Panniculus Retractor Use for Visualization of Fetal Anatomy: A Randomized Controlled Trial.

OBJECTIVE: To evaluate whether use of a panniculus retractor device for pregnant patients with body mass index (BMI) 40 or higher and a panniculus improves the completion rate of the fetal anatomic examination. METHODS: This was a randomized trial in which eligible patients with BMI 40 or higher and a panniculus were randomized to undergo their detailed fetal anatomic examination with a panniculus retractor device in place compared with usual care. The primary outcome was the completion rate of 16 prespecified views from the anatomic examination. Secondary outcomes included completion rate of all 64 views from our institution's detailed anatomic examination, duration of examination, major fetal anomaly detection rate, depth from the skin to amniotic cavity before and after retractor placement, patient and ultrasonographer satisfaction, and prespecified adverse events. We assumed a baseline completion rate of 23% for the primary outcome and targeted a twofold improvement with 80% power and two-sided α of 0.05, which resulted in a sample size of 132 participants. The goal enrollment was increased to 150 participants to account for potential dropout. Statistical tests included the Student's t test, χ2, and relative risks (RRs) as appropriate. RESULTS: From March to July of 2023, 150 participants completed the study: 74 in the retractor group and 76 in the usual care group. Baseline characteristics were similar between groups except for panniculus grade. The completion rate of 16 prespecified views was 25.7% (19/74) in the retractor group and 31.6% (24/76) in the control group (RR 0.81, 95% CI, 0.49-1.35). There were no significant differences between groups for any of the secondary outcomes. Patient satisfaction and ultrasonographer satisfaction were similar between groups. CONCLUSION: Use of a panniculus retractor device during the fetal anatomic examination for patients with BMI 40 or higher and a panniculus was well tolerated by patients and ultrasonographers but did not improve the completion rate of 16 prespecified fetal anatomic views. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT05764408.

Audit of low tidal volume ventilation in patients with hypoxic respiratory failure in a tertiary Australian intensive care unit.

A low tidal volume ventilation (LTVV) strategy improves outcomes in patients with acute respiratory distress syndrome (ARDS). Subsequently, a LTVV strategy has become the standard of care for patients receiving mechanical ventilation. This strategy is poorly adhered to within intensive care units (ICUs). A retrospective analysis was conducted of prescribed tidal volumes in mechanically ventilated patients with hypoxic respiratory failure between April 2013 and March 2017. Data collection included the establishment of a new data-entry box for patient height in March 2016, aimed at assisting the calculation of LTVV. We reviewed 836 ICU admissions, comprising 19,884 hours of ventilation. A total of 92% of admissions lacked patient height recording. When height was recorded, 54% of hours of ventilation were LTVV adherent. Non-LTVV hours for both groups involved higher tidal volumes (38%) rather than lower tidal volumes (8%). Non-LTVV-adherent hours were significantly (P<0.001) more likely to be associated with patient mortality than LTVV-adherent hours were. For all hours of ventilation, mean tidal volume before March 2016 was significantly higher (496 (standard deviation (SD) 101) ml, compared to after March 2016 (451 (SD 107) ml, P<0.001, 95% confidence interval for true difference in means 42 to 48 ml). However, this trend gradually reversed over time. There was a clinician preference for multiples of 50 ml. There was poor adherence to LTVV strategy in patients with hypoxic respiratory failure, which was associated with an increase in patient mortality. An electronic medical record intervention was successful in producing change, but this was not sustainable over time. Clinician ventilation prescribing habits were based on numerical simplicity rather than evidence-based practice.

Real-Time Continuous Glucose Monitoring in Gestational Diabetes: A Randomized Controlled Trial.

