Objective To assess the efficacy of therapeutic plasma exchange (TPE) following life-threatening COVID-19. Design, setting, and participants Open-label, randomized clinical trial of intensive care unit (ICU) patients with life-threatening COVID-19 [positive real-time-polymerase-chain-reaction test, plus acute respiratory distress syndrome (ARDS), sepsis, organ failure, hyperinflammation]. The study was terminated after 87/120 patients were enrolled. Intervention and randomization Standard treatment plus TPE (n = 43) versus standard treatment (n = 44), and stratified by peripheral arterial oxygen saturation/fraction of inspired oxygen (PaO 2 /FiO 2 ) ratio (> 150 versus ≤ 150). Main Outcomes and measures Primary outcomes were 35-day mortality and TPE safety. Secondary outcomes were association between TPE and mortality, improvement in Sequential Organ Function Assessment (SOFA) score, change in inflammatory biomarkers, days on mechanical ventilation (MV), and ICU length-of-stay. Results Eighty-seven patients [median years of age 49 (IQR: 34-63); 72 males (82.8%)] were randomized [44 to standard care; 43 to standard care plus TPE]. Days on MV (p=0.007) and ICU length-of-stay (p=0.02) were lower in the TPE group versus controls. Thirty-five-day mortality was lower in the TPE group (20.9% vs. 34.1% in controls), but this did not reach statistical significance [Kaplan-Meir analysis: p=0.582). TPE was associated with increased lymphocytes and ADAMTS-13 activity; plus decreased serum lactate, lactate dehydrogenase, ferritin, D-dimers, and interleukin-6. Multivariable regression analysis provided several predictors of 35-day mortality: PaO 2 /FiO 2 ratio [hazard ratio (HR): 0.98, 95% CI: 0.96-1.00, p=0.02], ADAMTS-13 activity (HR: 0.89, 95% CI: 0.82-0.98, p=0.01), and PE (HR: 3.57, 95% CI: 1.43-8.92, p=0.007). Post-hoc analysis revealed a significant reduction in SOFA score for TPE patients (p<0.05) compared to controls. Conclusion In critically ill COVID-19 patients the addition of TPE to standard ICU therapy was associated with faster clinical recovery and no increased 35-day mortality.
Extracorporeal life support (ECLS) is a means to support patients with acute respiratory failure. Initially, recommendations to treat severe cases of pandemic coronavirus disease 2019 (COVID‐19) with ECLS have been restrained. In the meantime, ECLS has been shown to produce similar outcomes in patients with severe COVID‐19 compared to existing data on ARDS mortality. We performed an international email survey to assess how ECLS providers worldwide have previously used ECLS during the treatment of critically ill patients with COVID‐19. A questionnaire with 45 questions (covering, e.g., indication, technical aspects, benefit, and reasons for treatment discontinuation), mostly multiple choice, was distributed by email to ECLS centers. The survey was approved by the European branch of the Extracorporeal Life Support Organization (ELSO); 276 ECMO professionals from 98 centers in 30 different countries on four continents reported that they employed ECMO for very severe COVID‐19 cases, mostly in veno‐venous configuration (87%). The most common reason to establish ECLS was isolated hypoxemic respiratory failure (50%), followed by a combination of hypoxemia and hypercapnia (39%). Only a small fraction of patients required veno‐arterial cannulation due to heart failure (3%). Time on ECLS varied between less than 2 and more than 4 weeks. The main reason to discontinue ECLS treatment prior to patient’s recovery was lack of clinical improvement (53%), followed by major bleeding, mostly intracranially (13%). Only 4% of respondents reported that triage situations, lack of staff or lack of oxygenators, were responsible for discontinuation of ECLS support. Most ECLS physicians (51%, IQR 30%) agreed that patients with COVID‐19‐induced ARDS (CARDS) benefitted from ECLS. Overall mortality of COVID‐19 patients on ECLS was estimated to be about 55%. ECLS has been utilized successfully during the COVID‐19 pandemic to stabilize CARDS patients in hypoxemic or hypercapnic lung failure. Age and multimorbidity limited the use of ECLS. Triage situations were rarely a concern. ECLS providers stated that patients with severe COVID‐19 benefitted from ECLS.
SUMMARY SummaryWe report a unique case of diabetic ketoacidosis in which a relatively low potassium level on admission was associated with consequent lifethreatening and refractory arrhythmia secondary to inappropriate use of intravenous insulin and bicarbonate therapy. The latter was reversed by rapid bolus potassium injection. Although we do not advocate this approach in every case, we emphasise that a bolus injection of potassium may be life saving in such cases. The lessons from this case have led to multidisciplinary meetings and modification of the institute's diabetic ketoacidosis clinical pathway. BACKGROUND
Diabetic Ketoacidosis (DKA) is a serious and potentially a fatal complication of diabetes mellitus. Tools to guarantee proper, evidence-based, guideline implementation are of paramount importance and an essential element for quality patient care. Clinical pathways represent one such tool that clearly promotes the implementation of guidelines and research evidence into clinical practice. The aims of this study were to measure quantitatively and qualitatively the impact of a specially structured Resident-friendly, DKA clinical pathway on the application of evidence-based management standards and its acceptability by the treating resident physicians. A retrospective chart review of patients who were admitted prior to and after the launching of the clinical pathway and a questionnaire assessment of resident's acceptance of the pathway format were undertaken. Eighty one episodes of DKA in a total of 58 patients fulfilled the criteria for inclusion in the study. Thirty seven admissions were on the pathway (45.7%) and 44 were not (54.3%). Documentation of severity indices of patients who were admitted under the pathway were significantly improved with a trend for a shorter hospital stay. The duration of intravenous insulin therapy, intensive care unit consultation and diabetes educator involvement in patient care were not different between the two groups. Residents found the pathway user-friendly, educationally very valua-* Corresponding author. I. S. Hassan et al. 265 ble, reduced their workload and had a positive effect on their DKA management skills.Conclusions: Use of specially structured, resident-friendly pathway led to significant improvement in documentation of DKA severity indices and empowered our residents with evidence-based knowledge and skills to deal with this serious diabetic complication.
Mediastinal mass syndrome (MMS) is a devastating respiratory and haemodynamic condition that might be encountered postintubation if special precautions are not carefully undertaken. We describe a case of MMS in a 21-year-old woman with a fatal outcome following emergency intubation for acute respiratory failure.
IntroductionCarbon monoxide poisoning can be associated with life-threatening complications, including significant and disabling cardiovascular and neurological sequelae.Case presentationWe report a case of carbon monoxide poisoning in a 25-year-old Saudi woman who presented to our facility with status epilepticus and cardiopulmonary arrest. Her carboxyhemoglobin level was 21.4 percent. She made a full recovery after we utilized a neuroprotective strategy and normobaric oxygen therapy, with no delayed neurological sequelae.ConclusionsBrain protective modalities are very important for the treatment of complicated cases of carbon monoxide poisoning when they present with neurological toxicities or cardiac arrest. They can be adjunctive to normobaric oxygen therapy when the use of hyperbaric oxygen is not feasible.
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