Tracheoesophageal fistula in a COVID-19 patient.

The number of patients requiring admission in intensive care units and prolonged invasive mechanical ventilation (MV) has increased significantly during the coronavirus disease 2019 (COVID-19) pandemic. Tracheoesophageal fistula (TEF) following prolonged invasive MV is a rare condition. Numerous COVID-19 pathophysiological mechanisms and treatment-related effects might support the increase of tracheal complications in this subgroup of patients. We report a case of TEF in a COVID-19 patient submitted to prolonged invasive MV and discuss its diagnosis and management.

The Role of Noninvasive Ventilation in Patients with "Do Not Intubate" Order in the Emergency Setting.

BACKGROUND: Noninvasive ventilation (NIV) is being used increasingly in patients who have a "do not intubate" (DNI) order. However, the impact of NIV on the clinical and health-related quality of life (HRQOL) in the emergency setting is not known, nor is its effectiveness for relieving symptoms in end-of-life care. OBJECTIVE: The aim of this prospective study was to determine the outcome and HRQOL impact of regular use of NIV outcomes on patients with a DNI order who were admitted to the emergency room department (ED). METHODS: Eligible for participation were DNI-status patients who receive NIV for acute or acute-on-chronic respiratory failure when admitted to the ED of a tertiary care, university-affiliated, 600-bed hospital between January 2014 and December 2014. Patients were divided into 2 groups: (1) those whose DNI order related to a decision to withhold therapy and (2) those for whom any treatment, including NIV, was provided for symptom relief only. HRQOL was evaluated only in group 1, using the 12-item Short Form Health Survey (SF-12). Long-term outcome was evaluated 90 days after hospital discharge by means of a telephone interview. RESULTS: During the study period 1727 patients were admitted to the ED, 243 were submitted to NIV and 70 (29%) were included in the study. Twenty-nine (41%) of the 70 enrollees received NIV for symptom relief only (group2). Active cancer [7% vs 35%, p = 0,004] and neuromuscular diseases [0% vs. 17%] were more prevalent in this group. NIV was stopped in 59% of the patients in group 2 due to lake of clinical benefit. The in-hospital mortality rate was 37% for group 1 and 86% for group 2 0,001). Among patients who were discharged from hospital, 23% of the group 1 and all patients in group 2 died within 90 days. Relative to baseline, no significant decline in HRQOL occurred in group 1 by 90 days postdischarge. CONCLUSION: The survival rate was 49% among DNI-status patients for whom NIV was used as a treatment in ED, and these patients did not experience a decline in HRQOL throughout the study. NIV did not provide significant relief of symptoms in more than half the patients who receive it for that purpose.

Venous thromboembolism risk factors and practices of prophylaxis: ENDORSE study results in Portugal.

BACKGROUND: Venous thromboembolism (VTE) risk assessment is a cornerstone for the achievement of best practices and outcomes. Epidemiologic data and practices related to venous thromboprophylaxis as considered by the global ENDORSE study, (Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting), enrolled 68,183 patients from 32 countries, in which Portugal. Within ENDORSE, data from all participant countries analyzed to determine their risk of VTE and to evaluate the suitability of prophylaxis. METHODS: European patients were enrolled from randomly selected hospitals in Portugal (European Hospital Register), according to ENDORSE study inclusion/exclusion criteria. The Seventh ACCP evidence-based consensus guidelines were employed to evaluate VTE risk and prophylaxis use. RESULTS: From a total of 3,145 beds assessed, 2,183 were considered eligible and 1,632 met all criteria. Of these, 860 (52.7%; 95% CI 50.3-55.1) were at risk of VTE: 525 surgical patients (68.9%; 95% CI 65.5-72.1) and 335 medical patients (38.5%; 95% CI 35.3-41.2). The rate of prophylaxis according to ACCP guidelines in overall patients at risk was 58.5% (503 patients). The prophylaxis rate for VTE was 59% (310 patients) in surgical patients and 57.6% (n=193) in medical patients. 39.7% of surgical patients and 39.4 % of medical patients who did not meet the criteria for prophylaxis were also on prophylaxis with an anticoagulant, which was considered to be inappropriate. CONCLUSIONS: More than a half of these hospitalized patients in Portugal were deemed at risk of VTE and less than two-thirds of them received appropriate prophylaxis. New strategies are required for implementation of venous thromboprophylaxis in Portuguese hospitals.

Immediate and long-term impact of medical emergency teams on cardiac arrest prevalence and mortality: a plea for periodic basic life-support training programs.

OBJECTIVE: To evaluate whether the introduction of a program including a medical emergency team responding to widened criteria together with the institution-wide training on basic life support of all hospital staff would decrease cardiac arrest prevalence and mortality in patients at risk, in the immediate and long-term periods after the program. DESIGN: Before-after design. SETTING: Urban general hospital with 470 beds. PATIENTS: All patients admitted in the hospital between 2002 and 2006 were eligible. All patients with a medical emergency team activation were included. We compared cardiac arrest prevalence and mortality and in-hospital mortality before (2002), after (2003-2004), and long term after (2005-2006) the program implementation. MEASUREMENTS AND MAIN RESULTS: There was a significant (p = .037) decrease of 27% (95% confidence interval, 2%-46%) in cardiac arrest occurrence, 33% decrease (p = .014) in cardiac arrest mortality (95% confidence interval, 8%-52%), and a nonsignificant (p = .152) decrease of 17% (95% confidence interval, -7%-36%) in in-hospital mortality associated with the program implementation. No significant differences were found for any of the outcome variables between before and long term after periods. The main factor associated with in-hospital mortality was cardiac arrest. Factors affecting cardiac arrest were age, comorbidities, measures started before medical emergency team arrival and the intervention/program. The effect in the prevention of cardiac arrest has an adjusted relative risk, 0.646 (95% confidence interval, 0.450-0.876) and an absolute risk reduction of adjusted relative risk, 18% (95% confidence interval, 6%-29%). The program prevented one cardiac arrest for every five medical emergency team activations. CONCLUSIONS: Widening criteria for hospital emergency calls together with an integrated training program may reduce cardiac arrest prevalence and mortality in at-risk patients. Program effectiveness was critically related to the staff education, awareness, and responsiveness to physiologic instability of the patients. Long-term effectiveness of the program may decrease in the absence of periodic and continued implementation of educational interventions.