OBJECTIVE: To evaluate whether real-time continuous glucose monitoring improves glycemic control over intermittent self-monitoring of blood glucose in gestational diabetes. STUDY DESIGN: We performed a single-institution randomized controlled trial. Patients with gestational diabetes were randomized to use either real-time or blinded continuous glucose monitoring. The primary outcome was mean sensor glucose level during the fourth week of continuous glucose monitoring use. Secondary outcomes included glycemic control and a composite of obstetric and neonatal outcomes. RESULTS: Of the 40 enrolled patients, 12 (60%) patients in the blinded continuous glucose monitoring group and 11 (55%) in the real-time continuous glucose monitoring group completed 4 weeks of monitoring and were included in the final analysis. There was no significant difference in mean sensor glucose level between the blinded continuous glucose monitoring group (98.9 ± 8.9 mg/dL) and the real-time continuous glucose monitoring group (107.5 ± 11.4 mg/dL). There were also no significant differences in the time spent in glycemic target, maternal, or neonatal outcomes. CONCLUSION: Our study shows that the use of continuous glucose monitoring with real-time feedback did not significantly decrease mean glucose values compared with intermittent self-monitoring of blood glucose after 4 weeks of continuous glucose monitoring use.

Tension pneumomediastinum: A literal form of chest tightness.

Tension pneumomediastinum is a rare and life-threatening complication of mediastinal emphysema which can occur with mechanical ventilation. We present a case of tension mediastinum associated with mechanical ventilation in a patient with Acute Respiratory Distress Syndrome due to Pneumocystis jirovecii pneumonia. We discuss the mechanism and pathophysiology of tension pneumomediastinum, the potential association with Pneumocystis jirovecii pneumonia and recruitment manouvres, and its definitive emergency treatment.

Comparison of continous-wave Doppler ultrasound monitor and echocardiography to assess cardiac output in intensive care patients.

BACKGROUND: Continuous-wave Doppler (CWD) ultrasound through the left ventricular outflow tract is one modality used for non-invasive cardiac output measurement. The ultrasonic cardiac output monitor (USCOM) is a relatively new monitor which uses a small, transcutaneous ultrasound probe to measure cardiac output with CWD via the suprasternal window. It is faster and less complex to train new users than conventional echocardiography. In addition to stroke volume (SV), the USCOM can calculate stroke volume variation (SVV) and the Smith-Madigan inotropy index (SMII), which is an estimate of the pre-load independent contractility of the myocardium. OBJECTIVE: To assess the level of agreement between cardiac output measured with conventional echocardiography and with USCOM. METHODS: A prospective, observational, multicentre trial of patients admitted to the intensive care units of two hospitals. After excluding patients with aortic stenosis, any patient undergoing a clinically indicated echocardiogram also underwent a subsequent USCOM study for comparison. RESULTS: We enrolled 121 patients in the study, with aortic stenosis the main reason for patient exclusion. Of the study patients, 63% were mechanically ventilated, 84% were in sinus rhythm, and the mean age of the study cohort was 66 years (SD, 17 years). There was a very strong correlation between SV as measured by the USCOM and by echocardiography. The mean difference in SV was 0.33 mL (SD, 5.62 mL), r2 = 0.956, and Bland-Altman analysis confirmed no significant bias with acceptable limits of agreement between the methods. Patients who were fluid responsive had an SVV cut point on the receiver operating characteristic curve of 21%, and sensitivity and specificity of 95%. A low SMII (< 1.1 watts/m2) calculated with the USCOM did not correlate well with low cardiac output status, with a sensitivity of only 69%. CONCLUSIONS: SV (and thus cardiac output) measured using the USCOM correlated well with echocardiographic cardiac output measurement, which suggests that the USCOM could be a valuable haemodynamic tool for assessment of cardiac output and fluid responsiveness in critically ill patients if patients with aortic stenosis are excluded. Inotropy, as a parameter of low cardiac output, was not useful in this cohort of patients.

Implementing High-Value Care.

OBJECTIVES: Our objectives were to assess physician knowledge of costs of products, tests, and services commonly used by obstetrician/gynecologists (OB/GYNs) and identify those items that could be eliminated without decreasing quality of care by performing a prospective observational pilot study. METHODS: An anonymous electronic survey was distributed to 70 OB/GYN providers at Greenville Memorial Hospital. Survey items included common laboratory tests, medications, and clinical services. The survey was used to identify items with high cost for which there were less costly but equally efficacious alternatives. As an educational intervention, grand rounds reviewing the survey results, as well as recommendations that would allow for lean healthcare changes, were conducted. Utilization and cost savings were tracked for a 1-year preintervention and a 1-year postintervention. RESULTS: In total, 50 of 70 providers (71%) completed the survey. Hydrocortisone acetate/pramoxine hydrochloride and dinoprostone vaginal inserts were targeted for intervention. Use of the dinoprostone vaginal insert decreased 50.5% with a savings of $66,500 when comparing the preintervention period with the postintervention period. Use of hydrocortisone acetate/pramoxine hydrochloride decreased 90% with a savings of $92,655. Combined, the decreased use of these products led to a $159,155 cost savings in the 1-year postintervention period. CONCLUSIONS: OB/GYN providers at our institution had a poor working knowledge of costs. Through the use of a survey and educational intervention, we demonstrated that simple interventions could lead to high-quality, lean healthcare changes.

