Obstetric Disorders and Critical Illness.

In this article, we discuss some of the more common obstetric-related conditions that can lead to critical illness and require management in an ICU. These include the hypertensive disorders of pregnancy, postpartum hemorrhage, hemolysis, elevated liver enzymes, and low platelet syndrome, acute fatty liver of pregnancy, amniotic fluid embolism, and peripartum cardiomyopathy. We also discuss pulmonary embolism and Covid-19. Despite not being specific to obstetric patients, pulmonary embolism is a common, life-threatening diagnosis in pregnancy with particular risks and management aspects. Covid-19 does not seem to occur with higher frequency in pregnant women, but it leads to higher rates of ICU admissions and mechanical ventilation in pregnant women than in their nonpregnant peers. Its prevalence during our current global pandemic makes it important to discuss in this article. We provide a basis for critical care physicians to be engaged in informed conversations and management in a multidisciplinary manner with other relevant providers in the care of critically ill pregnant and postpartum women.

In-hospital cardiac arrest in patients with coronavirus 2019.

BACKGROUND: Coronavirus Disease 2019 (COVID-19) has caused over 1 200 000 deaths worldwide as of November 2020. However, little is known about the clinical outcomes among hospitalized patients with active COVID-19 after in-hospital cardiac arrest (IHCA). AIM: We aimed to characterize outcomes from IHCA in patients with COVID-19 and to identify patient- and hospital-level variables associated with 30-day survival. METHODS: We conducted a multicentre retrospective cohort study across 11 academic medical centres in the U.S. Adult patients who received cardiopulmonary resuscitation and/or defibrillation for IHCA between March 1, 2020 and May 31, 2020 who had a documented positive test for Severe Acute Respiratory Syndrome Coronavirus 2 were included. The primary outcome was 30-day survival after IHCA. RESULTS: There were 260 IHCAs among COVID-19 patients during the study period. The median age was 69 years (interquartile range 60-77), 71.5% were male, 49.6% were White, 16.9% were Black, and 16.2% were Hispanic. The most common presenting rhythms were pulseless electrical activity (45.0%) and asystole (44.6%). ROSC occurred in 58 patients (22.3%), 31 (11.9%) survived to hospital discharge, and 32 (12.3%) survived to 30 days. Rates of ROSC and 30-day survival in the two hospitals with the highest volume of IHCA over the study period compared to the remaining hospitals were considerably lower (10.8% vs. 64.3% and 5.9% vs. 35.7% respectively, p < 0.001 for both). CONCLUSIONS: We found rates of ROSC and 30-day survival of 22.3% and 12.3% respectively. There were large variations in centre-level outcomes, which may explain the poor survival in prior studies.

Putting It All Together: Clinical Considerations in the Care of Critically Ill Obstetric Patients with COVID-19.

Pregnant patients with severe acute respiratory syndrome coronavirus 2, the virus responsible for the clinical condition newly described in 2019 as coronavirus disease 2019 (COVID-19) and illness severity to warrant intensive care have a complex disease process that must involve multiple disciplines. Guidelines from various clinical societies, along with direction from local health authorities, must be considered when approaching the care of an obstetric patient with known or suspected COVID-19. With a rapidly changing landscape, a simplified and cohesive perspective using guidance from different clinical society recommendations regarding the critically-ill obstetric patient with COVID-19 is needed. In this article, we synthesize various high-level guidelines of clinical relevance in the management of pregnant patients with severe disease or critical illness due to COVID-19. KEY POINTS: · When caring for severely ill obstetric patients with COVID-19, one must be well versed in the complications that may need to be managed including, but not limited to adult respiratory distress syndrome with need for mechanical ventilation, approach to refractory hypoxemia, hemodynamic shock, and multiorgan system failure.. · Prone positioning can be done safely in gravid patients but requires key areas of support to avoid abdominal compression.. · For the critically ill obstetric patient with COVID-19, the focus should be on supportive care as a bridge to recovery rather than delivery as a solution to recovery..

Hospital Preparedness for COVID-19: A Practical Guide from a Critical Care Perspective.

In response to the estimated potential impact of coronavirus disease (COVID-19) on New York City hospitals, our institution prepared for an influx of critically ill patients. Multiple areas of surge planning progressed, simultaneously focused on infection control, clinical operational challenges, ICU surge capacity, staffing, ethics, and maintenance of staff wellness. The protocols developed focused on clinical decisions regarding intubation, the use of high-flow oxygen, engagement with infectious disease consultants, and cardiac arrest. Mechanisms to increase bed capacity and increase efficiency in ICUs by outsourcing procedures were implemented. Novel uses of technology to minimize staff exposure to COVID-19 as well as to facilitate family engagement and end-of-life discussions were encouraged. Education and communication remained key in our attempts to standardize care, stay apprised on emerging data, and review seminal literature on respiratory failure. Challenges were encountered and overcome through interdisciplinary collaboration and iterative surge planning as ICU admissions rose. Support was provided for both clinical and nonclinical staff affected by the profound impact COVID-19 had on our city. We describe in granular detail the procedures and processes that were developed during a 1-month period while surge planning was ongoing and the need for ICU capacity rose exponentially. The approaches described here provide a potential roadmap for centers that must rapidly adapt to the tremendous challenge posed by this and potential future pandemics.

Vaginal Burn from Alkaline Battery in an 8-Year-Old.

