Prone position plexopathy: an avoidable complication of prone positioning for COVID-19 pneumonitis?

Prone positioning is a mainstay of management for those presenting to the intensive care unit with moderate-to-severe acute respiratory distress syndrome due to COVID-19. While this is a necessary and life-saving intervention in selected patients, careful positioning and meticulous care are required to prevent compression and traction of the brachial plexus, and resultant brachial plexopathy. We describe two patients who developed a brachial plexus injury while undergoing prone positioning for management of COVID-19 pneumonitis. Both patients were diabetic and underwent prolonged periods in the prone position during which the plexopathy affected arm was abducted for 19 and 55 hours, respectively. We discuss strategies to reduce the risk of this rare but potentially disabling complication of prone positioning.

The Role of a Liaison Team in ICU Family Communication During the COVID 19 Pandemic.

CONTEXT: In the name of public safety, a general suspension on hospital visiting was imposed in the U.K., prohibiting family and friends to visit hospitalized patients, even if they were critically ill. OBJECTIVES: we aimed to assess the impact of the FLT on the communication with patients' family and friends (PFF), especailly around end-of-life care, and their interaction with CC clinicians. METHODS: A retrospective, mixed-methods analysis of a family liaison team (FLT) formed by redeployed clinicians in critical care (CC) during the first surge of the 2020 COVID 19 pandemic. RESULTS: The FLT was constituted predominantly of non-ICU consultants (30/39, 77%). Following two one-hourly webinars around basic communication skills, the FLT facilitated over 12,000 video and telephone calls with 172 patients' family and friends (PFF). The majority of the PFF interviewed were mostly, very or extremely satisfied with the frequency, ease, understanding, honesty, completeness, and consistency of the information provided. Approximately 5% of the interviewees reported to be slightly or very dissatisfied in one or more of the following 3 categories: frequency, consistency, and ease of getting the information. The thematic analysis identified 3 themes: 1) being there with/ for the patient; 2) breakdown in communication; 3) disbelief at the speed of deterioration. In 14.9% of cases there was documented discrepancy between the information transmitted by the CC team and that by the FLT, particularly around the severity of the patient's illness and their imminent death. CONCLUSION: The formation of a dedicated FLT was feasible and associated with high levels of satisfaction by the PFF. Friction was created when communication was not consistent and did not convey the severity of the patient's condition, to prepare the PFF for a bad outcome.

Promoting low-flow anaesthesia and volatile anaesthetic agent choice.

BACKGROUND: As doctors, we are increasingly aware of the financial implications of our practice. The need to work in a more conscientious, efficacious and cost-effective manner is greater than ever before. Environmental and financial benefits can be seen through employing the use of low-flow anaesthesia. AIMS: This quality improvement project aimed to make anaesthetic practice more environmentally friendly and to reduce departmental spending. This could be achieved by promoting the use of low-flow anaesthesia and by encouraging isoflurane use where appropriate. METHODS: All anaesthetic consultants and trainees were invited to fill out an initial questionnaire relating to their personal preferences and practices when conducting anaesthesia. There were specific questions relating to low-flow anaesthesia and isoflurane use. Our main measure of improvement was any decrease in the number of bottles of volatile agent ordered by the department from pharmacy. Monthly spot audits were conducted to assess gas flow rates and volatile agent use in theatre. Departmental spending figures relating to the purchase of volatile agent bottles were obtained from pharmacy. Information was then disseminated to anaesthetists on a monthly basis via a 'low-flow board', which showed pictorial and graphical representations of differing gas flows and volatile agent usage in relation to cost. RESULTS: Our project showed a trend for the increased use of low-flow anaesthesia within the department. We also showed a decrease in the number of bottles of volatile agent ordered: 18% fewer bottles ordered compared with the same period the previous year. This represented a 25% decrease in total departmental expenditure on volatile agents despite an increase in theatre activity. CONCLUSION: Increasing awareness regarding anaesthetic choices and promoting low-flow anaesthesia and isoflurane use, translated into an overall decreased departmental spend on volatile agents without affecting patient care.