Vitamin K Deficiency Embryopathy from Hyperemesis Gravidarum.

A 21-year-old primigravida had a pregnancy complicated by hyperemesis gravidarum (HG) beginning at 7-week gestation. Despite medical therapy, she lost 18% of her prepregnancy weight. Early ultrasound at 14 weeks demonstrated a flattened facial profile with nasal hypoplasia (Binder phenotype) consistent with vitamin K deficiency from HG. She had a percutaneous endoscopic gastrojejunostomy tube placed for enteral feeding at 15-week gestation. At repeated anatomy ultrasound at 21-week gestation, delivery, and postnatal pediatric genetics exam, nasal hypoplasia was consistent with vitamin K deficiency embryopathy from HG. Nausea and vomiting of pregnancy is a common condition. HG, the most severe form, has many maternal and fetal effects. Evaluation of vitamin K status could potentially prevent this rare and disfiguring embryopathy.

Diabetic ketoacidosis due to fulminant type 1 diabetes: A rare subtype of type 1 diabetes leading to unusual sequelae.

Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes (T1D), which without treatment leads to death. Fulminant type 1 diabetes (FT1D) is a subtype characterised by a markedly rapid and almost complete destruction of pancreatic ß-cells, with acute onset leading to severe metabolic derangement and commonly ICU admission. We present a case of an 18-year-old male presenting with FT1D with two rare complications of pneumomediastinum and stress-induced cardiomyopathy (SIC) with significant myocardial necrosis. We also discuss the aetiology of the pneumomediastinum; the latest thoughts on SIC: moving beyond the simple description of 'Takotsubo cardiomyopathy'; the role of troponins in critical illness; and genetic predisposition for DKA due to FT1D.

Ante-partum necrotising myometritis due to Streptococcal toxic shock.

Group A streptococcus (GAS) causes severe infections in obstetric patients. A rare complication is rapidly progressive necrotising myometritis. Postpartum necrotising myometritis has been previously described; however, antenatal development of such a condition is extremely rare. We present a patient who developed antenatal necrotising myometritis and toxic shock syndrome (TSS) due to GAS during the first trimester of pregnancy, eventually requiring hysterectomy and bilateral oophorectomy. We discuss the rare complication of ante-partum necrotising myometritis, as well as the antibiotic therapy, and treatment of TSS associated with severe Group A Streptococcal infections.

Thyroid storm causing placental abruption: Cardiovascular and management complications for the Intensivist.

Thyroid storm is a rare and serious complication of pregnancy which can lead to spontaneous abortion, preterm delivery, preeclampsia and cardiac failure. It is also associated with high maternal and foetal mortality if not diagnosed and managed promptly. The diagnosis of thyroid storm in pregnancy can pose significant challenges due to its presentation being similar to other pregnancy-related complications. We present a patient who developed thyroid storm at 29 weeks of pregnancy, which resulted in pre-term delivery, cardiac failure and thyroidectomy. We discuss the treatment of thyroid storm in pregnancy, the decision making involved in proceeding to thyroidectomy or to use radio-iodine, and foetal thyroid status in thyrotoxicosis.

ACE inhibitor-induced angioedema: a case report and review of current management.

Angiotensin-converting enzyme inhibitors (ACEIs) have replaced diuretics and Β-blockers as first-line agents for treating hypertension. Cough is a recognised side effect of ACEI treatment, and because of this, patients often have their medication changed to an angiotensin II receptor blocker (AIIRB). Both ACEIs and AIIRBs are associated with angioedema. We present a case of a late-onset angioedema associated with pyrexia and raised levels of inflammatory markers. We also discuss the causes and treatments of angioedema, and current controversies surrounding ACEIs and AIIRBs and their relation to anaphylaxis and angioedema.