Background: Thrombotic thrombocytopenic purpura (TTP) is an uncommon haematological disease which can occur at any age and may present with COVID-19. This case describes a COVID-19 complication associated with a presentation resembling TTP. Case description: A 51-year-old man who had received a kidney transplant and was on immunosuppressant medication, was admitted to a critical care unit with severe COVID-19 pneumonia/acute respiratory distress syndrome (ARDS) which required intubation, mechanical ventilation and inotropic support. The course was complicated by the classic pentad of thrombocytopenia, intravascular haemolysis, acute kidney injury, neurological symptoms and fever, which prompted the diagnosis of probable TTP. After five sessions of therapeutic plasma exchange, the patient’s general status improved, he was weaned off mechanical ventilation and his renal panel and haemolytic markers normalized. Conclusion: TTP is a life-threatening condition which requires urgent management with therapeutic plasma exchange. This case highlights some possible complications of COVID-19 generally and in immunocompromised patients specifically. The potential role of plasma exchange in COVID-19 patients without a positive diagnosis of TTP (the so-called ‘TTP resembling presentation’) is an area of further research.

Although, Enteral Nutrition (EN) is a long established practice in critical care but, the ideal prescription and administration still represent a challenge. Patients admitted to intensive care unit, always receive less EN than the prescribed volume, leading to increase the risk of malnutrition, and contributing to negative hospital outcomes. Also contamination of the enteral formulations is very common and might lead to the occurrence of nosocomial infections in the form of diarrhea, bacteremia and pneumonia. EN delivery is available in two main systems: An Open System (OS) or Closed System (CS) which sometimes called a «Ready to Hang» system (RTH). Despite recognition of the importance of nutrition within the modern health agenda, evaluation of the efficacy of how such feeds are delivered (open or closed) is very limited. This review highlights current practice and areas of concern and establishes our current knowledge in this field.

Background: The global spread of the novel strain of coronavirus referred to as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has resulted in the continuous rise in the hospitalization of people suffering from COVID-19 in various parts of the world. The predominant symptoms experienced by patients diagnosed with SARS-CoV-2 infection include pneumonia and acute respiratory distress syndrome (ARDS). These symptoms have contributed to the high mortality rate of COVID-19 patients across the globe. Recent studies have indicated that nebulized unfractionated heparin (UFH) can be employed in the treatment of pneumonia and acute respiratory distress syndrome (ARDS) in hospitalized patients who have been diagnosed with SARS-CoV-2 infection. Case description: The case study for this investigation was a 37-year-old Saudi woman who had muscular dystrophy, bronchial asthma, and diabetes mellitus. This hospitalized patient who was a wheelchair bound was admitted to the intensive care unit (ICU) due to the onset of severe COVID-19 related pneumonia and ARDS. The patient was intubated and placed on high mechanical ventilation support with protective lung strategy (low tidal volume and high PEEP level), prone positioning, administering inhaled nitric oxide therapy, and the intravenous infusion methylprednisolone together with antiviral agents and empiric antibiotics for seven days. Despite the administration of this maximal therapy, she continued to have refractory hypoxemia and severe ARDS. As a result, a high dose of UFH was administered to the patient through nebulization. After administering nine different doses of nebulized UFH, the patient’s oxygenation and inflammatory markers have remarkably improved, then she had a very smooth course and successfully weaned off mechanical ventilation. Conclusion: This treatment strategy resulted in a significant improvement in the P/F ratio, a remarkable reduction in the bilateral lung infiltrates and inflammatory markers and eventually weaning of mechanical ventilation in the COVID-19 patient. This case suggests that nebulized UFH has a strong scientific and biological basis to test its use as a therapy for COVID-19 pneumonia and ARDS as it may offer huge clinical benefit across the time course of the disease as well may prevent progression of infection If administered early at the onset of symptoms, and may finally prevent the needs for mechanical ventilation. Learning points: Randomized controlled trials should be carried out to investigate the clinical impacts of nebulized UFH in both prevention and treatment of COVID-19 pneumonia/AERDS.

high incidence of relative adrenal insufficiency and usage of stress dose Hydrocortisone in addition to Fludrocortisone in both Annane and APROCCHSS trials was associated with significant reduction in mortality. 4,5 While CORTICUS and ADRENAL Trials failed to reveal any benefits related to using steroid in septic shock. 6,7 So it sounds that, the problem is the difficulty to find a magic drug to work effectively alone in septic shock. Dr. Marik and his group used a very intelligent idea. They used mixture of drugs assuming their perfect synergism and looked at their effect on sepsis mortality. 8

kg/day). Energy and protein must now be seen as a "power couple" in the new nutrition paradigm.