Bilateral vocal cords paralysis requiring urgent tracheostomy on COVID-19 patient: a case report.

BACKGROUND: SARS-CoV-2 infection has many manifestations, including otolaryngological symptoms. CASE PRESENTATION: A 60-year-old man with severe dyspnea underwent endotracheal intubation followed by 68 h of mechanical ventilation. After extubation, he left the ICU without any significant complications. Four days after the extubation, he developed dyspnea, which deteriorated the next 2 days, and stridor became evident. A fiberoptic laryngoscope revealed bilateral vocal cord edema and paralysis, which required an emergency airway. We decided to perform an awake tracheostomy under local anesthesia while considering protection for airborne infection to healthcare providers. The tracheostomy was closed when the edema and paralysis of the vocal cords were ameliorated. CONCLUSIONS: A COVID-19 patient who underwent injurious ventilation developed vocal cord paralysis and edema 6 days after extubation, leading to an emergency tracheostomy. Close attention to the upper airway of COVID-19 patients is essential since the pathophysiology of the present incident may be specific to the viral infection.

Therapeutic and Adverse Effects of Thrombomodulin Alfa to Treat Sepsis-Induced Disseminated Intravascular Coagulation.

In the treatment of disseminated intravascular coagulation (DIC), which is a complication of underlying diseases such as infections and malignant tumors, effective plasma concentrations of thrombomodulin (TM) alfa range from 300 to 900 ng/mL; however, appropriate concentrations when treating sepsis-induced DIC are unknown. Thus, our aim was to determine the relationship between plasma concentrations of TM alfa and its therapeutic effects, and hemorrhagic adverse events. First, we calculated the plasma trough concentrations of TM alfa in septic DIC patients. Next, we divided patients into two groups according to their plasma concentrations into a low- and high-concentration group based on a cut-off value of 600 ng/mL. Fourteen and 35 patients were included in the low- and high-concentration groups, respectively. The Japanese Association for Acute Medicine DIC diagnostic criteria score 4 days after TM alfa administration decreased significantly by 2.06 points from baseline in the high-concentration group compared with 0.71 points in the low-concentration group. The 90-day survival rate was significantly higher in the high-concentration group (85.4%) than in the low-concentration group (49.0%) (hazard ratio, 0.27; 95% confidence interval: 0.09-0.86). In contrast, the incidence of serious hemorrhage was not significantly different between the groups. The recommended plasma concentration of TM alfa in the treatment of septic DIC was determined to be higher than 600 ng/mL, and a dose of 380 U/kg (0.06 mg/kg) was necessary to achieve this concentration.

Frequency and outcome of post-extubation dysphagia using nurse-performed swallowing screening protocol.

BACKGROUND: Post-extubation dysphagia reportedly occurs in 3%-60% of patients and is independently associated with poor patient outcomes. AIM: The aim of this study was to investigate the frequency of post-extubation dysphagia, as diagnosed using our novel nurse-performed swallowing screening protocol, and to evaluate patient outcomes, including the frequency of discharge home, the length of the intensive care unit and hospital stays, the frequency of hospital-acquired pneumonia and death in the intensive care unit and hospital. DESIGN: This was a prospective cohort study. METHODS: This study was conducted in a mixed intensive care unit in a critical care hospital in Japan. Between October 2016 and September 2017, the swallowing functions of 216 patients were assessed using our novel screening protocol. To investigate the correlation between dysphagia and patient outcomes, we compared a dysphagia group with a no dysphagia group. RESULTS: Twenty-five patients (11·6%) were diagnosed with dysphagia. The frequency of discharge home, which was the primary outcome, was significantly lower in the patients with dysphagia (60% versus 87·4%, P = 0·002). Dysphagia was also correlated with longer hospital stay and higher mortality. A binomial logistic regression analysis, including the variables of dysphagia, Acute Physiology and Chronic Health Evaluation II score and duration of ventilator use, showed that dysphagia was an independent risk factor for a lower incidence of discharge home. CONCLUSION: Among patients admitted to a mixed intensive care unit, post-extubation dysphagia was correlated with a poor prognosis. RELEVANCE TO CLINICAL PRACTICE: The current study emphasizes the poor prognosis of patients with dysphagia after extubation. Dysphagia developed in more than 1 in 10 patients post-extubation; therefore, monitoring for a swallowing disorder is crucial in daily nursing in the intensive care unit.

