Gastric outlet obstruction due to an intragastric balloon in a patient returning from the Caribbean.

Key Clinical Message: Gastric outlet obstruction can be a dangerous complication of intragastric balloons, as it can result in severe metabolic alkalosis. As weight loss procedures and medical tourism become more popular, physicians should have a high index of suspicion for complications of invasive procedures, particularly in returning travelers. Abstract: Intragastric balloons for weight loss have decreased in frequency in the United States. However, they are still frequent in low- and middle-income countries. Severe complications occur in less than 3% of patients who undergo this procedure. Herein, we present a case of gastric outlet obstruction, severe metabolic alkalosis, and refeeding syndrome in a patient returning from the Dominican Republic. She presented with 2 weeks of emesis and obstipation, followed by a pre-syncope and altered mental status. An intragastric mass was observed on computerized tomography, which was characterized as an intragastric balloon and retrieved endoscopically. All metabolic derangements were corrected, and the patient improved without sequelae. As weight loss procedures and medical tourism become more popular, physicians should have a high index of suspicion for complications of invasive procedures, particularly in returning travelers.

ICU outcomes in Covid-19 patients with obesity.

The reviews of this paper are available via the supplemental material section.

Management of life-threatening hemoptysis.

It is estimated that 5-14% of patients presenting with hemoptysis will have life-threatening hemoptysis, with a reported mortality rate between 9 and 38%. This manuscript provides a comprehensive literature review on life-threatening hemoptysis, including the etiology and mechanisms, initial stabilization, and management of patients. There is no consensus on the optimal diagnostic approach to life-threatening hemoptysis, so we present a practical approach to utilizing chest radiography, computed tomography, and bronchoscopy, alone or in combination, to localize the bleeding site depending on patient stability. The role of angiography and embolization as well as bronchoscopic and surgical techniques for the management of life-threatening hemoptysis is reviewed. Through case presentation and flow diagram, an overview is provided on how to systematically evaluate and treat the bronchial arteries, which are responsible for hemoptysis in 90% of cases. Treatment options for recurrent hemoptysis and definitive management are discussed, highlighting the role of bronchial artery embolization for recurrent hemoptysis.

Use of ultrasound-measured internal jugular vein collapsibility index to determine static intracardiac pressures in patients with presumed pulmonary hypertension.

BACKGROUND: Bedside ultrasound helps to estimate volume status in critically ill patients and has traditionally relied on diameter, respiratory variation, and collapsibility of the inferior vena cava (IVC) to reflect fluid status. We evaluated collapsibility of the internal jugular vein (IJ) with ultrasound and correlated it with concomitant right heart catheterization (RHC) measurements in patients with presumed pulmonary hypertension. METHODS AND RESULTS: We studied 71 patients undergoing RHC for evaluation of pulmonary hypertension. Using two-dimensional ultrasound (Sonosite, Washington, USA), we measured the diameter of the IJ at rest, during respiratory variation, and during manual compression. Collapsibility index during respiration (respiratory CI) and during manual compression (compression CI) was calculated. We correlated mean right atrial pressure (mRAP) and pulmonary artery occlusion pressure (PAOP) defined by RHC measurements with respiratory and compression CI. A secondary goal was examining correlations between CI calculations and B-type natriuretic peptide (BNP) levels. Baseline characteristics demonstrated female predominance (n = 51; 71.8%), mean age 59.5 years, and BMI 27.3. There were significant correlations between decrease in compression CI and increase in both mRAP (Spearman: - 0.43; p value = 0.0002) and PAOP (Spearman: - 0.35; p value = 0.0027). In contrast, there was no significant correlation between respiratory CI and either mRAP (Spearman: - 0.14; p value = 0.35) or PAOP (Spearman:- 0.12; p value = 0.31). We also observed significant negative correlation between compression CI and BNP (Spearman: - 0.31; p value = 0.01) but not between respiratory CI and BNP (Spearman: - 0.12; p value = 0.35). CONCLUSION: Increasing use of ultrasound has led to innovative techniques for estimating volume status. While prior ultrasound studies have used clinical parameters to estimate fluid status, our study used RHC measurements and demonstrated that compression CI potentially reflects directly measured mRAP and PAOP.

Outcomes of a ventilator-associated pneumonia bundle on rates of ventilator-associated pneumonia and other health care-associated infections in a long-term acute care hospital setting.

