scholarly journals A critical COVID-19 patient managed with timely evaluation, early prone positioning ventilation, and a multi-pronged pharmacotherapy

2021 ◽  
Vol 19 ◽  
pp. 205873922110259
Author(s):  
Mian Peng ◽  
Rongsong Li ◽  
Weiling Cao ◽  
Weiqing Li ◽  
Ming Wu ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Clinical Symptoms ◽  
Treatment Plan ◽  
Drug Regimen ◽  
Prone Positioning ◽  
Thymosin Α1 ◽  
Standard Drug ◽  
Normal White Blood Cell ◽  
Epidemic Area ◽  
Life Threatening

There is not yet a standard drug regimen for the treatment of coronavirus disease 2019 (COVID-19) patients. Here, we summarize our experience and successful treatment plan with a critical COVID-19 patient who required mechanical ventilation (MV). A 56-year-old man presented with a fever, cough, and dyspnea. He had not been to a medium/high risk epidemic area in the past year and had no family history of a disease cluster. COVID-19 was suspected based on clinical symptoms and radiologically detected ground-glass lung changes in the context of a normal white blood cell count (WBCC) and lymphocyte fraction (L%). A diagnosis of COVID-19 was confirmed by nucleic acid testing. Initially, he was started on noninvasive ventilation (NIV). Because his respiratory distress worsened over the following 2 h, he was transitioned to mechanical ventilation (MV), placed in prone positioning 12 h/day, and given a multi-pronged pharmacotherapy regimen that included an antiviral cocktail (lopinavir/ritonavir plus α-interferon), an immunity enhancer (thymosin α1), an anti-coagulant to prevent thrombosis (heparin). He was given an antibiotic to treat an opportunistic nosocomial infection. The patient has recovered well. The regimen applied in this case of timely evaluation, early prone positioning with MV, and a multi-pronged pharmacotherapy may be an effective strategy for patients with critical COVID-19, particularly with respect to preventing life-threatening worsening of the illness.

scholarly journals Proning related bilateral anterior ischaemic optic neuropathy in a patient with COVID-19 related acute respiratory distress syndrome

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Kirsty Michelle Clarke ◽  
Vivi Riga ◽  
Amy-lee Shirodkar ◽  
Joel Meyer
Keyword(s):  
Mechanical Ventilation ◽  
Acute Respiratory Distress Syndrome ◽  
Visual Field ◽  
Respiratory Distress Syndrome ◽  
Distress Syndrome ◽  
Vision Loss ◽  
Prone Positioning ◽  
Disc Oedema ◽  
Ischaemic Optic Neuropathy ◽  
The Right

Abstract Background Non-arteritic ischaemic optic neuropathy (NAION) is a rare but harmful complication of prone positioning. Prone mechanical ventilation is a therapeutic strategy which has been used extensively during the COVID-19 pandemic to treat acutely hypoxemic patients with COVID-19 related acute respiratory distress syndrome (ARDS). Though a small number of cases of unilateral NAION have been reported in patients testing positive for the SARS-CoV-2 virus, we describe what is to our knowledge, the first reported case of bilateral NAION occurring in a patient proned extensively for the treatment of COVID-19 related ARDS. We consider the potential aetiological factors leading to NAION after prone mechanical ventilation in patients with COVID-19 and suggest strategies to protect against its development. Case presentation : We report a case of severe, irreversible, visual impairment secondary to bilateral anterior ION in a fifty-five-year-old male who underwent eight episodes of prone mechanical ventilation to treat COVID-19 related ARDS. Once weaned from his sedation he reported bilateral painless vision loss, and bedside ophthalmological assessment identified a reduced visual acuity of 3/30 unaided in the left eye and counting fingers in the right. Dilated indirect ophthalmoscopy revealed inferotemporal optic disc oedema with splinter haemorrhages in the right eye and mild disc oedema, temporal pallor, and nerve fibre layer haemorrhages inferiorly in the left eye. Humphrey visual field 24 − 2 testing confirmed a severely constricted visual field with macular sparing on the right and depressed inferonasal vision with preserved peripheral vision on the left eye. OCT disc imaging shortly after diagnosis revealed bilateral disc swelling and flame haemorrhages in the right eye. Conclusions NAION is a devastating, but preventable complication of prone positioning, which may pose significant risk of vision loss in patients with COVID-19 related ARDS.

scholarly journals Treatment and therapeutic strategies for pituitary apoplexy in pregnancy: a case series

