Even though endotracheal tube (ETT) size selection is often the result of clinical judgement, factors such as age, gender, height, body mass index (BMI), and anticipated bronchoscopies are often considered before insertion. 1-3 The objective of this study was to explore whether gender differences exist in ventilator-associated event (VAE) development based on larger ETT selection. The surveillance paradigms for VAEs are established by the Centers for Disease Control and Prevention. 4 They denote 3 categories of increasing progression in mechanically ventilated patients from a ventilator-associated condition (VAC), to an infection-related ventilator-associated complication (IVAC), and finally to possible ventilator-associated pneumonia (PVAP). Our a priori hypothesis for this study was that an 8.0-mm ETT is associated with less risk of VAEs because a larger diameter is optimal for pulmonary hygiene. Methods

Rituximab or Rituxan is a common drug used in the treatment of lymphomas. It is almost always used in conjunction with other chemotherapy regimens. Mechanism of action involves killing of the CD 20+ cells. Rituximab is implicated in precipitating tumor lysis syndrome (TLS) in patients with diffused large B cell lymphoma (DLBCL). The precise pathophysiological mechanism is not well known. Here, we present a case where the patient only received Rituxan for her newly diagnosed B-cell lymphoma which triggered a tumor lysis cascade. This in turn resulted in multiple electrolyte disturbances, multi-organ failure, and mortality. This report discusses the case presentation in addition to the different types of TLS and how this knowledge can be applied in the clinical setting for the future.

The use of ascorbic acid or vitamin C in patients with septic shock is a topic of significant investigation. Some argue it decreases both morbidity and mortality in patients with septic shock, while others state that it provides no additional changes in a patient's outcome. This literature review looks at patients with septic shock, and investigates the role of high dose vitamin C (HDVC) in reducing the rate of stage 3 acute kidney injury (AKI), intensive care unit (ICU) mortality, hospital mortality, and length of ICU stay. METHODS:A thorough search of the literature was conducted to perform a meta-analysis of the available studies that compared the efficacy of HDVC to standard care or placebo in patients with septic shock. This search was performed using PubMed, Embase, and Cochrane for data on the subject matter of study from inception to April 20, 2021. We only considered randomized controlled trials for our analysis. From each study, we collected the number of patients with septic shock who underwent treatment with either HDVC or standard care/placebo. The primary outcome was the rate of stage 3 AKI. Secondary outcomes were ICU mortality, hospital mortality, and length of ICU stay. The random-effects model was used to calculate the risk ratios (RR), mean differences (MD), and confidence intervals (CIs). A p-value <0.05 was considered statistically significant. Heterogeneity was assessed using Higgins I2 index.RESULTS: Nine randomized controlled trials involving 1503 patients were including in the meta-analysis. Five studies reported the rate of stage 3 AKI, and it was not significantly lower in those receiving HDVC when compared to standard care/placebo (39.0% vs. 37.5%, RR 1.03, 95% CI 0.89-1.20, p= 0.68, I2= 0%). Four studies reported the rate of ICU mortality, and it was not significantly lower in those receiving HDVC when compared to standard care/placebo (20.1% vs. 18.6%, RR 1.07, 95% CI 0.84-1.38, p= 0.58, I2= 0%). Six studies reported the rate of hospital mortality, and it was not significantly lower in those receiving HDVC when compared to standard care/placebo (22.5% vs. 25.7%, RR 0.88, 95% CI 0.55-1.40, p= 0.58, I2= 73%). Six studies reported length of ICU stay, which was found to be similar between both the HDVC and standard care/placebo groups (MD¼ 0.02 days, 95% CI -0.10-0.15, p= 0.73, I2= 0%). CONCLUSIONS:Our meta-analysis demonstrates that the use of HDVC for patients with septic shock does not significantly reduced the rate of stage 3 AKI, ICU mortality, or hospital mortality. HDVC also does not did not significantly reduce the length of ICU stay. Further data should be collected to confirm our findings.CLINICAL IMPLICATIONS: The use of HDVC for patients with septic shock is not effective in reducing occurrence stage 3 AKI when compared to standard care/placebo. However, the use HDVC also does not significantly increase the rate of mortality and length of ICU stay.

Rationale: Post-extubation acute respiratory failure (ARF), post-extubation pneumonia (PEP) and intensive care unit (ICU) mortality are some the most serious complications in the ICU setting. Several methods are currently being investigated in preventing these serious complications. This literature review looks at the role of high flow nasal oxygen (HFNO) compared to non-invasive ventilation (NIV) and the efficacy of HFNO in preventing reintubation. Methods: We conducted a thorough search of the literature to conduct a systematic review and meta-analysis of the available studies that investigated the efficacy of HFNO compared to NIV in preventing reintubation after recent extubation. This comprehensive search was performed using PubMed, Embase, and Cochrane Central Register of Controlled Trials for data on the subject matter of study from inception to December 18, 2020. We considered randomized controlled trials, cohort studies and case-control studies. From each study, we collected the number of patients who underwent treatment with either HFNO or NIV after extubation. The primary outcome was the occurrence of ARF requiring reintubation. Secondary outcomes were the occurrence of VAP and ICU mortality. The random-effects model was used to calculate the risk ratios (RR) and confidence intervals (CIs). A p-value <0.05 was considered statistically significant. Heterogeneity was assessed using Higgins I 2 index. Results: Five randomized controlled trials involving 1153 patients were including in this meta-analysis. The rate of reintubation was not found to be significantly lower in patients receiving HFNO when compared to those receiving NIV after extubation (17.2% vs. 16.2%, RR 1.09, 95% CI 0.84-1.41, p= 0.52, I 2 = 0%). The rates of ICU mortality after extubation were not found to be significantly lower in patients receiving HFNO when compared to those receiving NIV (7.3% vs. 7.40%, RR 0.99, 95% CI 0.65-1.49, p= 0.95, I 2 = 0%). Two studies reported the rate of PEP, which was not found to be significantly lower in patients receiving HFNO when compared to those receiving NIV after extubation (6.82% vs. 7.55%, RR 0.89, 95% CI 0.56-1.44, p= 0.64, I 2 = 0%). Conclusion: Our meta-analysis demonstrates that the use of HFNO after extubation, when compared to NIV, does not significantly reduce the rate of reintubation, ICU mortality, or PEP. HFNO may however produce similar results to NIV when used post-extubation in regards to the outcomes of study in this meta-analysis, but further data from future studies is needed to support this claim.

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