Method for Prediction of Efficacy of Sugammadex Administered to Recover from Rocuronium-Induced Neuromuscular Blockade in Gynecological Laparoscopic Surgery Cases.

Sugammadex (SDX), a neuromuscular blocking-reversal agent, quickly reverses neuromuscular blockade induced by rocuronium (RCR). SDX dosage is set according to the state of neuromuscular blockade determined with a neuromuscular monitoring device. However, in clinical situations, such a devise is not frequently used. Here, we report construction of a method for theoretically setting SDX dose by which the optimum reverse time (RT) can be obtained for individual patients even when the device is not available. The subjects were 42 adult female patients who underwent laparoscopic surgery from 1 August 2015 to 31 March 2016, during which RCR and SDX were administered. We formulated an equation for theoretically calculating the RCR residual ratio (RR) in blood after SDX administration. Furthermore, we examined the relationship between RR and RT. Based on the results obtained, we developed a method for predicting RT using RR. We excluded 1 subject as the RT value was detected as an outlier in our analysis. Multiple regression analysis was performed using standard body weight, serum creatinine, total bilirubin, and RR as explanatory variables. The number of subjects with a prediction error of RT within ±1 min was 36 (87.8%) of 41 in multiple regression analysis. We could predict RT following SDX administration by using the RT prediction expression with RR obtained for subjects administered RCR during the surgery. Furthermore, our results suggest that the SDX dose able to achieve optimum RT may be set prior to surgery on the basis of the present methodology.

A case of disseminated cryptococcosis with necrotizing fasciitis in a non-HIV patient.

Case: Disseminated cryptococcosis is a well-recognized condition among HIV patients, but it also occurs in non-HIV patients. Necrotizing fasciitis caused by cryptococcus is rare. An 81-year-old man who had received steroid therapy presented with erythema and pain in his right thigh. After the rapid progression of symptoms and a failure to respond to antibiotic therapy, a clinical diagnosis of necrotizing fasciitis was made. We performed debridement, and yeasts were detected using a Gram stain of the fascia. We treated the patient with liposomal amphotericin B. On day 3, he developed meningitis. Cryptococcus neoformans was detected in the blood, fascia, and cerebrospinal fluid. Flucytosine was added to liposomal amphotericin B. Outcome: Despite the antifungal treatment, new regions of dissemination to the skin developed, and the patient died of multiple organ failure. Conclusion: A diagnosis of disseminated cryptococcosis should be considered in a differential diagnosis of necrotizing fasciitis among immunocompromised patients, regardless of their HIV status.

A rare case of pericardial hemangioma with bloody pericardial effusion.

A 78-year-old woman presented with leg edema and exertional dyspnea. Echocardiography revealed a smooth-surfaced mass adjacent to the left atrium in the pericardial cavity with a massive pericardial effusion. Pericardiocentesis resulted in the drainage of a bloody effusion. Magnetic resonance imaging documented a mass having isointensity on T1- and hyperintensity on T2-weighted images. In addition, the mass was evenly enhanced with gadolinium 10 min after administration. By surgical resection, a 25 × 30 mm in diameter tumor was excised together with a left atrial wall portion. The pathological examination made a final diagnosis as hemangioma. Based on these findings, we report the rare case of pericardial hemangioma with a bloody pericardial effusion, which presented with heart failure symptoms. Although bloody pericardial effusion is considered a supportive characteristic for malignant tumors, we could preoperatively make a precise diagnosis of benign hemangioma by means of several imaging modalities.