BACKGROUND: Life-threatening injury from battery ingestion has mandated changes in the manufacture of battery-operated devices. Whilst esophageal burns are commonly publicized, there is scarce literature on vaginal burns and their potential morbidity. CASE: An 8-year-old girl presented with self-report of a "fluffy toy" per vagina. Under general anesthesia, her vagina was examined and the mucosa appeared coated in a "blue fur." It was soon identified as corrosive damage from an alkaline button battery. Fistula and rectal injury were excluded. Symptomatic relief was achieved with the use of estradiol lidocaine intravaginal concoction following removal. SUMMARY AND CONCLUSIONS: Optimal management of a vaginal foreign body relies upon clinical suspicion, familiarity with prepubertal vaginal instrumentation, and expeditious removal of inserted batteries to avoid serious morbidity.

Augmentation of platelet and endothelial cell eNOS activity decreases sepsis-related neutrophil-endothelial cell interactions.

NO is an important mediator of microvascular patency and blood flow. The purpose of this study was to examine the role of enhanced eNOS activity in attenuating sepsis-induced neutrophil-endothelial cell interactions. Microslides coated with human umbilical vein endothelial cells were stimulated with plasma from patients with septic shock. Neutrophil and platelets from control subjects were also stimulated with plasma from patients in septic shock and perfused over stimulated endothelial cells. l-Arginine (LA) with and without NG-monomethyl l-arginine (LNMMA), a nonselective NOS inhibitor, and N-(3-(aminomethyl) benzyl acetamide) ethanimidamide dihydrochloride (1400W), a highly selective iNOS inhibitor, were added to the septic plasma. The number of neutrophils adherent to endothelial cells, neutrophil rolling velocity, and the number of neutrophil aggregates were determined. Cell activation and the formation of platelet-neutrophil aggregates were assessed by flow cytometry. Separate experiments were done with isolated platelets using platelet aggregometry. l-Arginine significantly decreased sepsis-related neutrophil adhesion and aggregation and increased rolling velocity. The addition of LNMMA to LA and cell suspensions reversed the effects of LA on these parameters, whereas the addition of 1400W had no effect on LA-related changes. Platelet-neutrophil aggregation, platelet aggregation, platelet activation, and neutrophil activation induced by septic plasma were also significantly decreased by LA. Again, the addition of LNMMA reversed the effects of LA on these parameters, whereas 1400W had no effect on LA-related changes. These data suggest that enhancement of platelet and endothelial cell eNOS activity decreases sepsis-induced neutrophil-endothelial cell interactions and may play a role in maintaining microvascular patency in septic shock.

Co-operative versus independent transport of different cargoes by Kinesin-1.

Kinesin motors drive the intracellular transport of multiple cargoes along microtubule tracks; yet, how kinesins discriminate among their many potential cargoes is unknown. We tested whether Kinesin-1 cargoes compete, co-operate or are transported independently of each other. We focused on Kinesin-1 cargoes that bind directly to the kinesin light chain (KLC) subunit, namely the c-Jun NH(2)-terminal kinase-interacting proteins (JIPs) 1 and 3, Kidins220/ARMS and PAT1. Overexpression of individual cargo proteins in differentiated CAD cells resulted in mislocalization of the endogenous protein but had no effect on localization of other cargo proteins to neurite tips. Thus, while transport of distinct cargoes is saturable, they do not compete with each other. Interestingly, we found that low expression of JIP1 or JIP3 enhanced the transport of the other JIP to neurite tips. Moreover, JIP1 and JIP3 require each other for transport. Co-operative transport is due to an interaction between JIP1 and JIP3 as well as distinct binding sites on the KLC tetratricopeptide repeat (TPR) bundle: the TPR groove binds to C-terminal residues of JIP1, whereas the TPR surface binds to internal residues in JIP3. Formation of a JIP1/JIP3/KLC complex is necessary for efficient JIP1 or JIP3 transport in neuronal cells. Thus, JIP scaffolding proteins are transported in a co-operative manner, despite the independent transport of other Kinesin-1 cargoes.

Microsatellite instability in canine mammary gland tumors.

BACKGROUND: Genomic instability is a hallmark of cancer and may be required for the accumulation of cancer-causing mutations within cells. One form of genomic instability occurs in tandem nucleotide repeats and is known as microsatellite instability (MSI). HYPOTHESIS: We hypothesized that MSI can be observed in canine mammary gland tumors (MGT) and represents a potential carcinogenic mechanism in dogs. ANIMALS: Thirty-five dogs with MGTs and 9 dogs with other tumors were recruited from the University of Minnesota Veterinary Medical Center and referring veterinary clinics. METHODS: A panel of 21 canine microsatellite (MS) markers was amplified by polymerase chain reaction (PCR) from deoxyribonucleic acid obtained from blood and from fresh or formalin-fixed, paraffin-embedded tumor tissues. PCR products were evaluated by using capillary electrophoresis, and the chromatograms were analyzed by using genotyping software. MS genotypes obtained from fresh and formalin-fixed tumor tissues were compared, as were MS genotypes from normal tissue and tumor tissue. RESULTS: Genotypes obtained from formalin-fixed and fresh tissues were identical for all MS in 9 tumors evaluated, suggesting excellent concordance between the 2 sample types. For the 35 canine mammary tumors evaluated, 13 (37%) had stable genotypes; 22 (63%) exhibited aberrations in 1 or 2 MS; and 4 tumors (11%) demonstrated high-level instability, with aberrations in 29 to 61% of MS. CONCLUSIONS AND CLINICAL IMPORTANCE: Although some low-level MSI often is observed, high-level MSI is an infrequent finding in canine mammary tumors. Further evaluations are required to better characterize this phenomenon and to determine its relevance to canine carcinogenesis.