Long-term trends in ventilator-associated pneumonia (VAP) rates, and other health care-associated infections, were examined prior to, during, and after introduction of a VAP bundle in a long-term acute care hospital setting. VAP incidence rate declined in a step-wise fashion and reached a null value. Incidence rates of bacteremia from any cause declined in a similar fashion. The incidence rates of vancomycin-resistant enterococci and methicillin-resistant Staphylococcus aureus colonization or infection rates also decreased, but that of Clostridium difficile infection did not. VAP in the long-term acute care hospital setting can be controlled over time with implementation of Centers for Disease Control and Prevention-based VAP bundle. This outcome also may decrease certain other health care-associated infections.

Use of airway pressure release ventilation is associated with a reduced incidence of ventilator-associated pneumonia in patients with pulmonary contusion.

BACKGROUND: Past studies suggest that airway pressure release ventilation (APRV) is associated with reduced sedative requirements and increased recruitment of atelectatic lung, two factors that might reduce the risk for ventilator-associated pneumonia (VAP). We investigated whether APRV might be associated with a decreased risk for VAP in patients with pulmonary contusion. MATERIALS: Retrospective cohort study. RESULTS: Of 286, 64 (22%) patients requiring mechanical ventilation for >48 hours met criteria for pulmonary contusion and were the basis for this study. Subjects with pulmonary contusion had a significantly higher rate of VAP than other trauma patients, [VAP rate contusion patients: 18.3/1,000, non-contusion patients: 7.7/1,000, incidence rate ratio 2.37 (95% confidence interval [CI], 1.11-4.97), p=0.025]. Univariate analysis showed that APRV (hazard ratio, 0.15 [0.03-0.72; p=0.018]) was associated with a decreased incidence of VAP. Cox proportional hazards regression, using propensity scores for APRV to control for confounding, supported a protective effect of APRV from VAP (hazard ratio, 0.10 [95% CI, 0.02-0.58]; p=0.01). Pao2/FiO2 ratios were higher during APRV compared with conventional ventilation (p<0.001). Subjects attained the goal Sedation Agitation Score for an increased percentage of time during APRV (median [interquartile range (IQR)] 72.7% [33-100] of the time) compared with conventional ventilation (47.2% [0-100], p=0.044), however, dose of sedatives was not different between these subjects. APRV was not associated with hospital mortality (odds ratio 0.57 [95% CI, 0.06-5.5]; p=0.63) or ventilator-free days (No APRV 15.4 vs. APRV 13.7 days, p=0.49). CONCLUSION: Use of APRV in patients with pulmonary contusion is associated with a reduced risk for VAP.

Epidemiology of ventilator-associated pneumonia in a long-term acute care hospital.

OBJECTIVE: To characterize the epidemiology and microbiology of ventilator-associated pneumonia (VAP) in a long-term acute care hospital (LTACH). DESIGN: Retrospective study of prospectively identified cases of VAP. SETTING: Single-center, 207-bed LTACH with the capacity to house 42 patients requiring mechanical ventilation, evaluated from April 1, 2006, through January 31, 2008. METHODS: Data on the occurrence of VAP were collected prospectively as part of routine infection surveillance at Radius Specialty Hospital. After March 2006, Radius Specialty Hospital implemented a bundle of interventions for the prevention of VAP (hereafter referred to as the VAP-bundle approach). A case of VAP was defined as a patient who required mechanical ventilation at Radius Specialty Hospital for at least 48 hours before any symptoms of pneumonia appeared and who met the Centers for Disease Control and Prevention criteria for VAP. Sputum samples were collected from a tracheal aspirate if there was clinical suspicion of VAP, and these samples were semiquantitatively cultured. RESULTS: During the 22-month study period, 23 cases of VAP involving 19 patients were associated with 157 LTACH admissions (infection rate, 14.6%), corresponding to a rate of 1.67 cases per 1,000 ventilator-days, which is a 56% reduction from the VAP rate of 3.8 cases per 1,000 ventilator-days reported before the implementation of the VAP-bundle approach (P< .001). Microbiological data were available for 21 (91%) of 23 cases of VAP. Cases of VAP in the LTACH were frequently polymicrobial (mean number +/- SD, 1.78+/-1.0 pathogens per case of VAP), and 20 (95%) of 21 cases of VAP had at least 1 pathogen (Pseudomonas species, Acinetobacter species, gram-negative bacilli resistant to more than 3 antibiotics, or methicillin-resistant Staphylococcus aureus) cultured from a sputum sample. LTACH patients with VAP were more likely to have a neurological reason for ventilator dependence, compared with LTACH patients without VAP (69.6% of cases of VAP vs 39% of cases of respiratory failure; P= .014). In addition, patients with VAP had a longer length of LTACH stay, compared with patients without VAP (median length of stay, 131 days vs 39 days; P= .002). In 6 (26%) of 23 cases of VAP, the patient was eventually weaned from use of mechanical ventilation. Of the 19 patients with VAP, 1 (5%) did not survive the LTACH stay. CONCLUSIONS: The VAP rate in the LTACH is lower than the VAP rate reported in acute care hospitals. Cases of VAP in the LTACH were frequently polymicrobial and were associated with multidrug-resistant pathogens and increased length of stay. The guidelines from the Centers for Disease Control and Prevention that are aimed at reducing cases of VAP appear to be effective if applied in the LTACH setting.

