We describe a case of spontaneous retroperitoneal hematoma leading to abdominal compartment syndrome and organ failure during a complicated orthotopic heart transplantation in a patient previously on mechanical circulatory support. After the patient had been weaned of cardiopulmonary bypass, the patient suddenly became hemodynamically unstable despite good LV and RV function. While the patient was resuscitated, high intra-abdominal pressures were noted on a novel monitor measuring real-time intra-abdominal pressures and urinary output. The early detection of high intra-abdominal pressures led to a swift decompressive laparotomy with the detection of retroperitoneal hematoma and subsequent hemodynamic stabilization.
Introduction Regional anesthesia offers an alternative to general anesthesia and may be advantageous in low resource environments. There is a paucity of data regarding the practice of regional anesthesia in low- and middle-income countries. Using access data from a free Android app with curated regional anesthesia learning modules, we aimed to estimate global interest in regional anesthesia and potential applications to clinical practice stratified by World Bank income level. Methods We retrospectively analyzed data collected from the free Android app “Anesthesiologist” from December 2015 to April 2020. The app performs basic anesthetic calculations and provides links to videos on performing 12 different nerve blocks. Users of the app were classified on the basis of whether or not they had accessed the links. Nerve blocks were also classified according to major use (surgical block, postoperative pain adjunct, rescue block). Results Practitioners in low- and middle-income countries accessed the app more frequently than in high-income countries as measured by clicks. Users from low- and middle-income countries focused mainly on surgical blocks: ankle, axillary, infraclavicular, interscalene, and supraclavicular blocks. In high-income countries, more users viewed postoperative pain blocks: adductor canal, popliteal, femoral, and transverse abdominis plane blocks. Utilization of the app was constant over time with a general decline with the start of the COVID-19 pandemic. Conclusion The use of an in app survey and analytics can help identify gaps and opportunities for regional anesthesia techniques and practices. This is especially impactful in limited-resource areas, such as lower-income environments and can lead to targeted educational initiatives.
Acute pancreatitis is a risk factor for intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS). Immediate detection and management of IAH and ACS are critical for patient survival. Obtaining accurate and consistent intra-abdominal pressure and urinary output with high frequency is challenging, but critical for effective patient management. The presented case is of a 40-year-old man with a history of chronic alcoholism who developed severe acute pancreatitis. The patient was fluid resuscitated for distributive shock; hypoxic respiratory failure, intubation, and anuria followed. Real-time monitoring of urinary output and intra-abdominal pressure (IAP) allowed for early recognition of acute kidney injury (AKI) and ACS leading to early surgical intervention. Normalized IAP returned renal function and re-establishment of stable hemodynamics without vasopressors.
Diabetic ketoacidosis (DKA) is a potentially fatal endocrine emergency resulting from uncontrolled diabetes mellitus (DM). The development of DKA has been linked to a number of precipitating factors such as infectious process, ischemia, medications, and other medical-surgical illnesses. These factors have been found to aggravate or unmask pre-existing glucose dysregulation secondary to absolute or relative insulin deficiency and increased levels of counter-regulatory hormones. We describe the case of a 61-year-old male with a history of insulin dependent DM who develops DKA postoperatively after a three-vessel coronary artery bypass surgery and mitral valve repair while in the intensive care unit (ICU). The patient's postoperative course was complicated by presumed pneumonia and hyperactive delirium. On postoperative day (POD) five, the patient's insulin infusion was held due to non-symptomatic hypoglycemia. Eleven hours later, the insulin infusion was resumed to treat DKA after laboratory findings revealed hyperglycemia, an elevated β-hydroxybutyrate, and anion gap metabolic acidosis. Multiple contributing factors for the development of DKA are suspected and discussed. It is paramount that clinicians are knowledgeable of the multiple factors that can contribute to the development of DKA in the ICU.
Extracorporeal membrane oxygenation (ECMO) has become an increasingly utilized modality for the support of patients with severe cardiac or pulmonary dysfunction. Unfortunately, the costs and expertise required to maintain a formal ECMO program preclude the vast majority of hospitals from employing such technology routinely. These barriers to implementation of an effective ECMO program highlight the importance of the safe transport of patients in need of extracorporeal support. While many centers with extensive expertise in the management of patients on extracorporeal support have demonstrated their ability to transport those same patients, the ability of new ECMO programs to provide such transportation remains poorly studied. We established an ECMO program at our institution and immediately provided equipment and personnel to transport patients in need of or receiving extracorporeal support to our institution. Overall, we found that 13 out of 28 patients transported to our institution on ECMO or for consideration of ECMO support during the first 15 months of the program survived to hospital discharge. During that period, four incidents associated with patient transport occurred but none were related to ECMO support or adversely affected patient outcome. These observations demonstrate that new ECMO programs can safely and reliably transport patients on or in need of extracorporeal support.
