiac ultrasonography. SETTINGS AND DESIGN: Thirty physicians and technicians enrolled in a medical training course, sponsored by SAMS. METHODS: Ultrasound simulation models were created onsite by using psyllium, gelatin, a hotel coffee maker, and Pyrex dishes. Lamb hearts were used to teach visual diagnosis and subsequent drainage of pericardial effusions. Penrose drains were used to teach vein identification and cannulation under dynamic ultrasound guidance. Two phantoms with a total of 14 penrose drains were created, serving 30 health-care providers. STATISTICAL ANALYSIS USED: N/A. RESULTS: Feedback from participants was positive and within one month of the course, two cases of pericardial tamponade were diagnosed and surgically treated in the largest trauma hospital operated by SAMS. CONCLUSIONS: Homemade ultrasound phantoms are a promising cost-effective means for meeting an educational gap in ultrasound training, particularly for resource-limited hospitals and possibly more broadly in residency education.

Gastroenteritis and Miliary Lung Opacities: An Interesting Combination of Findings.

A 19-year-old man with a one-year history of vaping with multiple emergency room visits for acute gastroenteritis like symptoms was noted to have asymptomatic hypoxia with a PaO2 of 65 mmHg. Computed tomography revealed bilateral nodular lung infiltrates. History was negative for travel, allergies, or animal exposure. An infectious work-up was negative for bacterial, viral, or fungal infections, including bronchoalveolar lavage sample cultures. He did not show improvement upon initial empiric antibacterial and antifungal treatment. His hypoxia improved with systemic steroids. E-cigarette-associated lung injury (EVALI) is a diagnosis of exclusion, and unfortunately, may produce prolonged gastrointestinal symptoms with clinically silent but severe lung injury.

Intersegmental kinetics significantly impact mapping from finger musculotendon forces to fingertip forces.

Predicting the fingertip force vector resulting from excitation of a given muscle remains a challenging but essential task in finger biomechanical modeling. While the conversion of musculotendon force to fingertip force can significantly be affected by finger posture, current techniques utilizing geometric moment arms may not capture such complex postural effects. Here, we attempted to elucidate the postural effects on the mapping between musculotendon force and fingertip force through in vitro experiments. Computer-controlled tendon loading was implemented on the 7 index finger musculotendons of 5 fresh-frozen cadaveric hands across different postures. The resulting fingertip forces/moments were used to compute the effective static moment arm (ESMA), relating tendon force to joint torque, at each joint. The ESMAs were subsequently modeled in three different manners: independent of joint angle; dependent only upon the corresponding joint angle; or dependent upon all joint angles. We found that, for the reconstruction of the fingertip force vector, the multi-joint ESMA model yielded the best outcome, both in terms of direction and magnitude of the vector (mean reconstruction error <4° in direction and <2% in the magnitude), which indicates that intersegmental force transmission through a joint is affected by the posture of neighboring joints. Interestingly, the ESMA model that considers geometric changes of individual joints, the standard model used in biomechanical stimulations, often yielded worse reconstruction results than the simple constant-value ESMA model. Our results emphasize the importance of accurate description of the multi-joint dependency of the conversion of tendon force to joint moment for proper prediction of fingertip force direction.