Bone cement implantation syndrome: the role of echocardiography and multidisciplinarity.

Bone cement implantation syndrome (BCIS) is a potentially serious complication after joint replacement surgery, resulting from bone marrow debris and cement embolisation, culminating in pulmonary and cardiovascular collapse. Echocardiography aids in diagnosis and management. We present a woman in her 80s with grade II BCIS. CT angiogram was inconclusive, but echocardiography revealed hyperechogenic material and right ventricular dysfunction, confirming the diagnosis. She received cardiovascular and respiratory support in a level II intensive care unit, showing full recovery of the right ventricle function when it was later reassessed. This potentially fatal condition is successfully managed if recognised early with adequate supportive care. Echocardiography might guide the diagnosis, consolidating supportive measures.

Near-fatal pheochromocytoma crisis after beta-blocker and tumour haemorrhage.

Pheochromocytomas are rare neuroendocrine tumors characterised by the secretion of catecholamines and their metabolites. While some patients may be asymptomatic, they can also present with various symptoms including hypertensive crisis, headaches, palpitations, diaphoresis or other signs of catecholamine toxicity. Adrenal haemorrhage, though rare, is a potentially fatal complication that is often diagnosed during autopsy. In all patients with suspected pheochromocytoma, regardless of whether haemorrhagic conversion has occurred, prompt diagnosis is imperative. Early identification allows for the timely initiation of treatment, preventing potentially life-threatening complications. This case report details the haemorrhagic conversion of an undiagnosed pheochromocytoma in a female patient in her 30s.

Baclofen overdose with unique cardiovascular effects.

CASE PRESENTATION: A woman in her 70s was found unresponsive and brought to our hospital with respiratory distress, cardiomyopathy and volatile alternation between hypotension and hypertension. She was intubated and admitted to intensive care for supportive treatment of suspected baclofen overdose. She gradually recovered and was discharged 10 days after presentation. Laboratory testing confirmed baclofen overdose. CONCLUSION: This case illustrates the classic features of baclofen toxicity but also includes unusual features including ST elevations on ECG and apical ballooning on echocardiogram. Lack of immediate laboratory testing can be a significant diagnostic challenge, so a high index of suspicion is needed to definitively diagnose baclofen overdose. Furthermore, haemodynamic volatility requires careful and frequent re-evaluation of treatment, so early recognition and anticipation of complications are essential for effective management of this life-threatening condition.

Hyperangulated versus Macintosh blades for intubation with videolaryngoscopy in ICU: the randomised multicentre INVIBLADE-ICU trial study protocol.

INTRODUCTION: Compared with the operating room, tracheal intubations in the intensive care unit (ICU) are associated with worsened glottic view, decreased first-time success rate and increase in the technical difficulty of intubation and incidence of complications. Videolaryngoscopes (VLs) have been proposed to improve airway management, and while recent studies have confirmed that VLs improve intubation conditions in this patient population, there remains a lack of clarity regarding the selection between a standard Macintosh blade or a hyperangulated one, to determine which yields the best outcomes. The purpose of this study was to compare successful intubation on the first attempt with the Macintosh VL versus the hyperangulated VL during tracheal intubation in ICU patients. We hypothesise that tracheal intubation using the hyperangulated VL will improve the frequency of successful intubation on the first attempt. METHODS AND ANALYSIS: The INtubation VIdeolaryngoscopy BLADE-ICU trial is a prospective, multicentre, open-label, interventional, randomised, controlled superiority study conducted in 29 ICUs in Spain. Patients will be randomly assigned in a 1:1 ratio to undergo intubation using a Macintosh VL (control group) or a hyperangulated VL (experimental group) for the first intubation attempt. The primary outcome is successful intubation on the first attempt. The secondary outcomes include the time to intubation, attempts for successful intubation, laryngoscopic vision assessed with the modified Cormack-Lehane scale, the need for adjuvant airway devices for intubation, difficulty assessed by the anaesthesiologist and complications during tracheal intubation. Enrolment began on 1 May 2024 and is expected to be completed in 2025. ETHICS AND DISSEMINATION: The study protocol was approved on 29 February 2024, by the Ethics Committee of Galicia (CEImG, code No. 2024-031).The results will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT06322719.