2021 ◽  
Vol 15 (1) ◽  
Author(s):  
Yuya Kato ◽  
Yoshikazu Ogawa ◽  
Teiji Tominaga
Keyword(s):  
Pituitary Apoplexy ◽  
Clinical Symptoms ◽  
Case Series ◽  
Optimal Timing ◽  
Presenting Symptoms ◽  
Pathological Evaluation ◽  
Mother And Child ◽  
Life Threatening ◽  
In Pregnancy

Abstract Background Pregnancy is a known risk factor for pituitary apoplexy, which is life threatening for both mother and child. However, very few clinical interventions have been proposed for managing pituitary apoplexy in pregnancy. Case presentation We describe the management of three cases of pituitary apoplexy during pregnancy and review available literature. Presenting symptoms in our case series were headache and/or visual disturbances, and the etiology in all cases was hemorrhage. Conservative therapy was followed until 34 weeks of gestation, after which babies were delivered by cesarean section with prophylactic bolus hydrocortisone supplementation. Tumor removal was only electively performed after delivery using the transsphenoidal approach. All three patients and their babies had a good clinical course, and postoperative pathological evaluation revealed that all tumors were functional and that they secreted prolactin. Conclusions Although the mechanism of pituitary apoplexy occurrence remains unknown, the most important treatment strategy for pituitary apoplexy in pregnancy remains adequate hydrocortisone supplementation and frequent hormonal investigation. Radiological follow-up should be performed only if clinical symptoms deteriorate, and optimal timing for surgical resection should be discussed by a multidisciplinary team that includes obstetricians and neonatologists.

scholarly journals Tuck and Turn: A Protocol for Prone Positioning of Critically Ill Patients with COVID-19 on Mechanical Ventilation

2020 ◽  
Vol 101 (12) ◽  
pp. e153
Author(s):  
Jamie Savitzky ◽  
Talia Rothfus ◽  
Sally Wong ◽  
Kristina Fusco ◽  
Caitlin Hynes ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Prone Positioning

An Evidence-Based Protocol for Manual Prone Positioning of Patients With ARDS

2021 ◽  
Vol 41 (6) ◽  
pp. 55-60
Author(s):  
Patrick Ryan ◽  
Cynthia Fine ◽  
Christine DeForge
Keyword(s):  
Mechanical Ventilation ◽  
Acute Respiratory Distress Syndrome ◽  
Respiratory Distress Syndrome ◽  
Respiratory Distress ◽  
Distress Syndrome ◽  
Medical Center ◽  
Academic Medical Center ◽  
Prone Positioning ◽  
Hypoxemic Respiratory Failure ◽  
Unplanned Extubations

Background Manual prone positioning has been shown to reduce mortality among patients with moderate to severe acute respiratory distress syndrome, but it is associated with a high incidence of pressure injuries and unplanned extubations. This study investigated the feasibility of safely implementing a manual prone positioning protocol that uses a dedicated device. Review of Evidence A search of CINAHL and Medline identified multiple randomized controlled trials and meta-analyses that demonstrated both the reduction of mortality when prone positioning is used for more than 12 hours per day in patients with acute respiratory distress syndrome and the most common complications of this treatment. Implementation An existing safe patient-handling device was modified to enable staff to safely perform manual prone positioning with few complications for patients receiving mechanical ventilation. All staff received training on the protocol and use of the device before implementation. Evaluation This study included 36 consecutive patients who were admitted to the medical intensive care unit at a large academic medical center because of hypoxemic respiratory failure/acute respiratory distress syndrome and received mechanical ventilation and prone positioning. Data were collected on clinical presentation, interventions, and complications. Sustainability Using the robust protocol and the low-cost device, staff can safely perform a low-volume, high-risk maneuver. This method provides cost savings compared with other prone positioning methods. Conclusions Implementing a prone positioning protocol with a dedicated device is feasible, with fewer complications and lower costs than anticipated.

