Evaluation of Unfractionated Heparin Dosing by Antifactor Xa During Targeted Temperature Management Post Cardiac Arrest.

Purpose: To evaluate unfractionated heparin (UFH) dosing guided by antifactor Xa levels during targeted temperature management (TTM) post-cardiac arrest. Methods: Single-center, retrospective, observational study between January 1, 2014 and September 1, 2020. Patients initiated on TTM post-cardiac arrest and UFH were evaluated for inclusion. Patients included were ≥18 years of age and received weight-based UFH for ≥6 hours with 2 antifactor Xa levels drawn at target temperature. Excluded patients had no available temperature readings, received extracorporeal membrane oxygenation (ECMO) or factor Xa inhibitor (within 72 hours), or had hypertriglyceridemia or hyperbilirubinemia. The primary endpoint was to evaluate the proportion of patients that achieved a therapeutic antifactor Xa level between 0.3 and 0.7 IU/mL at steady state during TTM. Secondary endpoints included average UFH dose and average time to therapeutic antifactor Xa level at steady state; percent of first and total antifactor Xa levels subtherapeutic, therapeutic, and supratherapeutic during TTM. Results: A total of 73 patients met inclusion criteria. Of these, 21 patients achieved steady-state therapeutic antifactor Xa levels during TTM. The average time and dose to steady-state therapeutic antifactor Xa levels were 8.1 ± 4.5 hours and 9.9 ± 3.2 units/kg/hour. Overall, 61.7% of first and 47.4% of all antifactor Xa levels were supratherapeutic during TTM. Three (4.1%) patients experienced a major bleeding event. Conclusions: Guideline recommended UFH dosing, 12 or 18 units/kg/hour, during TTM resulted in more supratherapeutic antifactor Xa levels. Reduction of UFH infusion dose to 10 units/kg/hour may be required during TTM to maintain therapeutic antifactor Xa levels.

Usefulness of thrombolysis in cardiac arrest secondary to suspected or confirmed pulmonary embolism.

Acute pulmonary embolism (PE) is a form of venous thromboembolism associated with significant morbidity and mortality. Massive PE, characterized by hemodynamic instability, has been reported as a common cause of cardiac arrest. Thrombolytic agents have therefore been identified as a potential rescue therapy to restore circulatory perfusion. This study describes use patterns of systemic thrombolysis in cardiac arrest and corresponding patient outcomes. A multicenter retrospective chart review was conducted to evaluate adult patients who received rescue thrombolysis during cardiac arrest for suspected or confirmed PE. A total of 27 patients were included. PE was confirmed in 4 patients (15%). Pulseless electrical activity was the initial rhythm in 21 patients (78%), with a median cardiac arrest duration of 23 minutes in patients with return of spontaneous circulation (ROSC) vs 42.5 minutes in patients without ROSC. Among the 11 patients (41%) with ROSC, two (7%) survived to hospital discharge. Notable characteristics of the two survivors included a confirmed PE, an initial presenting rhythm of pulseless electrical activity, and administration of alteplase within 5 minutes of cardiac arrest. We recommend early administration of rescue thrombolysis when there is a high clinical index of suspicion that PE is the cause of the arrest.

Acute lung injury secondary to e-cigarettes or vaping.

As of October 2019, 1299 cases of "e-cigarette, or vaping, product use associated lung injury" (EVALI) have been reported in the USA, with 26 deaths. Multiple patterns of lung injury have been reported, including lipoid pneumonia, organizing pneumonia, and acute eosinophilic pneumonia, with radiographic findings including diffuse pulmonary infiltrates. We report a case of lipoid pneumonia secondary to EVALI. Physicians should be alert to recognizing these patterns of lung injury, as well as emphasizing to patients the importance of e-cigarette cessation.

Left upper lobe torsion in pneumothorax.

We report a case of left upper lobe torsion in a patient who had a pneumothorax as a complication of subclavian venous access for an elective neurosurgical operation. Despite appropriate management of the pneumothorax, the patient's chest radiograph did not improve. Computed tomography of the chest was concerning for left upper lobe torsion. Fiberoptic bronchoscopy revealed near complete obstruction of the left upper lobe bronchus. Review of computed tomography imaging before and after bronchoscopy and subsequent thoracotomy confirmed lobar torsion. Consideration of lobar torsion in the differential diagnosis of patients with persistently abnormal chest imaging despite appropriate management after complications of routine procedures is important for early recognition and intervention of a potentially life-threatening problem.

Massive hemoptysis managed by rescue extracorporeal membrane oxygenation.

Massive hemoptysis can have a rapid and potentially fatal clinical course. A 68-year-old woman presented with recurrent hemoptysis complicated by refractory hypoxemia and shock despite aggressive intervention. The use of veno-venous extracorporeal membrane oxygenation was a nontraditional intervention that ultimately proved to be lifesaving, but is by no means recommended for routine use in this setting.