SGLT-2i associated diabetic ketoacidosis in the setting of cardiogenic shock.

Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus. Sodium-glucose co-transport inhibitors (SGLT-2i), a treatment for type 2 diabetes, have demonstrated a survival benefit in patients with heart failure with reduced ejection fraction (HFrEF). Many patients with HFrEF have been started on SGLT-2i and sometimes transitioned off insulin due to improved glycaemic control. SGLT-2i have demonstrated an association with DKA. Here, we present a case of simultaneous cardiogenic shock and DKA in the setting of recent transition from insulin to an SGLT-2i. DKA in conjunction with decompensated heart failure is a combination that will likely occur more frequently as SGLT-2i use becomes more widespread in patients with HFrEF, and its identification and management require special considerations. Volume status, potassium management and recognition of DKA in these patients must be approached differently than in other cases of DKA.

Efficacy and safety of esketamine hydrochloride adjunct to sufentanil in non-surgical patients under mechanical ventilation in the ICU (SENSATION trial): protocol for a multicentre, single-blind, randomised controlled trial.

INTRODUCTION: Pain is common in patients receiving mechanical ventilation in the intensive care unit (ICU). Intravenous opioids are recommended as first-line therapy for pain management; however, opioids have adverse side effects. Based on low-quality evidence, low-dose ketamine is therefore recommended as an opioid adjunct to reduce opioid consumption. Esketamine is an alternative to ketamine with greater efficacy and fewer side effects. However, evidence on the use of esketamine in patients receiving mechanical ventilation is lacking. This study investigates the efficacy and safety of esketamine as an adjunct to sufentanil for analgesic therapy in non-surgical ICU patients under mechanical ventilation. METHODS AND ANALYSIS: This ongoing multicentre, single-blind, randomised controlled trial is being conducted at six ICUs in China. 132 non-surgical patients under mechanical ventilation will be randomly assigned to the standard care and S-ketamine groups at a 1:1 ratio. Patients in the standard care group received a minimal dose of sufentanil as the sole analgesic agent. Patients in the S-ketamine group received a minimal dose of sufentanil in addition to an esketamine infusion at a fixed rate of 0.2 mg/kg/hour for analgesia. The primary outcome is mean hourly sufentanil consumption during the treatment period. ETHICS AND DISSEMINATION: This study was approved by the Ethics Committee of Chongqing University Cancer Hospital (CZLS2022067-A). Participants are required to provide informed consent. The results of this trial will be reported in peer-reviewed journals and presented at conferences. TRIAL REGISTRATION NUMBER: ChiCTR2200058933.

Analysis of emergency resuscitative thoracotomy in the combat setting.

INTRODUCTION: Emergency resuscitative thoracotomy (ERT) is a resource-intensive procedure that can deplete a combat surgical team's supply and divert attention from casualties with more survivable injuries. An understanding of survival after ERT in the combat trauma population will inform surgical decision-making. METHODS: We requested all encounters from 2007 to 2023 from the Department of Defense Trauma Registry (DoDTR). We analysed any documented thoracotomy in the emergency department and excluded any case for which it was not possible to distinguish ERT from operating room thoracotomy. The primary outcome was 24-hour mortality. RESULTS: There were 48 301 casualties within the original dataset. Of those, 154 (0.3%) received ERT, with 114 non-survivors and 40 survivors at 24 hours. There were 26 (17%) survivors at 30 days. The majority were performed in role 3. The US military made up the largest proportion among the non-survivors and survivors. Explosives predominated in both groups (61% and 65%). Median Composite Injury Severity Scores were lower among the non-survivors (19 vs 33). Non-survivors had a lower proportion of serious head injuries (13% vs 40%) and thorax injuries (32% vs 58%). Median RBC consumption was lower among non-survivors (10 units vs 19 units), as was plasma (6 vs 16) and platelets (0 vs 3). The most frequent interventions and surgical procedures were exploratory thoracotomy (n=140), chest thoracostomy (n=137), open cardiac massage (n=131) and closed cardiac massage (n=121). CONCLUSION: ERT in this group of combat casualties resulted in 26% survival at 24 hours. Although this proportion is higher than that reported in civilian data, more rigorous prospective studies would need to be conducted or improvement in the DoDTR data capture methods would need to be implemented to determine the utility of ERT in combat populations.