Coccidioidomycosis of the Larynx in Infants and Adults

1977 ◽  
Vol 86 (5) ◽  
pp. 655-660 ◽  
Author(s):  
Paul H. Ward ◽  
David Morledge ◽  
George Berci ◽  
Harmon Schwartz
Keyword(s):  
United States ◽  
Amphotericin B ◽  
Clinical Symptoms ◽  
Skin Testing ◽  
Fungal Disease ◽  
Southwestern United States ◽  
Positive Skin ◽  
Life Threatening ◽  
Primary Form

Coccidioidomycosis is a fungal disease endemic to the southwestern United States. The primary form of the disease is relatively benign and many patients, after exposure by inhalation of the sapyrophytic form of the organism, convert from negative to positive skin testing without significant clinical symptoms. The less common disseminated form represents a serious life-threatening disease and can present with granulomatous changes in the larynx. The authors' experience with disseminated coccidioidomycosis presenting in the larynx of adults and infants successfully treated with amphotericin B are presented and discussed.

scholarly journals Unusual dyspnea in a hemodialysis patient: A case report

10.3823/2607 ◽  
2019 ◽  
Vol 12 ◽  
Author(s):  
Ching-Hsiang Wang ◽  
Jenq-Shyong Chan ◽  
Chung-Chi Yang ◽  
Po-Jen Hsiao
Keyword(s):  
Hemodialysis Patient ◽  
Pleural Cavity ◽  
Middle Age ◽  
Clinical Symptoms ◽  
Rapid Development ◽  
Previous History ◽  
Final Diagnosis ◽  
Spontaneous Hemothorax ◽  
Life Threatening ◽  
History Of

The typical clinical symptoms of hemothorax include a rapid development of chest pain or dyspnea, which may be life-threatening without immediate management. As we know, spontaneous hemothorax, a collection of blood within the pleural cavity without previous history of trauma or other cause, which usually onsets suddenly. The early and accurate diagnosis of spontaneous hemothorax is imperative in clinical practice. We reported a middle-age male undergoing regular hemodialysis was referred to our emergency department due to unknown cause of dyspnea and acute respiratory failure. Chest radiography revealed bilateral patchy infiltration of lung. Pleural tap analysis showed exudative pleural effusion with numerous red blood cells. Video-assisted thoracic surgery (VATS) were performed and confirmed the final diagnosis of spontaneous hemothorax. He was then successfully treated with the surgery of VATS combined chest tube thoracostomy.

scholarly journals Awake Prone Position in Hypoxemic Patients with Coronavirus Disease 19 (COVI-PRONE): A Study protocol and Statistical Analysis Plan for Randomized Clinical Trial

2021 ◽  
Author(s):  
Zainab Al Duhailib ◽  
Yaseen Arabi ◽  
Sarah Culgin ◽  
Jason Weatherald ◽  
Ken Kuljit S. Parhar ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Prone Position ◽  
Controlled Trial ◽  
Invasive Mechanical Ventilation ◽  
Target Population ◽  
Altered Mental Status ◽  
Hemodynamic Instability ◽  
Hospital Length Of Stay ◽  
Prone Positioning ◽  
Serious Adverse Events

Background Coronavirus disease 2019 (COVID-19), may progress to respiratory failure requiring invasive mechanical ventilation. Due to ventilator shortage and healthcare systems strain, affordable interventions such as awake prone positioning has been used to improve oxygenation, however, the effect of this intervention on patient-important outcomes is uncertain. The COVI-PRONE trial aims to determine if awake prone positioning in hypoxemic COVID-19 patients reduces the need for invasive mechanical ventilation. Study design A pragmatic, multicenter, international, parallel-group, and stratified randomized controlled trial, aiming to enrol 400 hospitalized adults with COVID-19. Participants The target population is hospitalized adults with confirmed or suspected COVID-19, hypoxemia that requires ≥40% oxygen or ≥ 5 L/min by nasal cannula, and abnormal chest x-ray. We will exclude patients with any of the following: immediate need for intubation; altered mental status; contraindication to prone positioning; hemodynamic instability; body mass index > 40 kg/m2; third trimester pregnancy; do not intubate status; previous enrolment or intubation within the same hospital admission; and prone positioning for more than one day prior to randomization. Study intervention and control Following informed a priori or deferred consent, eligible patients will be centrally randomized to either the intervention arm (prone positioning) or standard of care (no prone positioning). Patients randomized to the prone position will be required to either self-prone or assist-prone for a total of eight to ten hours per day until they meet pre-specified stopping criteria. Study outcomes The primary outcome is invasive mechanical ventilation at 30-days of randomization. Other outcomes include mortality at 60 days, invasive and non-invasive mechanical ventilation free days at 30 days, hospital length of stay at 60 days, days alive and outside of the hospital at 60 days, complications of proning, and serious adverse events.