Propylene glycol toxicity: a severe iatrogenic illness in ICU patients receiving IV benzodiazepines: a case series and prospective, observational pilot study.

STUDY OBJECTIVES: Benzodiazepines are commonly administered to medical ICU (MICU) patients. Propylene glycol (1,2-propanediol) is the solvent used to deliver lorazepam and diazepam IV. Although propylene glycol toxicity is increasingly recognized and reported, its incidence is unknown. Herein, we describe five MICU patients who acquired severe propylene glycol toxicity due to IV lorazepam or diazepam administration. Additionally, we evaluate the incidence of propylene glycol toxicity in MICU patients receiving IV lorazepam or diazepam. DESIGN: Case series and prospective, observational study. SETTING: Eighteen-bed MICU in a 550-bed urban academic hospital. PATIENTS AND METHODS: MICU patients administered IV benzodiazepines during a 3-month period were enrolled. Patients were categorized according to the IV benzodiazepine that they received. Laboratory data and highlights of their clinical course were recorded daily. The incidence of propylene glycol toxicity was determined and the groups compared. RESULTS: Forty-four patients were enrolled. Twenty-one patients received a benzodiazepine delivered in propylene glycol (lorazepam or diazepam), and 23 patients received a benzodiazepine delivered in an alternative solvent (midazolam). We found that four patients (19%) who received IV lorazepam or diazepam had metabolic evidence of propylene glycol toxicity. None of the patients had clinical deterioration. Neither metabolic abnormality nor clinical deterioration suggestive of propylene glycol toxicity were identified in subjects receiving IV midazolam. CONCLUSION: Propylene glycol toxicity is a potentially life-threatening iatrogenic complication that is common and preventable. It should be considered whenever a patient has an unexplained anion gap, unexplained metabolic acidosis, hyperosmolality, and/or clinical deterioration. Close monitoring of all patients receiving IV lorazepam or diazepam for early evidence of propylene glycol toxicity is warranted.

Intrapulmonary percussive ventilation vs incentive spirometry for children with neuromuscular disease.

BACKGROUND: Pulmonary infections can be life threatening for children with neuromuscular diseases who have impaired ability to clear secretions. Intrapulmonary percussive ventilation (IPV) is a pneumatic device that delivers air and aerosol to the lungs at frequencies of 200 to 300 cycles per minute at peak pressures from 20 to 40 cm H(2)O. Anecdotal reports and pilot studies show its safety and effectiveness in mobilizing secretions in patients with cystic fibrosis. OBJECTIVE: To test the hypothesis that IPV used in a pulmonary program for adolescents with neuromuscular disease would reduce the number of days of antibiotic use for pulmonary infection. METHODS: A randomized, controlled study was conducted to compare efficacy of IPV with incentive spirometry (IS) in reducing number of days of antibiotic use in adolescents with neuromuscular disease. The secondary endpoints were the number of respiratory infections, hospitalizations, and school days missed. RESULTS: A total of 18 patients were enrolled (9 IPV, 9 IS). Antibiotic use was significantly higher with IS (24/1000 patient-days) compared with IPV (0/1000 patient-days), (incidence rate ratio, 43; 95% confidence interval, 6-333). The IS group spent more days hospitalized (4.4/1000 patient-days vs 0/1000 patient-days) than the IPV group (incidence rate ratio, 8.5; 95% confidence interval, 1.1-67). The IPV group had 0 episodes of pneumonia or bacterial bronchitis compared with 3 events in the IS group, although this did not meet statistical significance. CONCLUSION: Intrapulmonary percussive ventilation as part of a preventive pulmonary regimen reduced days of antibiotic use and hospitalization for respiratory illness in adolescents with neuromuscular disease.