Effects of Etomidate on Postintubation Hypotension, Inflammatory Markers, and Mortality in Critically Ill Patients with COVID-19: An International, Multicenter, Retrospective Study.

OBJECTIVE: To evaluate the association of etomidate with postintubation hypotension, inflammation, and mortality in critically ill patients with COVID-19. DESIGN: International, multicenter, retrospective study. PARTICIPANTS: Critically ill patients hospitalized specifically for COVID-19 from three major academic institutions in the US and Europe. MAIN OUTCOME AND MEASURES: Patients were allocated into the etomidate (ET) group or another induction agent (OA) group. The primary outcome was postintubation hypotension. Secondary outcomes included postintubation inflammatory status, in-hospital mortality, and mortality at 30 days. RESULTS: 171 patients with a median age of 68 (IQR 58-73) years were included (ET, n = 98; OA, n = 73). Etomidate was associated with lower postintubation mean arterial pressure [74.33 (64-85) mm Hg versus 81.84 (69.75-94.25) mm Hg, p = 0.005] compared to other agents. No statistically significant differences were generally observed in inflammatory markers between the two groups at 7- and 14-days after admission to the intensive care unit. In-hospital mortality [77 (79%) versus 41 (56%), p = 0.003] and mortality at 30-days [78 (80%) versus 43 (59%), p = 0.006] were higher in the ET group. In multivariate logistic regression analysis, only etomidate (p = 0.009) and postintubation mean arterial pressure (p < 0.001) had a statistically significant effect on mortality, in contrast to stress-dose steroids (p = 0.301), after adjusting for creatinine (p = 0.695), blood urea nitrogen (p = 0.153), age (p = 0.055), oxygen saturation of hemoglobin (SpO2) (p = 0.941), and fraction of inspired oxygen (FiO2) (p = 0.712). CONCLUSIONS: Administration of a single-bolus dose of etomidate in critically ill patients with COVID-19 is associated with lower postintubation mean arterial pressure and higher in-hospital and 30-day mortality compared to other induction agents.

A Rare Case of HHV-6 Encephalitis in an Immunocompetent Host: Case Report and Literature Review.

Human herpesvirus-6 (HHV-6) is a virus known for causing the highly contagious infection, roseola infantum, and has been associated with causing encephalitis in pediatric patients and less commonly in adult patients as well. Regardless of the patient's age, the primary HHV-6 infection could be complicated by neurological sequelae including encephalitis, acute encephalopathy with biphasic seizures syndrome, or demyelinating disease. HHV-6 encephalitis does occur in an adult as a primary infection or reactivation. However, immunocompromised, hematopoietic stem cell transplantation patients, and solid organ transplant recipients are the most affected population. Here we present a rare case of HHV-6 encephalitis in a 26-year-old healthy immunocompetent male. HHV-6 viral DNA was detected in the cerebrospinal fluid during the acute stage of the disease, and the diagnosis was confirmed by quantitative polymerase chain reaction (PCR). The patient was treated with ganciclovir and had a complete response to treatment without any further complication. The pathophysiology, clinical course, and treatment in otherwise immunocompetent adult patients are also discussed.

A Rare Case of Listeria Septicemia and Meningitis in Liver Cirrhosis.

BACKGROUND Sepsis is a leading global cause of mortality, with the most common causative agents being Staphylococcus aureus, Streptococcus pneumoniae, and Escherichia coli. In septic patients with liver cirrhosis, the mortality rates are higher than in the general population due to altered liver function and an excessive innate immune response. In this demographic, sepsis is typically caused by spontaneous bacterial peritonitis or urinary tract infections and the causative agents are very predictable owing to known dysregulated immunological pathways studied in patients with cirrhosis. Listeria monocytogenes is not only a less common cause of sepsis, but also a rare cause in patients with cirrhosis. Moreover, concurrent meningitis and septicemia is even less common in this demographic. CASE REPORT Herein we present a patient with known liver cirrhosis from chronic alcohol use who presented with generalized complaints and was admitted to the Intensive Care Unit with septic shock and concomitant liver failure. Although his changes in mentation were initially attributed to sepsis with superimposed hepatic encephalopathy, he was also diagnosed with meningitis. Cultures from the cerebral spinal fluid and blood serum were positive for Listeria monocytogenes. The patient's family reported that he had not recently consumed deli meat, cheeses, or raw chicken, and there were no known outbreaks in the area at the time of diagnosis. CONCLUSIONS This report illustrates a rare case of concurrent septicemia and meningitis secondary to Listeria monocytogenes in a patient with liver cirrhosis and reviews current literature.

Backstabbed: routine lumbar puncture complicated by retroperitoneal hematoma and hemorrhagic shock.

Lumbar punctures (LPs) are commonly performed procedures, serving diagnostic and therapeutic purposes. They are generally safe, and serious, life-threatening complications are rare. We report a case of a patient who underwent an LP and subsequently developed shock. Imaging studies revealed a retroperitoneal hematoma with an active bleed. Interrogation of the lumbar branches in the interventional radiology suite revealed an active arterial bleed at the level of L3-L4 which was successfully embolized. We present this case to highlight the possibility of a rare complication of an LP and to emphasize the importance of early detection and resuscitative intervention.

Transection of lung as rare complication of pigtail catheter placement.

Pigtail catheters and chest tubes are commonly used for effective resolution of pneumothoraces and drainage of simple pleural effusions. Given their small calibers, better flexibility and more ease at the time of insertion, pigtail catheters are associated with lower risks of complications when compared to traditional chest tubes. Commonly reported complications of the pigtail catheters include the higher probability for clogging, kinking, and obstruction. Rare complications as air embolism, penetration of the heart and transection of the lungs are seldom reported in the literature. We present a case of an 81-year-old female presented with covid-19 pneumonia who developed bilateral spontaneous pneumothoraces requiring bilateral pigtail insertion. The patient developed worsening hypoxia and chest imaging revealed that the left pigtail was transected into the lung parenchyma. With this case report, we hope to bring to light a rare complication of pigtail placement.

Mortality in the coronary care unit.

OBJECTIVES: Currently, there are limited data on mortality or predictors of survival for patients admitted to the coronary care unit (CCU). The purpose of this study was to provide data on mortality in the modern-day CCU and to better define factors influencing patient survival. METHODS: A survey was conducted of all patients admitted to CCUs in New York City metropolitan academic hospitals in 2011, followed by a retrospective analysis comparing clinical data from 59 nonsurvivors with those from 897 survivors at two representative institutions. RESULTS: The weighted average mortality in the CCU across all hospitals was 5.6% (range 2.2-9.2%). The average age of the patients admitted to the CCU was 67 years, with 68% being male. Acute coronary syndromes accounted for 57% of all CCU admissions. Survival was worse in patients admitted for cardiac arrest (P=0.000), sepsis (P=0.002), primary respiratory failure (P=0.031), and systolic heart failure (P=0.003). Excluding patients who were made 'do not resuscitate' during their CCU stay, patients receiving treatments such as defibrillation after in-CCU cardiac arrest, right heart invasive monitoring, mechanical ventilation, inotropic support, emergent dialysis, or placement of an intra-aortic balloon pump had higher rates of in-CCU mortality. The most frequent causes of death were intractable cardiogenic shock, brain death, respiratory failure, multiorgan failure, or hypotension. CONCLUSION: This study provides additional mortality information for the modern-day CCU and should help identify factors that may predict survival.