Best Case/Worst Case-ICU: protocol for a multisite, stepped-wedge, randomised clinical trial of scenario planning to improve communication in the ICU in US trauma centres for older adults with serious injury.

INTRODUCTION: Poor communication about serious injury in older adults can lead to treatment that is inconsistent with patient preferences, create conflict and strain healthcare resources. We developed a communication intervention called Best Case/Worst Case-intensive care unit (ICU) that uses daily scenario planning, that is, a narrative description of plausible futures, to support prognostication and facilitate dialogue among patients, their families and the trauma ICU team. This article describes a protocol for a multisite, randomised, stepped-wedge study to test the effectiveness of the intervention on the quality of communication (QOC) in the ICU. METHODS AND ANALYSIS: We will follow all patients aged 50 and older admitted to the trauma ICU for 3 or more days after a serious injury at eight high-volume level 1 trauma centres. We aim to survey one family or 'like family' member per eligible patient 5-7 days following their loved ones' admission and clinicians providing care in the trauma ICU. Using a stepped-wedge design, we will use permuted block randomisation to assign the timing for each site to begin implementation of the intervention and routine use of the Best Case/Worst Case-ICU tool. We will use a linear mixed-effects model to test the effect of the tool on family-reported QOC (using the QOC scale) as compared with usual care. Secondary outcomes include the effect of the tool on reducing clinician moral distress (using the Measure of Moral Distress for Healthcare Professionals scale) and patients' length of stay in the ICU. ETHICS AND DISSEMINATION: Institutional review board (IRB) approval was granted at the University of Wisconsin, and all study sites ceded review to the primary IRB. We plan to report results in peer-reviewed publications and national meetings. TRIAL REGISTRATION NUMBER: NCT05780918.

Efficacy and safety of dynamic arterial elastance for weaning vasopressor support in septic shock patients: a randomised controlled trial protocol.

INTRODUCTION: The dynamic arterial elastance (EaDyn), calculated as pulse pressure variation divided by stroke volume variation, has been studied as a predictor of vasopressor weaning. However, its potential as a haemodynamic tool for tapering off vasopressors in patients with sepsis remains unexplored. Therefore, our study aimed to assess whether using EaDyn for weaning vasopressor support could reduce the duration of vasopressor support in patients with sepsis. METHODS AND ANALYSIS: This pragmatic single-centre controlled clinical trial will take place at Fundación Santa Fe de Bogotá, Colombia. Adult patients diagnosed with septic shock according to the sepsis-3 criteria and a Sequential Organ Failure Assessment score ≥4 will be included. A total of 114 patients (57 per group) will undergo conventional critical care monitoring, and the weaning of vasopressor support will be initiated based on the EaDyn or mean arterial pressure (MAP), depending on the assigned group. EaDyn will be estimated based on the measurements obtained from a PiCCO device connected to a PulsioFlex Monitoring Platform (PULSION Medical Systems SE, Feldkirchen, Germany). Our primary outcome is the difference in vasopressor support duration between the EaDyn and MAP groups.Participants and statisticians performing the statistical analysis will be blinded to the group allocation. Dependent and independent variables will be analysed through univariate and multivariate statistical tests. Since we will perform three repeated measurements for analysis, we will implement a Bonferroni post hoc correction. Additionally, Cox regression and Kaplan-Meier analyses will be conducted to address objectives related to time. ETHICS AND DISSEMINATION: This study was approved by the Ethics Committee at Fundación Santa Fe de Bogotá (CCEI-16026-2024). Written informed consent will be obtained from all participants. The results will be disseminated through publication in peer-reviewed journals and presentations at national and international events. TRIAL REGISTRATION NUMBER: NCT06118775.