OBJECTIVES: To determine the impact of coronavirus disease 2019 on burnout syndrome in the multiprofessional ICU team and to identify factors associated with burnout syndrome. DESIGN: Longitudinal, cross-sectional survey. SETTING: All adult ICUs within an academic health system. SUBJECTS: Critical care nurses, advanced practice providers, physicians, respiratory therapists, pharmacists, social workers, and spiritual health workers were surveyed on burnout in 2017 and during the coronavirus disease 2019 pandemic in 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Burnout syndrome and contributing factors were measured using the Maslach Burnout Inventory of Health and Human Service and Areas of Worklife Survey. Response rates were 46.5% (572 respondents) in 2017 and 49.9% (710 respondents) in 2020. The prevalence of burnout increased from 59% to 69% (p < 0.001). Nurses were disproportionately impacted, with the highest increase during the pandemic (58-72%; p < 0.0001) with increases in emotional exhaustion and depersonalization, and personal achievement decreases. In contrast, although burnout was high before and during coronavirus disease 2019 in all specialties, most professions had similar or lower burnout in 2020 as they had in 2017. Physicians had the lowest rates of burnout, measured at 51% and 58%, respectively. There was no difference in burnout between clinicians working in ICUs who treated coronavirus disease 2019 than those who did not (71% vs 67%; p = 0.26). Burnout significantly increased in females (71% vs 60%; p = 0.001) and was higher than in males during the pandemic (71% vs 60%; p = 0.01). CONCLUSIONS: Burnout syndrome was common in all multiprofessional ICU team members prior to and increased substantially during the pandemic, independent of whether one treated coronavirus disease 2019 patients. Nurses had the highest prevalence of burnout during coronavirus disease 2019 and had the highest increase in burnout from the prepandemic baseline. Female clinicians were significantly more impacted by burnout than males. Different susceptibility to burnout syndrome may require profession-specific interventions as well as work system improvements.
Objective To determine whether location-linked anaesthesiology calculator mobile application (app) data can serve as a qualitative proxy for global surgical case volumes and therefore monitor the impact of the coronavirus disease 2019 (COVID-19) pandemic. Methods We collected data provided by users of the mobile app“Anesthesiologist”during 1 October 2018–30 June 2020. We analysed these using RStudio and generated 7-day moving-average app use plots. We calculated country-level reductions in app use as a percentage of baseline. We obtained data on COVID-19 case counts from the European Centre for Disease Prevention and Control. We plotted changing app use and COVID-19 case counts for several countries and regions. Findings A total of 100 099 app users within 214 countries and territories provided data. We observed that app use was reduced during holidays, weekends and at night, correlating with expected fluctuations in surgical volume. We observed that the onset of the pandemic prompted substantial reductions in app use. We noted strong cross-correlation between COVID-19 case count and reductions in app use in low-and middle-income countries, but not in high-income countries. Of the 112 countries and territories with non-zero app use during baseline and during the pandemic, we calculated a median reduction in app use to 73.6% of baseline. Conclusion App data provide a proxy for surgical case volumes, and can therefore be used as a real-time monitor of the impact of COVID-19 on surgical capacity. We have created a dashboard for ongoing visualization of these data, allowing policy-makers to direct resources to areas of greatest need.
Introduction: Statins are cholesterol-lowering drugs with pleiotropic activities including inhibition of isoprenylation and reduction of signals driving cell proliferation and survival responses.
Methods: In this study we evaluated the effects of lovastatin acid and lactone on breast cancer MDAMB231 and MDAMB468 cells using a combination of proteomic and metabonomic profiling techniques.
Results: Lovastatin inhibited proliferation of breast cancer cell lines. MDAMB231 cells were more sensitive to its effects, and in most cases lovastatin acid showed more potency towards the manipulation of protein expression than lovastatin lactone. Increased expression of Rho inhibitor GDI-2 stabilized the non-active Ras homolog gene family member A (RhoA) leading to a decreased expression of its active, membrane-bound form. Its downstream targets cofilin, CDC42 and G3BP1 are members of the GTPase family affected by lovastatin. Our data indicated that lovastatin modulated the E2F1-pathway through the regulation of expression of prohibitin and retinoblastoma (Rb). This subsequently leads to changes of E2F-downstream targets minichromosome maintenance protein 7 (MCM7) and MutS homolog 2 (MSH2). Lovastatin also regulated the AKT-signaling pathway. Increased phosphatase and tensin homolog (PTEN) and decreased DJ-1 expression lead to a down-regulation of the active pAkt. Lovastatin's involvement in the AKT-signaling pathway was confirmed by an upregulation of its downstream target, tumor progressor NDRG1. Metabolic consequences to lovastatin exposure included suppression of glycolytic and Krebs cycle activity, and lipid biosynthesis.
Conclusions: The combination of proteomics and metabonomics enabled us to identify several key targets essential to the antitumor activity of lovastatin. Our results imply that lovastatin has the potential to reduce the growth of breast cancer cells.
Extracorporeal membrane oxygenation (ECMO) is an established therapy in the management of patients with refractory cardiogenic shock or acute respiratory failure.In this report, we describe the rapid development and implementation of an organized ECMO program at a facility that previously provided ad hoc support. The program provides care for patients within the Emory Healthcare system and throughout the Southeastern United States.From September 2014 to February 2015, 16 patients were treated with either venovenous or venoarterial ECMO with a survival to decannulation of 53.3% and survival to ICU discharge of 40%. 10/16 patients were transfers from outside facilities of which 2 were remotely cannulated and initiated on ECMO support by our ECMO transport team. Complications included intracerebral hemorrhage, bleeding from other sites, and limb ischemia.The results suggest that a rapidly developed ECMO program can provide safe transport services and provide outcomes similar to those in the existing literature. Key components appear to be institutional commitment, a physician champion, multidisciplinary leadership, and organized training. Further study is required to determine if outcomes will continue to improve.
Fluoroquinolones are commonly prescribed antimicrobials that have been implicated in alterations of glucose metabolism. We report a case of refractory fluoroquinolone-induced hypoglycemia in a patient with type-2 diabetes mellitus on glipizide that was successfully treated with octreotide. A patient was admitted with hypoglycemia after having been initiated on levofloxacin therapy. Despite treating the hypoglycemia supportively with multiple boluses of 25 g of dextrose, a continuous dextrose infusion, and glucagon, the patient experienced repeated episodes of rebound hypoglycemia. The persistent hypoglycemia was eventually reversed with the administration of subcutaneous octreotide. Clinicians should be cognizant of this adverse effect of fluoroquinolones, as well as predisposing risk factors, and consider octreotide as an adjunctive therapy for refractory hypoglycemia cases.