Adrenal crisis and autoimmune polyglandular syndromes.

We report a 67-year-old woman who presented with adrenal crisis as a manifestation of autoimmune polyglandular syndrome 2, a polygenic disorder characterized by concurrent primary adrenal insufficiency and either autoimmune thyroid disease or type 1 diabetes mellitus.

Optimizing laboratory test utilization in long-term acute care hospitals.

Laboratory tests can be considered inappropriate if overused or when repeated, unnecessary "routine" testing occurs. For chronically critically ill patients treated in long-term acute care hospitals (LTACHs), inappropriate testing may result in unnecessary blood draws that could potentially harm patients or increase infections. A quality improvement initiative was designed to increase physician awareness of their patterns of lab utilization in the LTACH environment. Within a large network of LTACHs, 9 hospitals were identified as having higher patterns of lab utilization than other LTACHs. Meetings were held with administrative staff and physicians, who designed and implemented hospital-specific strategies to address lab utilization. Lab utilization was measured in units of lab tests ordered per inpatient day (lab UPPD) for 8 months prior to the initial meeting and 7 months after the meeting. A repeated measures mixed model determined that postintervention lab utilization improved, on average and adjusted by case mix index, by 0.37 lab UPPD (t = -3.61, 95% CI 0.17 to 0.58) compared to the preintervention period. Overall, the case mix index 8 months prior to the intervention was no different than it was 7 months after the initial meeting (t[8] = -0.96, P = 0.37). Patient safety and outcome measures, including percentage of patients weaned from a ventilator, readmission rates, central catheter utilization rates, and the incidence of methicillin-resistant Staphylococcus aureus and other multidrug resistant organisms, showed no significant change. Hospital staff meetings focused on lab utilization and the development and deployment of tailored lab utilization strategies were associated with LTACHs achieving significantly lower lab utilization without negatively impacting quality outcomes.

Vanishing lung syndrome.

Giant bullae often mimic pneumothorax on radiographic appearance. We present the case of a 55-year-old man admitted to a referring hospital with dyspnea, cough, and increasing sputum production; he refused thoracotomy for tension pneumothorax and presented to our hospital for a second opinion. A computed tomography (CT) scan at our hospital revealed a giant bulla, which was managed conservatively as an exacerbation of chronic obstructive pulmonary disease. Thoracic surgery was consulted but advised against bullectomy. Giant bullae can easily be misdiagnosed as a pneumothorax, but the management of the two conditions is vastly different. Distinguishing between the two may require CT scan. Symptomatic giant bullae are managed surgically. We highlight the etiology, presentation, diagnosis, and treatment of bullous lung disease, especially in comparison to pneumothorax.

Unrecognized hemoglobin SE disease as microcytosis.

Hemoglobin SE disease was first described during the 1950s as a relatively benign microcytosis, but increasing prevalence has revealed a predisposition towards vasoocclusive sickling. Recognition of SE hemoglobinopathies' potential complications is crucial so medical measures can be utilized to avoid multiorgan injury.

Myxedema coma with cardiac tamponade and severe cardiomyopathy.

Myxedema coma is an infrequent but potentially fatal complication of hypothyroidism. We present a rare case of previously undiagnosed hypothyroidism presenting in cardiogenic shock from pericardial tamponade and depressed myocardial contractility in myxedema coma. Here, we focus on cardiovascular complications associated with the condition.

West Nile virus and the 2012 outbreak: The Baylor University Medical Center experience.

West Nile virus (WNV) has been responsible for multiple outbreaks and has shown evolution in its clinical manifestation. The Centers for Disease Control and Prevention has provided diagnostic criteria in classifying the variety of WNV infection; however, application of these criteria can prove challenging during outbreaks, and understanding the array of presentations and patient population is clinically important. In this article, we present the challenges encountered during the 2012 outbreak at one institution.

Anaplastic large-cell lymphoma in AIDS.

AIDS-related malignancies may alter clinical courses and result in death in critically ill patients. We present a case of a newly diagnosed AIDS patient with Pneumocystis jiroveci pneumonia, Epstein-Barr virus, and cytomegalovirus infections who was found to have widely metastatic kinase-negative anaplastic large-cell lymphoma. This case demonstrates the diversity in the malignant presentation of HIV-infected patients, outside of the more commonly observed non-Hodgkin lymphomas.

Metformin-induced lactic acidosis with emphasis on the anion gap.

The presence of an anion gap in a diabetic patient, especially if associated with evidence of compromised renal function, should prompt clinicians to consider metformin as a contributing factor. This consideration is especially important in patients with severe anion gaps associated with lactic acidosis out of proportion to the patient's clinical presentation.