Efficacy of Zoster Immune Globulin

PEDIATRICS ◽  
1974 ◽  
Vol 53 (4) ◽  
pp. 476-480
Author(s):  
Richard G. Judelsohn ◽  
Joel D. Meyers ◽  
Robert J. Ellis ◽  
Elaine K. Thomas
Keyword(s):  
High Risk ◽  
Disease Control ◽  
Immune Globulin ◽  
Immune Status ◽  
Clinical Symptoms ◽  
Normal Children ◽  
Therapeutic Modalities ◽  
Immunosuppressive Medications ◽  
Life Threatening ◽  
High Risk Children

Varicella may be a life-threatening infection in children who have immunodeficiency diseases or who are taking immunosuppressive medications. It was previously demonstrated that zoster immune globulin (ZIG) can prevent varicella in normal children if given within 72 hours of exposure, and its possible efficacy has been reported in high-risk immunodeficient children as well. A program for the distribution of ZIG to high-risk susceptibles was established at the Center for Disease Control in 1971. In 1972, 56 high-risk children were treated with ZIG after exposure. Forty-nine recipients had no clinical symptoms of varicella; at least 34 of these 49 had undetectable CF antibody before treatment, though their immune status by other serologic techniques was unknown. In the seven recipients who developed varicella, the disease was not life-threatening. ZIG may be preferable to other available therapeutic modalities in the prevention or modification of varicella.

Neuroleptic Malignant Syndrome and Serotonin Syndrome

2019 ◽  
Author(s):  
Richard Sanders ◽  
Richard Krysiak
Keyword(s):  
Neuroleptic Malignant Syndrome ◽  
Dopamine Agonists ◽  
Serotonin Syndrome ◽  
Clinical Symptoms ◽  
Altered Mental Status ◽  
Muscle Relaxants ◽  
Autonomic Instability ◽  
Life Threatening ◽  
Dopamine Circuits ◽  
Pharmacologic Treatments

Serotonin syndrome (SS) and neuroleptic malignant syndrome (NMS) are iatrogenic life-threatening conditions with similar clinical symptoms. Altered mental status, rigidity, and autonomic instability are common in both serotonin overload and toxic dopamine antagonism. It is paramount that providers understand the key differences between these two pathologies, as pharmacologic treatments can exacerbate the condition if SS is mistaken for NMS or vice versa. Hyperreflexia, clonus, diarrhea, and vomiting suggest the excessive activity of serotonin circuits in SS, whereas prominent rigidity and hyporeflexia suggest the underactivity of dopamine circuits in NMS. Supportive care and discontinuing the offending agent(s) are keys to treating both syndromes, but serotonin antagonists (eg, cyproheptadine) could be helpful in SS, whereas NMS may sometimes benefit from muscle relaxants (eg, dantrolene) and dopamine agonists (eg, bromocriptine). Following recovery, decisions about further use of an inciting agent (or similar agents) require reconsideration of risks, benefits, and alternatives, based on newly realized hazards. It is usually important to wait at least 2 weeks before rechallenge with any drugs resembling the inciting agents. This review contains 1 figure, 5 tables, and 29 references. Key Words: bromocriptine, cyproheptadine, dantrolene, Hunter criteria, neuroleptic malignant syndrome, parkinsonism, serotonin syndrome

Thoracic Transillumination: Aid in the Diagnosis and Treatment of Pneumopericardium

PEDIATRICS ◽  
1979 ◽  
Vol 64 (6) ◽  
pp. 958-960 ◽  
Author(s):  
Eresvita E. Cabatu ◽  
Edwin G. Brown
Keyword(s):  
Mechanical Ventilation ◽  
Continuous Positive Airway Pressure ◽  
Airway Pressure ◽  
Positive Airway Pressure ◽  
Hyaline Membrane Disease ◽  
Pericardial Tamponade ◽  
Review Of The Literature ◽  
Air Leak ◽  
Hyaline Membrane ◽  
Life Threatening

A frequent complication of continuous positive airway pressure and mechanical ventilation used to treat neonates who have hyaline membrane disease and other forms of respiratory distress is an air leak from alveolar rupture. Pneumothorax and pneumomediastinum are common. Pneumopericardium does not occur often, but it can be life-threatening if it produces acute cardiac tamponade. In a review of the literature, Brans and associates1 found that pneumopericardium in neonates was treated by pericardiocentesis in one half of the published cases; 79% of them survived or they ultimately died of complications unrelated to pericardial tamponade. However, only 32% of the infants treated conservatively survived.

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