Probiotics-related Clostridium butyricum bacteraemia after COVID-19, confirmed by whole-genome sequencing.

A man in his 70s was admitted to an intensive care unit with severe COVID-19 and treated with dexamethasone and tocilizumab. After recovery from COVID-19, he developed Clostridium butyricum bacteraemia and non-occlusive mesenteric ischaemia, with fatal outcome. He had been prescribed C. butyricum MIYAIRI 588 fine granules as probiotics for a month. The genome sequences of the C. butyricum isolate from the blood culture and C. butyricum MIYAIRI 588 fine granules were identical by single nucleotide polymorphism analysis. This is the first case of definitive probiotics-related C. butyricum bacteraemia after treatment of severe COVID-19.

Recovery from acute haemorrhagic leucoencephalitis secondary to COVID-19.

A man in his 50s presented with sudden onset expressive aphasia and right-sided facial droop after experiencing coryzal symptoms and malaise for 7 days prior to admission. A brain MRI showed a rapidly progressive mass effect across both hemispheres and cerebrospinal fluid analysis revealed neutrophil predominance with raised protein levels. Acute disseminated encephalomyelitis was provisionally diagnosed, and high-dose methylprednisone was initiated.On admission to the high dependency unit, the patient tested positive for COVID-19 and was treated with appropriate therapeutic agents for severe COVID-19. A subsequent brain biopsy confirmed a demyelinating process, strongly indicating a diagnosis of acute haemorrhagic leucoencephalitis when correlated with the presence of severe oedema on imaging. Nine sessions of plasma exchange were provided over 18 days.At the time of writing, the patient has made an excellent recovery. We urge clinicians to consider this diagnosis and these treatment options for an otherwise devastating condition.

Haemophagocytic lymphohistiocytosis (HLH) secondary to disseminated histoplasmosis infection in a patient with HIV.

A male in his 30s who was recently diagnosed with HIV arrived at the emergency department exhibiting an altered mental state and acute respiratory distress. Initial laboratory tests revealed a high anion gap metabolic acidosis, elevated liver enzyme levels and bicytopenia. A CT scan identified a miliary pattern. Bronchoscopy with bronchoalveolar lavage displayed epithelial and inflammatory cells. However, subsequent tests ruled out the presence of fungi, Pneumocystis organisms, malignancies, granulomas and viral inclusions. Broad-spectrum antibiotics with emphasis on Mycobacterium tuberculosis and antifungal treatments were administered. The regimen was adjusted after a positive urine test for the Histoplasma antigen.The patient later manifested signs and symptoms, including increased ferritin level, fever, splenomegaly, diminished natural killer cell function and heightened interleukin-2 receptor levels, confirming haemophagocytic lymphohistiocytosis. Given the patient's gravely decompensated state, the treatment incorporated dexamethasone, and the patient's vasopressor-resistant septic shock was addressed with methylene blue.

Efficacy of high-flow nasal oxygen therapy started in the emergency room versus conventional oxygen therapy in patients with acute hypoxaemic respiratory distress: protocol for a French multicentric, prospective, open and randomised superiority study protocol (HIFLOWED).

