Transient Diabetes Insipidus After Vasopressin Discontinuation.

Vasopressin infusion is commonly used in intensive care settings during states of advanced vasodilatory shock for its vasoconstrictive properties. Vasopressin also acts on renal tubular cell receptors in the collecting ducts of kidneys to allow for water reabsorption. The sudden discontinuation of vasopressin infusion can lead to the development of transient diabetes insipidus (DI) with classic findings of polyuria, dilute urine, and hypernatremia. We report the case of a 59-year-old male who underwent an emergent bedside cricothyrotomy procedure secondary to papillary carcinoma of the thyroid and subsequently developed septic shock requiring initiation of vasopressin infusion for hemodynamic support. He remained on vasopressin for five days before the infusion was discontinued after clinical improvement. Within 12 hours of vasopressin discontinuation, the patient developed polyuria (> 3 L/day urine output) with volumes as high as 1 L per hour. His serum sodium levels increased more than 10 mmol/L from 137 to 149 mmol/L. This case is unique from prior reports, as our patient was without any neurological or neurosurgical comorbidities that would predispose him to an organic central cause of DI. Furthermore, the patient's large-volume diuresis and serum abnormalities spontaneously self-improved within 24 hours without significant medical intervention. In conclusion, this case adds to a growing number of reports of transient DI following vasopressin withdrawal, demonstrating the need to formally recognize this occurrence as a potential consequence of vasopressin use in intensive care settings.

Lung ultrasound artifacts in COVID-19 patients.

Lung ultrasound is an essential tool in critical care, made more so by the enhanced precautions associated with the Covid-19 pandemic. Here we describe 2 cases of multiple, small shred signs seen on ultrasound of Covid-19 patients.

Sonographic Assessment of Intravascular Fluid Estimate (SAFE) Score by Using Bedside Ultrasound in the Intensive Care Unit.

OBJECTIVE: The objective of the study was to use an ultrasound-based numerical scoring system for assessment of intravascular fluid estimate (SAFE) and test its validity. METHODS: A prospective, observational study was carried out in the surgical intensive care unit (ICU) of an urban tertiary care teaching hospital. Patient's intravascular volume status was assessed using the standard methods of heart rate, blood pressure, central venous pressure, cardiac output, lactate and saturation of venous oxygen, and others. This was compared with assessment using bedside ultrasound evaluation of the cardiac function, inferior vena cava, lungs, and the internal jugular vein. Applying a numerical scoring system was evaluated by Fisher's exact testing and multinomial logistic model to predict the volume status based on ultrasound scores and the classification accuracy. RESULTS: 61 patients in the ICU were evaluated. 21 (34.4% of total) patients diagnosed with hypovolemia, and their ultrasound volume score was -4 in 14 (66.7%) patients, -3 in 5 (23.8%) patients, and 0 in 2 (9.5%) patients (p < 0.001). 18 (29.5% of total) patients diagnosed with euvolemia, and their ultrasound volume score was 0 in 11 (61.1%) patients, +1 in 4 (22.2%) patients, and -1 in 1 (5.6%) patient (p < 0.001). 18 (29.5% of total) patients diagnosed with euvolemia, and their ultrasound volume score was 0 in 11 (61.1%) patients, +1 in 4 (22.2%) patients, and -1 in 1 (5.6%) patient (p < 0.001). 18 (29.5% of total) patients diagnosed with euvolemia, and their ultrasound volume score was 0 in 11 (61.1%) patients, +1 in 4 (22.2%) patients, and -1 in 1 (5.6%) patient (p < 0.001). 18 (29.5% of total) patients diagnosed with euvolemia, and their ultrasound volume score was 0 in 11 (61.1%) patients, +1 in 4 (22.2%) patients, and -1 in 1 (5.6%) patient (. CONCLUSION: Using the SAFE scoring system to identify the IVV status in critically ill patients significantly correlates with the standard measures. A SAFE score of -4 to -2 more likely represents hypovolemia, -1 to +1 more likely represents euvolemia, and +2 to +4 more likely to be hypervolemia.

Clostridium difficile Enteritis after Total Abdominal Colectomy for Ulcerative Colitis.