Immediate postoperative management and complications on the intensive care unit.

The postoperative management of patients immediately after liver transplantation requires knowledge of this complex surgery and the physiology that accompanies liver failure. A multidisciplinary approach to the care of these patients is essential in order to reduce postoperative complications and preserve function in the transplanted organ. By their nature, patients undergoing liver transplantation have complicated medical problems before surgery which must be borne in mind when managing them after surgery. Haemorrhage, haemodynamic instability, acute renal failure, hepatic artery thrombosis and primary graft non-function are some of the complications that clinicians must be prepared for in the first days after transplantation. Pre-empting complications and acting rapidly to overt them is likely to have a considerable positive impact in these patients.

Bioelectric effects of quinine on polarized airway epithelial cells.

Quinine has been increasingly utilized as a placebo in cystic fibrosis (CF) clinical trials, including those leading to FDA approval of inhaled tobramycin, recent studies of anti-inflammatory aerosols such as glutathione, and clinical testing of hypertonic saline aerosols to augment mucous clearance. The drug effectively masks taste of experimental therapeutics, but could also confer changes in processes contributing to CF pathogenesis, including chloride secretion and paracellular ion permeability. In the Ussing chamber, concentrations of quinine (1 mg/ml) anticipated in the airways of CF subjects after aerosolization led to changes in chloride transport in Calu-3 (airway serous glandular) cell monolayers. Tissue resistance was significantly disrupted by the compound in both Calu-3 and primary airway epithelial cells in vitro. Lower doses of quinine (between 10 and 100 microg/ml) strongly inhibited the chloride secretory mechanism that utilizes CFTR, and forskolin activated I(SC) was reduced by approximately 24% and 44% in the presence of 10 and 100 microg/ml quinine, respectively. Our findings indicate that quinine disrupts airway epithelial functional integrity and blocks transepithelial chloride transport. The use of quinine as a taste-masking agent may have bioelectric effects relevant to CF trials using aerosolized drug delivery.

Activation of chloride secretion in cystic fibrosis cells and tissues by the substituted imidazole SRI 2931.

Recent interest in nucleotides and related agents as part of clinical trials in cystic fibrosis (CF) therapy have elicited efforts to identify novel compounds capable of activating transepithelial chloride (Cl(-)) transport in CF cells and tissues. From a library of nucleosides, bases, and other substituted heterocycles, 341 compounds were screened for their ability to activate anion transport in CF cells grown on permeable supports. One compound, SRI 2931, was found to confer prolonged and potent activity when administered to the apical surfaces of CF pancreatic epithelial cells, primary CF nasal epithelial cells, non-CF human colonic epithelial cells, and intact tissue taken from mouse models for CF. Concentrations of SRI 2931 (20 microM), which activated Cl(-) transport, had minimal effect on cell proliferation. SRI 2931 was not calcium (Ca(2+)) or cAMP dependent, suggesting important differences from conventional chloride secretagogues. The compound selectively released ATP from the apical, but not basolateral, surfaces of CF cells grown on permeable supports. The magnitude, longevity, and mechanism of action of the response provide a tool for dissecting pathways of epithelial ATP extracellular signaling and Cl(-) permeability.

CO(2) capture by a task-specific ionic liquid.

Reaction of 1-butyl imidazole with 3-bromopropylamine hydrobromide, followed by workup and anion exchange, yields a new room temperature ionic liquid incorporating a cation with an appended amine group. The new ionic liquid reacts reversibly with CO2, reversibly sequestering the gas as a carbamate salt. The new ionic liquid, which can be repeatedly recycled in this role, is comparable in efficiency for CO2 capture to commercial amine sequestering reagents, and yet is nonvolatile and does not require water to function.