Objectives
Prior studies suggest hypothermia may be beneficial in ARDS, but cooling causes shivering and increases metabolism. The objective of this study was to assess the feasibility of performing a randomized clinical trial (RCT) of hypothermia in patients with ARDS receiving treatment with neuromuscular blockade (NMB) because they cannot shiver.
Design
Retrospective study and pilot prospective open-label feasibility study.
Setting
Medical Intensive Care Unit.
Patients
Retrospective review of 58 patients with ARDS based on Berlin criteria and PaO2:FiO2 (P:F)<150 who received NMB. Prospective hypothermia treatment in 8 ARDS patients with (P:F)<150 receiving NMB.
Intervention
Cooling to 34°–36°C for 48h.
Measurements and Main Results
Core temperature, hemodynamics, serum glucose and electrolytes, and P:F, were sequentially measured and medians (interquartile ranges) presented, and 28-day ventilator-free days (VFDs), and hospital mortaltiy were calculated in historical controls and 8 cooled patients. Average patient core temperature was 36.7(36–37.3)°C and fever occurred during NMB in 30/58 retrospective patients. In the prospectively cooled patients core temperature reached target range ≤4h of initiating cooling, remained <36°C for 92% of the 48h cooling period without adverse events, and was lower than the controls (34.35(34–34.8)°C; p<0.0001). Compared with historical controls, the cooled patients tended to have lower hospital mortality (75% vs 53.4%; p=0.26), more VFDs (9(0–21.5) vs. 0(0–12); p=0.16) and higher day-3 P:F (255(160–270) vs. 171(120–214), p=0.024).
Conclusions
NMB alone does not cause hypothermia, but allowed ARDS patients to be effectively cooled. Results support conducting an RCT of hypothermia in ARDS and the feasibility of studying ARDS patients receiving NMB.
Spontaneous pneumomediastinum (SPM), a rare occurrence, is defined by the presence of extraluminal gas in the mediastinum in the absence of trauma or underlying parenchymal disease. It is usually benign and has been associated with the inhalation of marijuana, cocaine, and amphetamines. The breathing maneuvers along with cyclical vomiting have been postulated as the underlying etiology. We present a case of a 27-year-old previously healthy male who presented with sudden onset chest pain and was found to have marijuana-induced pneumomediastinum.
A 22-year-old man with bipolar disorder and anxiety presented with fevers, chills, nausea, vomiting, and a non-productive cough for four days. He reported a fever up to 40°C at home and an inability to tolerate oral intake for approximately two days. His cough was dry and not associated with sputum production or hemoptysis. He endorsed headaches and diarrhea as associated symptoms. He reported a significant tetrahydrocannabinol (THC) and nicotine vaping history, which included the use of two nicotine cartridges and one THC cartridge daily. His last use was approximately 1 week prior to presentation. He denied neck pain and stiffness, leg swelling, dysuria, and abdominal pain. There was no personal or family history of thromboembolism. His home medications, taken daily, included lamotrigine and escitalopram. He had no recent travel history or sick contacts. The patient lived in a college dormitory in a major U.S. city. He had no pets or recent contact with birds. He denied any known exposure to heavy metals, agricultural chemicals, or any dyes, foams, and resins. The patient had also never been exposed to toxic gases such as chlorine. It should be noted that this patient presented to the hospital for care approximately four months before the first U.S. case of COVID-19, and as such, this is not investigated as part of the work-up.
Physical examination findingsHis temperature was 37.8°C, blood pressure 140/ 65 mmHg, heart rate 102 beats/min, respirations 22 breaths/min, and oxygen saturation 90% on room air. He was well-developed and in no acute distress with decreased bilateral breath sounds in the lower lung fields on auscultation but no audible wheezes, rales, or rhonchi. His cardiovascular exam was unremarkable except for tachycardia. His abdomen was soft, nontender, and nondistended with normoactive bowel sounds. There was no peripheral edema.
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