Cardiogenic shock caused by disulfiram.

Drug intoxication with disulfiram is a rare condition that may lead to severe and potentially fatal cardiovascular manifestations such as cardiogenic shock. We report the case of a female patient with refractory shock after deliberate self-poisoning with disulfiram. Clinical, biochemical and echocardiographic assessment, as well as invasive monitoring confirmed cardiogenic shock associated with this drug. The known mechanisms of action of disulfiram are discussed, and the major collateral effects, especially cardiovascular effects, are described. We underscore the importance of suspecting this diagnosis and of adopting prompt and the most adequate therapeutic approach in this context.

Choque cardiogênico por dissulfiram / Cardiogenic shock caused by disulfiram / Shockcardiogénico por disulfiram

A intoxicação medicamentosa por dissulfiram é uma situação rara, mas, que pode se apresentar com manifestações cardiovasculares graves e potencialmente fatais, como choque cardiogênico. É apresentado o caso de uma paciente com choque refratário, após intoxicação voluntária por dissulfiram. A avaliação clínica e bioquímica, junto à avaliação ecocardiográfica e à monitorização invasiva, confirmaram tratar-se de um choque cardiogênico associado a esse fármaco. São discutidos os mecanismos de ação conhecidos do dissulfiram e descritos os principais efeitos colaterais, especialmente os cardiovasculares, alertando para a importância da suspeição diagnóstica e da abordagem terapêutica imediata mais adequada nesse contexto.

Drug intoxication with disulfiram is a rare condition that may lead to severe and potentially fatal cardiovascular manifestations such as cardiogenic shock. We report the case of a female patient with refractory shock after deliberate self-poisoning with disulfiram. Clinical, biochemical and echocardiographic assessment, as well as invasive monitoring confirmed cardiogenic shock associated with this drug. The known mechanisms of action of disulfiram are discussed, and the major collateral effects, especially cardiovascular effects, are described. We underscore the importance of suspecting this diagnosis and of adopting prompt and the most adequate therapeutic approach in this context.

La intoxicación medicamentosa por disulfiram es una situación rara, aunque puede presentarse con manifestaciones cardiovasculares graves y potencialmente fatales, como el shock cardiogénico. Este relato presenta el caso de una paciente con shock refractario, tras intoxicación voluntaria por disulfiram. La evaluación clínica y bioquímica, junto a la evaluación ecocardiográfica y el monitoreo invasivo, confirmaron tratarse de un shock cardiogénico asociado a ese fármaco. A lo largo del presente relato se discuten los mecanismos de acción del disulfiram conocidos, así como se describen los principales efectos colaterales, específicamente los cardiovasculares. En este sentido, también se alerta para la importancia de la sospecha diagnóstica y del abordaje terapéutico inmediato más adecuado a este contexto.

The emergency room--analysis and evaluation of an organizational model.

INTRODUCTION AND AIMS: The purpose of the emergency room is to treat critically ill patients and to prevent cardiac arrest in patients presenting with signs of physiological instability. This study has two main aims: 1) to describe the organizational model of the emergency room of Hospital Pedro Hispano based on 'chain of survival' principles; 2) to report an outcome analysis after the first year's operation with this organizational model. METHODS: Patients arriving at the emergency department of Hospital Pedro Hispano are processed by the Manchester Triage System. Patients presenting in a critical condition are coded red and immediately admitted to the emergency room. Patients classified as less critical but whose condition may worsen, with signs of physiological instability, are also admitted to the emergency room. This reflects the operating principles of the emergency room based on the prevention of cardiac arrest. All patients admitted to the emergency room have an emergency room chart, on which this study is based. RESULTS: Between May 1 2005 and April 30 2006, 1014 patients were admitted to the emergency room. Sixty-five percent of them were aged over 60 years. Altered consciousness was the most frequent reason for admission (17%), followed by respiratory failure (13%) and tachycardia (11%). Fifty-one patients (5%) were admitted after cardiac arrest. Sixty-six patients (7%) died in the emergency room, 57% of whom were admitted following cardiac arrest and 17% after shock of any etiology. A further 189 patients died during the course of their hospital stay after being discharged from the emergency room to other wards, which represents an overall mortality of 25%. CONCLUSION: Prevention and treatment of causes of cardiac arrest were the main reason for admission to the emergency room (altered consciousness, respiratory failure and tachycardia). Cardiac arrest was not among the main reasons for admission. However, when it occurs it has very high mortality; in the present study it was responsible for 5% of admissions and 53% of mortality. This organizational model may contribute to better use of resources as it enables re-orientation of patients to appropriate levels of care.