INTRODUCTION: Isolated Clostridium difficile small bowel enteritis is a rare condition with significant morbidity and mortality. PRESENTATION OF CASE: An 83-year-old female with refractory ulcerative colitis underwent a total proctocolectomy and end ileostomy. Her postoperative course was complicated with return to the operating room for repair of an incarcerated port site hernia. Subsequently, she developed septic shock and multiorgan failure requiring intubation and mechanical ventilation, renal replacement therapy, and high dose vasopressors. Diagnostic workup revealed diffuse small bowel wall thickening on computed tomography scan as well as positive nucleic acid amplification test for C. difficile toxin B gene. Despite treatment with antibiotics and maximum attempts at resuscitation, the patient expired. Discussion. C. difficile infection most commonly affects the colon but rarely can involve the small bowel. The pathogenesis of C. difficile enteritis is unclear but is believed to mirror that of colitis. Surgical patients are susceptible for C. difficile infection, as they tend to be relatively immunosuppressed in the postoperative period. Radiologic findings of enteritis may mimic those of colitis and this includes small bowel dilation and thickening. Treatment for this condition has not been well established but it is approached similar to colitis. CONCLUSION: Despite an increase in the number of case reports of C. difficile enteritis, it continues to be a rare but potentially fatal infection. Clinicians should maintain a high index of suspicion especially in patients with inflammatory bowel disease who undergo colon resections.

The Fundamentals of Critical Care Support: local experience and a look into the future.

Fundamentals of Critical Care Support (FCCS) is an educational course offered by the Society of Critical Care Medicine (USA) to provide and augment the basic knowledge for individuals managing critically ill patients. More than 10,000 clinicians every year throughout the world attend FCCS courses, preparing non-intensivists to manage critically ill patients for the first 24 h until a consultation can be secured. The most important emphasis of the FCCS course is to learn the basic principles and the adaptation of multidisciplinary approaches to managing the critically ill. The curriculum consists of integrated lectures and skills stations helping to provide the knowledge and guidance in decision making. This article is an account of one institution's experience in offering this course for over 12 years.

Inferior vena cava collapsibility loses correlation with internal jugular vein collapsibility during increased thoracic or intra-abdominal pressure.

PURPOSE: Point-of-care ultrasound evaluates inferior vena cava (IVC) and internal jugular vein (IJV) measurements to estimate intravascular volume status. The reliability of the IVC and IJV collapsibility index during increased thoracic or intra-abdominal pressure remains unclear. METHODS: Three phases of sonographic scanning were performed: spontaneous breathing phase, increased thoracic pressure phase via positive pressure ventilation (PPV) phase, and increased intra-abdominal pressure (IAP) phase via laparoscopic insufflation to 15 mmHg. IVC measurements were done at 1-2 cm below the diaphragm and IJV measurements were done at the level of the cricoid cartilage during a complete respiratory cycle. Collapsibility index was calculated by (max diameter - min diameter)/max diameter × 100 %. Chi square, t test, correlation procedure (CORR) and Fisher's exact analyses were completed. RESULTS: A total of 144 scans of the IVC and IJV were completed in 16 patients who underwent laparoscopic surgery. Mean age was 46 ± 15 years, with 75 % female and 69 % African-American. IVC and IJV collapsibility correlated in the setting of spontaneous breathing (r (2) = 0.86, p < 0.01). IVC collapsibility had no correlation with the IJV in the setting of PPV (r (2) = 0.21, p = 0.52) or IAP (r (2) = 0.26, p = 0.42). Maximal IVC diameter was significantly smaller during increased IAP (16.5 mm ± 4.9) compared to spontaneous breathing (20.6 mm ± 4.8, p = 0.04) and PPV (21.8 mm ± 5.6, p = 0.01). CONCLUSION: IJV and IVC collapsibility correlated during spontaneous breathing but there was no statistically significant correlation during increased thoracic or intra-abdominal pressure. Increased intra-abdominal pressure was associated with a significant smaller maximal IVC diameter and cautions the reliability of IVC diameter in clinical settings that are associated with intra-abdominal hypertension or abdominal compartment syndrome.

Feasibility of common carotid artery point of care ultrasound in cardiac output measurements compared to invasive methods.

