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Background Right ventricular (RV) dysfunction has been commonly reported in patients with Coronavirus disease 2019 (COVID-19), and is associated with mortality in mixed cohorts of patients requiring and not requiring invasive mechanical ventilation (IMV). Using RV-speckle tracking echocardiography (STE) strain analysis, we aimed to identify the prevalence of RV dysfunction (diagnosed by abnormal RV-STE) in patients with COVID-19 that are exclusively undergoing IMV, and assess association between RV dysfunction and 30 day mortality. We performed a prospective multicentre study across 10 ICUs in Scotland from 2/9/20 to 22/3/21. One-hundred-and-four echocardiography scans were obtained from adult patients at a single timepoint between 48 h after intubation, and day 14 of intensive care unit admission. We analysed RV-STE using RV free-wall longitudinal strain (RVFWLS), with an abnormal cutoff of  > −20%. We performed survival analysis using Kaplan–Meier, log rank, and multivariate cox-regression (prespecified covariates were age, gender, ethnicity, severity of illness, and time since intubation). Results Ninety-four/one-hundred-and-four (90.4%) scans had images adequate for RVFWLS. Mean RVFWLS was −23.0% (5.2), 27/94 (28.7%) of patients had abnormal RVFWLS. Univariate analysis with Kaplan–Meier plot and log-rank demonstrated that patients with abnormal RVFWLS have a significant association with 30-day mortality (p = 0.047). Multivariate cox-regression demonstrated that abnormal RVFWLS is independently associated with 30-day mortality (Hazard-Ratio 2.22 [1.14–4.39], p = 0.020). Conclusions Abnormal RVFWLS (> −20%) is independently associated with 30-day mortality in patients with COVID-19 undergoing IMV. Strategies to prevent RV dysfunction, and treatment when identified by RVFWLS, may be of therapeutic benefit to these patients. Trial Registration: Retrospectively registered 21st Feb 2021. ClinicalTrials.gov Identifier: NCT04764032.

Introduction Cardiac disease remains the largest single cause of maternal death. Whilst uncommon, left ventricular failure during pregnancy and delivery can be devastating to both mother and child. Echocardiography can play a significant role in rapidly establishing a diagnosis, guiding initial therapy and then monitoring response. Clinical vignettes The history, presentation and management of three cases of peri-partum left ventricular failure is examined: stress cardiomyopathy in a 34 year old with twins, left ventricular dysfunction secondary to pre-eclampsia in a 22 year old with a singleton pregnancy and a true peri-partum cardiomyopathy in a 42 year old with IVF twins. The defining risk factors, presenting characteristics and echocardiographical findings for each pathology are highlighted. Conclusion Echocardiography is playing an increasingly important role in the immediate assessment and management of left ventricular failure. This is especially true in the peri-partum woman, where establishing the correct therapy is both challenging and crucial due to the significant cardiovascular changes that occur around the time of delivery. To this end we believe that echocardiography should be rapidly available to guide the management of these patients by a multidisciplinary team made up of obstetricians, cardiologists, anaesthetists and intensive care physicians.

Background. Infections are common in intensive care units (ICUs) and burns units. Empiric antibiotic therapy is often required, and as such it is important to have a good knowledge of the resident organisms in these departments. Antibiotic resistance is becoming an increasing problem both internationally and in South Africa (SA) and it is important to monitor organism sensitivity. Objectives. To establish the spectrum and sensitivity of nosocomial pathogens in an SA government referral hospital ICU and burns unit. Methods. We report the findings from a retrospective audit of all cultures sent from the ICU and burns unit of an SA urban hospital for a 6-month period between January and June 2008. Results. The results showed a prevalence of Gram-negative organisms in the ICU department, in particular Klebsiella pneumoniae and Escherichia coli. There was a prevalence of Gram-positive organisms in the burns unit. Overall resistance to co-amoxiclav and erythromycin was found to be high (49% and 53%, respectively), resistance to ciprofloxacin and gentamicin was moderate (30% and 35%, respectively) and resistance to piperacillin-tazobactam and the carbapenems remained low (21% for piperacillin-tazobactam, 2% for ertapenem and 19% for meropenem). When looking at individual species, it was noted that K. pneumoniae had high resistance to ampicillin (97%), moderate resistance to co-amoxiclav and ciprofloxacin (35% and 43%, respectively) and low resistance to piperacillin-tazobactam, ertapenem, meropenem and colistin (12%, 0%, 5% and 0%, respectively). E. coli was seen to have high resistance to ampicillin (79%), but low resistance to co-amoxiclav (4%), ciprofloxacin (9%), piperacillin-tazobactam (0%), ertapenem (0%), meropenem (4%) and colistin (0%). Conclusion. This study demonstrates the prevalence of Gram-negative organisms in an SA government hospital ICU. It also demonstrates the presence of resistance mechanisms in the organisms cultured for almost all available classes of antibiotics, albeit some at low levels. The development of multi-and pan-resistant pathogenic organisms is both an SA and worldwide problem. In particular, the threat posed by resistant Gram-negative bacteria is likely to manifest itself in ICUs where septic patients unresponsive to standard antimicrobial regimens will inevitably end up. Frequent assessment of resistance patterns and appropriately designed empirical treatment protocols must remain a priority for all critical care departments.

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On awakening in the recovery room after a general anaesthetic for ear, nose and throat surgery, a 28-year-old woman reported central chest pain. She had received topical nasal cocaine solution preoperatively. She required intravenous opioids and sublingual glyceryl trinitrate before the pain settled. There was no evidence of significant myocardial injury and the patient was discharged later that day. The use of topical nasal cocaine solution in anaesthesia and its adverse myocardial effects are discussed.