Abnormal Right Ventricular Free Wall Strain Prior to Prone Ventilation May Be Associated With Worse Outcome of Patients With COVID-19-Associated Acute Respiratory Distress Syndrome.

We investigated the effect of prone ventilation on right ventricular (RV) function of intubated patients with COVID-19-associated acute respiratory distress syndrome by measuring both conventional RV functional variables (namely, tricuspid annular peak systolic velocity, tricuspid annular plane systolic excursion, and fractional area change) and right ventricular free wall strain (RVFWS) using transthoracic speckle-tracking echocardiography at baseline (before prone positioning), 18 hours after prone positioning, and 1 hour after supine repositioning. We found that transthoracic echocardiography was feasible in a considerable proportion (nine patients, 75% of our cohort) of patients undergoing prone ventilation. Also, abnormal as opposed to normal RVFWS values (in the absence of conventional variables of RV dysfunction) at baseline were associated with higher mortality (100% vs 20%; p = 0.048). Finally, we found that, among patients without acute cor pulmonale or conventional markers of RV dysfunction, one session of prone ventilation may not affect right myocardial strain.

Hospital Resources May Be an Important Aspect of Mortality Rate among Critically Ill Patients with COVID-19: The Paradigm of Greece.

For critically ill patients with coronavirus disease 2019 (COVID-19) who require intensive care unit (ICU) admission, extremely high mortality rates (even 97%) have been reported. We hypothesized that overburdened hospital resources by the extent of the pandemic rather than the disease per se might play an important role on unfavorable prognosis. We sought to determine the outcome of such patients admitted to the general ICUs of a hospital with sufficient resources. We performed a prospective observational study of adult patients with COVID-19 consecutively admitted to COVID-designated ICUs at Evangelismos Hospital, Athens, Greece. Among 50 patients, ICU and hospital mortality was 32% (16/50). Median PaO2/FiO2 was 121 mmHg (interquartile range (IQR), 86-171 mmHg) and most patients had moderate or severe acute respiratory distress syndrome (ARDS). Hospital resources may be an important aspect of mortality rates, since severely ill COVID-19 patients with moderate and severe ARDS may have understandable mortality, provided that they are admitted to general ICUs without limitations on hospital resources.

Simultaneous "traumatic Gerbode" and aortic rupture due to blunt chest trauma.

The Gerbode defect is characterized by a perimembranous ventricular septal defect between the left ventricle and the right atrium. This intracardiac shunt is a congenital defect but may be iatrogenic after valve surgery or atrioventricular node ablation, may be the result of endocarditis or may be traumatic. It is really rarely encountered as sequelae of non-penetrating heart trauma, and their clinical manifestations may often be unrecognized in the multi-injured patient. However, they are serious complications, and their diagnostic approach is not always feasible. We hereby present a case of a young man with the left ventricle to the right atrium communication after blunt thoracic trauma due to a car accident and concomitant rupture of the thoracic aorta. We present also the case and the ways of treatment according to the international bibliography.

Electrical muscle stimulation preserves the muscle mass of critically ill patients: a randomized study.