BACKGROUND: Cardiac output (CO) measurement in the intensive care unit (ICU) requires invasive devices such as the pulmonary artery (PA) catheter or arterial waveform pulse contour analysis (PCA). This study tests the accuracy and feasibility of point of care ultrasound (POCUS) of the common carotid artery to estimate the CO non-invasively and compare it to existing invasive CO measurement modalities. METHODS: Patients admitted to the surgical and cardiothoracic ICU in a tertiary university-affiliated academic center during a 4-month period, with invasive hemodynamic monitoring devices for management, were included in this cohort study. Common carotid artery POCUS was performed to measure the CO and the results were compared to an invasive device. RESULTS: Intensivists and ICU fellows, using ultrasound of the common carotid artery, obtained the CO measurements. Images of the Doppler flow and volume were obtained at the level of the thyroid gland. Concurrent CO measured via invasive devices was recorded. The patient cohort comprised 36 patients; 52 % were females. The average age was 59 ± 13 years, and 66 % were monitored via PCA device and 33 % via PA catheter. Intraclass correlation coefficient (ICC) analysis demonstrated almost perfect correlation (0.8152) between measurements of CO via ultrasound vs. invasive modalities. The ICC between POCUS and the invasive measurement via PCA was 0.84 and via PA catheter 0.74, showing substantial agreement between the ultrasound and both invasive modalities. CONCLUSIONS: Common carotid artery POCUS offers a non-invasive method of measuring the CO in the critically ill population.

Point of care ultrasound (POCUS) telemedicine project in rural Nicaragua and its impact on patient management.

BACKGROUND: Point of care ultrasound (POCUS) is a useful diagnostic tool in medicine. POCUS provides an easy and reproducible method of diagnosis where conventional radiologic studies are unavailable. Telemedicine is also a great means of communication between educators and students throughout the world. HYPOTHESIS: Implementing POCUS with didactics and hands-on training, using portable ultrasound devices followed by telecommunication training, will impact the differential diagnosis and patient management in a rural community outside the United States. MATERIALS AND METHODS: This is an observational prospective study implementing POCUS in Las Salinas, a small village in rural western Nicaragua. Ultrasound was used to confirm a diagnosis based on clinical exam, or uncover a new, previously unknown diagnosis. The primary endpoint was a change in patient management. International sonographic instructors conducted didactic and practical training of local practitioners in POCUS, subsequently followed by remote guidance and telecommunication for 3 months. RESULTS: A total of 132 patients underwent ultrasound examination. The most common presentation was for a prenatal exam (23.5 %), followed by abdominal pain (17 %). Of the 132 patients, 69 (52 %) were found to have a new diagnosis. Excluding pregnancy, 67 patients of 101 (66 %) were found to have a new diagnosis. A change in management occurred in a total of 64 (48 %) patients, and 62 (61 %) after excluding pregnancy. CONCLUSION: Implementing POCUS in rural Nicaragua led to a change in management in about half of the patients examined. With the appropriate training of clinicians, POCUS combined with telemedicine can positively impact patient care.

Model Point-of-Care Ultrasound Curriculum in an Intensive Care Unit Fellowship Program and Its Impact on Patient Management.

Objectives. This study was designed to assess the clinical applicability of a Point-of-Care (POC) ultrasound curriculum into an intensive care unit (ICU) fellowship program and its impact on patient care. Methods. A POC ultrasound curriculum for the surgical ICU (SICU) fellowship was designed and implemented in an urban, academic tertiary care center. It included 30 hours of didactics and hands-on training on models. Minimum requirement for each ICU fellow was to perform 25-50 exams on respective systems or organs for a total not less than 125 studies on ICU. The ICU fellows implemented the POC ultrasound curriculum into their daily practice in managing ICU patients, under supervision from ICU staff physicians, who were instructors in POC ultrasound. Impact on patient care including finding a new diagnosis or change in patient management was reviewed over a period of one academic year. Results. 873 POC ultrasound studies in 203 patients admitted to the surgical ICU were reviewed for analysis. All studies included were done through the POC ultrasound curriculum training. The most common exams performed were 379 lung/pleural exams, 239 focused echocardiography and hemodynamic exams, and 237 abdominal exams. New diagnosis was found in 65.52% of cases (95% CI 0.590, 0.720). Changes in patient management were found in 36.95% of cases (95% CI 0.303, 0.435). Conclusions. Implementation of POC ultrasound in the ICU with a structured fellowship curriculum was associated with an increase in new diagnosis in about 2/3 and change in management in over 1/3 of ICU patients studied.

Racial differences in vasopressor requirements for septic shock.