INTRODUCTION: Acute respiratory failure is a life-threatening condition frequently found in the emergency department. High-flow nasal oxygen (HFNO) is increasingly used in emergency departments for patients with hypoxaemic acute respiratory failure. However, despite the increasing number of studies, its potential advantages regarding the need for therapeutic escalation and mortality have not been precisely evaluated. Our objective is to compare conventional oxygen therapy to HFNO when they are initiated during the first hour following the patient's arrival at the emergency department, with the hypothesis that HFNO would reduce the need for ventilatory therapy escalation. METHODS AND ANALYSIS: This is a multicentric, prospective, open and randomised superiority study. 500 inpatients will be randomised (1:1) to receive conventional oxygen therapy or HNFO. The primary outcome is a failure in the oxygen therapy defined as the need for a therapeutic escalation within 4 hours after therapy initiation. ETHICS AND DISSEMINATION: The study has been submitted and approved by the Comité de Protection des Personnes Nord Ouest IV (20 October 2020). As required, a notification was sent to the Agence nationale de sécurité du médicament et des produits de santé (22 October 2020). The research results will be published in peer-reviewed publications and presented at international conferences. TRIAL REGISTRATION NUMBER: NCT04607967.

Paradoxical Brain Herniation: An Unexpected Diagnosis.

Paradoxical herniation is a dreadful neurosurgical complication often underdiagnosed, which typically becomes evident over the course of weeks to months after the initial intervention. Here we present a unique case with manifestations in the post-operative period. A patient initially referred to neurosurgery for a meningioma underwent an uneventful surgical excision, followed by the transient placement of a lumbar drain for 48 hours. On the first post-operative day, the patient exhibited progressively altered neurological status, with corresponding imaging revealing a transfalcine herniation, necessitating emergent decompressive craniectomy. Despite the medical and surgical interventions, there were continuous signs of neurological and imaging worsening, with increase in herniation, which led to the diagnosis suspicion of a paradoxical brain herniation. Consequently, a rapid reversal of neurological deficits was observed after applying maneuvers to augment the intracranial pressure, followed by cranioplasty. This case illustrates the utmost importance of clinical suspicion for the uncommon complications of neurointerventions.

Use of pressure muscle index to guide pressure support ventilation setting: a study protocol and statistical plan for a prospective randomised controlled proof-of-concept trial.

INTRODUCTION: Although pressure support ventilation is one of the most commonly used assisted ventilation modes in intensive care units, there is still a lack of precise strategies for setting pressure support. By performing an end-inspiratory airway occlusion, the difference between the peak and plateau airway pressure, which is defined as pressure muscle index (PMI), can be easily measured on the ventilator screen. Previous studies have shown that PMI is accurate in detecting high and low inspiratory effort. No study has been conducted to investigate the use of PMI as an indicator for setting inspiratory pressure support. METHOD AND ANALYSIS: This is a study protocol for a prospective, single-centre, randomised controlled, pilot trial. Sixty participants undergoing pressure support ventilation will be randomly assigned in a 1:1 ratio to the control group or intervention group, with pressure support adjusted according to standard care or guided by the PMI strategy for 48 hours, respectively. The feasibility of the PMI-guided strategy will be evaluated. The primary endpoint is the proportion of inspiratory effort measurements within a well-accepted 'normal' range, which is predefined as oesophageal pressure-time product per minute between 50 and 200 cmH2O⋅s/min, for each patient during 48 hours of pressure support adjustment. ETHICS AND DISSEMINATION: The study protocol has been approved by Beijing Tiantan Hospital (KY2023-005-02). The data generated in the present study will be available from the corresponding author on reasonable request. The results of the trial will be submitted to international peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT05963737; ClinicalTrials.org.

Concurrent existence of cold agglutinin disease and ANCA-associated vasculitis with fulminant pulmonary-renal syndrome poses significant treatment challenges.

We present a case of a man in his 40s with pulmonary-renal syndrome due to myeloperoxidase-positive antineutrophil cytoplasmic antibodies-associated vasculitis and concurrent cold agglutinin disease, a combination that has not yet been described in the literature. The fulminant course of the disease, including the need for kidney replacement therapy and mechanical ventilation posed a significant treatment challenge due to haemolytic complications.

Application of speaking valves in adult patients with tracheostomy: a protocol for a systematic review and meta-analysis.