INTRODUCTION: Critically ill patients are characterized by increased loss of muscle mass, partially attributed to sepsis and multiple organ failure, as well as immobilization. Recent studies have shown that electrical muscle stimulation (EMS) may be an alternative to active exercise in chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) patients with myopathy. The aim of our study was to investigate the EMS effects on muscle mass preservation of critically ill patients with the use of ultrasonography (US). METHODS: Forty-nine critically ill patients (age: 59 +/- 21 years) with an APACHE II admission score >or=13 were randomly assigned after stratification upon admission to receive daily EMS sessions of both lower extremities (EMS-group) or to the control group (control group). Muscle mass was evaluated with US, by measuring the cross sectional diameter (CSD) of the vastus intermedius and the rectus femoris of the quadriceps muscle. RESULTS: Twenty-six patients were finally evaluated. Right rectus femoris and right vastus intermedius CSD decreased in both groups (EMS group: from 1.42 +/- 0.48 to 1.31 +/- 0.45 cm, P = 0.001 control group: from 1.59 +/- 0.53 to 1.37 +/- 0.5 cm, P = 0.002; EMS group: from 0.91 +/- 0.39 to 0.81 +/- 0.38 cm, P = 0.001 control group: from 1.40 +/- 0.64 to 1.11 +/- 0.56 cm, P = 0.004, respectively). However, the CSD of the right rectus femoris decreased significantly less in the EMS group (-0.11 +/- 0.06 cm, -8 +/- 3.9%) as compared to the control group (-0.21 +/- 0.10 cm, -13.9 +/- 6.4%; P < 0.05) and the CSD of the right vastus intermedius decreased significantly less in the EMS group (-0.10 +/- 0.05 cm, -12.5 +/- 7.4%) as compared to the control group (-0.29 +/- 0.28 cm, -21.5 +/- 15.3%; P < 0.05). CONCLUSIONS: EMS is well tolerated and seems to preserve the muscle mass of critically ill patients. The potential use of EMS as a preventive and rehabilitation tool in ICU patients with polyneuromyopathy needs to be further investigated. TRIAL REGISTRATION: clinicaltrials.gov: NCT00882830.

Fatal post-traumatic zygomycosis in an immunocompetent young patient.

Zygomycosis, a relatively uncommon infection, usually occurs among immunocompromised individuals. It has been reported only rarely in trauma patients. A fatal case is reported of pulmonary and rapidly progressive cutaneous zygomycosis in a young, otherwise healthy farmer, with multiple bone fractures, wounds and soft tissue injuries after an accident with an agricultural machine in the field. Rhizopus spp. was isolated from both cultures of bronchial washings and wound samples. The diagnosis was confirmed by histopathological examination of tissue specimens from a large wound. Despite systemic antifungal therapy and surgical debridement, the patient's condition deteriorated and he died from refractory septic shock.

End-inspiratory occlusion maneuver during transesophageal echocardiography for patent foramen ovale detection in intensive care unit patients.

OBJECTIVE: Mechanically ventilated patients in the intensive care unit cannot cooperate to perform the Valsalva maneuver during echocardiography for detection of patent foramen ovale. We evaluated the effectiveness of the end-inspiratory occlusion maneuver to enhance detection of patent foramen ovale in this patient population. DESIGN: Prospective interventional study. SETTING: The 40-bed intensive care unit of a university hospital. PATIENTS AND PARTICIPANTS: Twenty five sedated and mechanically ventilated intensive care unit patients referred by their attending physician for bedside transesophageal echocardiography and agitated saline contrast study for detection of patent foramen ovale. INTERVENTION: Agitated saline contrast study with end-inspiratory occlusion maneuver. MEASUREMENTS AND RESULTS: All patients underwent a complete transesophageal echocardiographic study without any complications. Reduction in right atrial cross-sectional area (from 15.80 +/- 6.08 cm2 to 12.40 +/- 4.63 cm2; p < 0.001) and interatrial septum deviation during the maneuver were recorded in all patients. Microbubbles imaged in the left atrium within three cardiac cycles after injection of agitated saline diagnosed patent foramen ovale in three patients. When end-inspiratory occlusion maneuver was added, patent foramen ovale was diagnosed in seven patients (McNemar chi2 = 9.33, p = 0.0023). CONCLUSIONS: The end-inspiratory occlusion maneuver enhances the sensitivity of transesophageal echocardiography with agitated saline contrast study for diagnosing intermittent patent foramen ovale in critically ill mechanically ventilated patients.

Successful resuscitation with thrombolysis of a patient suffering fulminant pulmonary embolism after recent intracerebral haemorrhage.

We report the life-saving administration of thrombolysis during cardiopulmonary resuscitation in a patient with recent intracerebral haemorrhage. A 53-year-old male with intracerebral haemorrhage was admitted to the intensive care unit. On the 24th day of treatment he suffered cardiac arrest with pulseless electrical activity. Transoesophageal echocardiography was performed during ongoing cardiopulmonary resuscitation. Thrombi in the right heart cavities with excessive right ventricular dysfunction confirmed the diagnosis of fulminant pulmonary embolism. Permanent restoration of a spontaneous rhythm was feasible only after administration of systemic thrombolysis with recombinant tissue plasminogen activator. Neurological examination and a computed tomogram of the brain did not show rebleeding. We conclude that under extreme circumstances absolute contraindications to thrombolysis should be weighed against the potential benefit.