OBJECTIVE: The objective of this study was to compare vasopressor requirements between African American (AA) patients and white patients in septic shock. METHODS: This was a retrospective cohort review conducted over a 2-year period measuring total and mean dosage of various vasopressors used between two racial groups during the treatment of patients admitted with septic shock. The study included patients admitted to the intensive care unit with septic shock at an 805-bed tertiary, academic center. All septic shock patients were managed with vasopressors. Vasopressor selection, dosage, and duration were at the discretion of the treating physician. Total, mean, and duration of vasopressor dosing requirements were obtained for study participants. Comorbidities, prehospitalization antihypertensive medication requirements, intravenous fluids given during the septic shock phase, and source of infection were analyzed. RESULTS: One hundred fifty-nine patients with septic shock were analyzed, of which 96 (60.4%) were AAs (P < 0.059). African Americans had higher rates of end-stage renal disease and hypertension compared with whites, 85.7% vs. 14.3% (P < 0.011; odds ratio [OR], 15.684) and 68.3% vs. 31.7% (P < 0.007; OR, 3.357), respectively. Norepinephrine (NE) was administered to 150 patients, 57.2% of which were AAs (P < 0.509). Thirteen patients received dopamine (5% AAs, P < 0.588), 40 patients received phenylephrine (15.7% AAs, P < 0.451), and five patients received epinephrine (1.9% AAs, P < 0.660). Comparing vasopressors between races, only NE showed statistical significance via logistic regression modeling for the AA race in terms of total dosage (AAs 736.8 [SD, 897.3] µg vs. whites 370 [SD, 554.2] µg, P < 0.003), duration of vasopressor used (AAs 38.38 [SD, 34.75] h vs. whites 29.09 [SD, 27.11] h, P < 0.037), and mean dosage (AAs 21.08 [SD, 22.23] µg/h vs. whites 12.37 [SD, 13.86] µg/h, P < 0.01). Mortality between groups was not significant. Logistic regression identified discrepancy of the mean dose NE in AAs compared with whites, with OR of 1.043 (P = 0.01). CONCLUSIONS: African American patients with septic shock were treated with higher doses of NE and required longer duration of NE administration compared with white patients.

Ultrasonography versus chest radiography after chest tube removal for the detection of pneumothorax.

BACKGROUND: Bedside ultrasound technology is an innovative, cost-effective, safe, and reproducible method used to make efficient decisions that directly affect the care of critical care patients. PURPOSE: To validate the use of ultrasound technology when compared with the use of standard chest radiography for the detection of pneumothorax following chest tube removal. METHODS: A prospective observational comparison study of 50 cardiothoracic patients with surgically placed pleural chest tubes was conducted. The accuracy of bedside ultrasound technology was compared with standard chest radiography to detect pneumothorax. RESULTS: The sample kappa statistic was 1.000, indicating a perfect agreement between bedside ultrasonography and chest radiography in the detection of pneumothorax. Completion of the bedside ultrasound procedure took significantly less time than chest radiography. CONCLUSIONS: Bedside ultrasound technology is as accurate as chest radiography in detecting pneumothorax following chest tube removal and can save institutions' time and money.

Effect of lower limb compression devices on thermodilution cardiac output measurement.

OBJECTIVE: The aim of this study was to determine whether lower limb (calf) sequential compression devices (SCDs) have a significant effect on thermodilution cardiac output measurements using a pulmonary artery catheter. DESIGN: Prospective clinical investigation. SETTING: Surgical and neurosurgical intensive care units in a university hospital. PATIENTS: A total of 43 patients with pulmonary artery catheters and bilateral lower limb SCDs. MEASUREMENTS AND MAIN RESULTS: Cardiac output was measured (average of three) when the SCDs were off (T1), during the first 2-4 secs of the inflation cycle (T2), during seconds 4-8 of the inflation cycle (T3), and when the SCDs were off again (T4). Cardiac output measurements were consistently lower when measured during the SCD inflation cycle. The decrease in cardiac output ranged from 7.58% to 49.5%, with a mean reduction of 24.51% in the first 2-4 seconds and 20.61% during seconds 4-8 (p < .001). Two patients displayed an increase in cardiac output during the inflation cycle; one patient had an increase of 2.78% and the other an increase of 13.5%. In 11 patients, measurements were also made using a pulse contour-analysis cardiac output device, but no changes in pulse contour-analysis cardiac output were observed during the same time period. CONCLUSIONS: Thermodilution cardiac output measurements via a pulmonary artery catheter should not be done during the inflation cycle of lower limb SCDs because they produce a falsely low cardiac output.