INTRODUCTION: Tracheostomy is a common emergency procedure for critically ill patients to secure their airway. The speaking valve is a one-way ventilation valve that is attached to the end of the tracheostomy tube to help the patient remodel subglottic pressure. However, the efficacy and safety of speaking valves in adult patients with tracheostomy remain controversial. The purpose of this protocol is to describe and evaluate the effectiveness, safety and impact on the quality of life of speaking valves in adult patients with tracheostomy. METHODS AND ANALYSIS: We will search four English databases (PubMed, Embase, Cochrane Library and Web of Science), grey literature websites and reference lists of original studies to screen for studies that might meet the criteria. The two authors will independently screen the literature, extract data and assess the quality and risk of bias of the included studies. The primary outcomes will focus on the patients' swallowing function, vocalisation and quality of life. We will use a fixed effects model or a random effects model based on heterogeneity testing or a descriptive analysis only. The quality of evidence on the effects of interventions will be assessed using the Grading of Recommendations Assessment, Development, and Evaluation. ETHICS AND DISSEMINATION: This study is based on the literature in the database and does not require the approval of the ethics committee. The results will be disseminated through a peer-reviewed journal and conferences. PROSPERO REGISTRATION NUMBER: CRD42024502906.

Associations of the staffing structure of intensive care units and high care units on in-hospital mortality among patients with sepsis: a cross-sectional study of Japanese nationwide claims data.

OBJECTIVE: The objective was to analyse the associations of intensive care unit (ICU) and high care unit (HCU) organisational structure on in-hospital mortality among patients with sepsis in Japan's acute care hospitals. DESIGN: Multicentre cross-sectional study. SETTINGS: Patients with sepsis aged ≥18 years who received critical care in acute care hospitals throughout Japan between April 2018 and March 2019 were identified using the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB). INTERVENTIONS: None. PARTICIPANTS: 10 968 patients with sepsis were identified. ICUs were categorised into three groups: type 1 ICUs (fulfilling stringent staffing criteria such as experienced intensivists and high nurse-to-patient ratios), type 2 ICUs (less stringent criteria) and HCUs (least stringent criteria). PRIMARY OUTCOME MEASURE: The study's primary outcome measure was in-hospital mortality. Cox proportional hazards regression analysis was performed to examine the impact of ICU/HCU groups on in-hospital mortality. RESULTS: We analysed 2411 patients (178 hospitals) in the type 1 ICU group, 3653 patients (422 hospitals) in the type 2 ICU group and 4904 patients (521 hospitals) in the HCU group. When compared with the type 1 ICU group, the adjusted HRs for in-hospital mortality were 1.12 (95% CI 1.04 to 1.21) for the type 2 ICU group and 1.17 (95% CI 1.08 to 1.26) for the HCU group. CONCLUSION: ICUs that fulfil more stringent staffing criteria were associated with lower in-hospital mortality among patients with sepsis than HCUs. Differences in organisational structure may have an association with outcomes in patients with sepsis, and this was observed by the NDB.

Weil's disease in a temperate climate: diagnostic uncertainty and the importance of prompt antibiotic treatment.

A man in his 50s presents with a short history of rigors, back pain and dark urine. This was associated with scleral icterus. He was initially treated as urosepsis due to perinephric fat stranding on his first CT but continued to deteriorate with worsening sepsis requiring intensive care admission. He had a conjugated hyperbilirubinaemia (peak 708 µmol/L) with normal liver enzymes, anaemia, thrombocytopaenia, acute kidney injury requiring filtration and respiratory failure requiring ventilatory support. A subsequent CT revealed mediastinal lymphadenopathy and extensive ground-glass changes with patchy consolidation. When his history was revisited, exposure to rodents was identified, and serological testing for leptospirosis subsequently came back positive. This case explores the causes of hyperbilirubinaemia in leptospirosis, the dangers of tunnel vision in diagnostic medicine and the importance of prompt antibiotic therapy in Weil's disease.