Kinetics of progenitor hemopoetic stem cells in sepsis: correlation with patients survival?

BACKGROUND: Current theories underline the crucial role of pro-inflammatory mediators produced by monocytes for the pathogenesis of sepsis. Since monocytes derive from progenitor hemopoetic cells, the kinetics of stem cells was studied in peripheral blood of patients with sepsis. METHODS: Blood was sampled from 44 patients with septic syndrome due to ventilator-associated pneumonia on days 1, 3, 5 and 7 upon initiation of symptoms. Concentrations of tumour necrosis factor-alpha (TNFalpha), interleukin (IL)-6, IL-8 and G-CSF were estimated by ELISA. CD34/CD45 cells were determined after incubation with anti-CD45 FITC and anti-CD34 PE monocloncal antibodies and flow cytometric analysis. Samples from eight healthy volunteers served as controls. RESULTS: Median of CD34/CD45 absolute count of controls was 1.0/mul. Respective values of the total study population were 123.4, 112.4, 121.5 and 120.9/mul on days 1, 3, 5 and 7 (p < 0.0001 compared to controls). Positive correlations were found between the absolute CD34/CD45 count and the absolute monocyte count on days 1, 5 and 7. Survival was prolonged among patients with less than 310/microl CD34/CD45 cells on day 1 compared to those with more than 310/microl of CD34/CD45 cells (p: 0.022). Hazard ratio for death due to sepsis was 5.47 (p: 0.039) for CD34/CD45 cells more than 310/microl. Median IL-6 on day 1 was 56.78 and 233.85 pg/ml respectively for patients with less than 310/microl and more than 310/microl CD34/CD45 cells (p: 0.021). CONCLUSION: Stem cells are increased in peripheral blood over all days of follow-up compared to healthy volunteers. Patients with counts on day 1 less than 310/microl are accompanied by increased survival compared to patients with more than 310/microl.

Increased levels of serum S100B protein in critically ill patients without brain injury.

There is increasing evidence that the release of S100B protein, which is an acknowledged marker of brain injury, is also induced by other causes including hemorrhagic shock. The aim of this study was to investigate the serum concentration of S100B in critically ill mechanically ventilated patients with various degrees of organ dysfunction but without evidence of brain injury or any other neurological disorder and its possible association with tissue perfusion indices. Forty-six critically ill mechanically ventilated patients were studied on intensive care unit admission and until 6 days later. Measurement of serum S100B protein was obtained daily at the time of laboratory sampling and blood gas and lactate analysis. All patients exhibited increased levels of serum S100B levels at least once (median, 0.31 microg/L; interquartile range 25%-75%, 0.17-0.68 microg/L; range 0.04-18 microg/L). There was a significant correlation between S100B and arterial lactate (r, 0.66; P < 0.001), mean arterial pressure (MAP) (r, -0.41; P < 0.001), and pH (r, -0.37; P < 0.001). Serum concentrations of S100B were significantly higher in the presence of hemoglobin (Hb) level of less than 7 mg/dL compared with those measured when Hb level was greater than 7 mg/dL (median, 1.61 mg/dL; interquartile range 25%-75%, 0.66-3.57, vs. median, 0.29; interquartile range 25%-75%, 0.15-0.56, respectively; P < 0.001). Multiple regression analysis with dependent variable S100B and independent variables lactate, Hb, pH, and MAP showed that the only independent variable was the lactate (r, 0.79; r2, 0.62; P < 0.001). Sequential organ failure assessment score was positively associated with S100B values (P < 0.05). In conclusion, serum levels of S100B protein are elevated in critically ill patients, in the absence of an apparent brain damage. Increased S100B values correlated positively with lactate levels and negatively with MAP and pH. Low Hb level is associated with increased S100B levels. These results indicate that serum S100B protein concentration may be related to tissue hypoperfusion.