scholarly journals Acute Respiratory Failure From Hypermagnesemia Requiring Prolonged Mechanical Ventilation

2020 ◽  
Vol 8 ◽  
pp. 232470962098489
Author(s):  
Khalid Sawalha ◽  
Krishna Kakkera
Keyword(s):  
Respiratory Failure ◽  
Prolonged Mechanical Ventilation ◽  
Kidney Injury ◽  
Flaccid Paralysis ◽  
Free Fluid ◽  
Intermittent Hemodialysis ◽  
Diffuse Abdominal Pain ◽  
Initial Imaging ◽  
Brain Stem Reflexes ◽  
Upper Abdomen

Electrolyte abnormalities are an underrecognized cause of respiratory failure in the intensive care unit. One such abnormality is a relatively rare phenomenon of hypermagnesemia resulting in paralysis. A 73-year-old Caucasian male patient presented to the emergency department with diffuse abdominal pain of 2-day duration. He received magnesium citrate and gastrointestinal cocktail for his constipation after initial imaging showed constipation. In view of acute worsening, follow-up computed tomography of the abdomen was done, which showed free air in upper abdomen along with free fluid. Hence, he was taken for emergent laparotomy with repair of pyloric ulcer perforation with omental patch. Post procedure course was complicated by sepsis, acute kidney injury, and respiratory failure with hypoxemia and hypercapnia. On physical examination the patient had flaccid paralysis in all his extremities along with absent brain stem reflexes. Extensive workup including imaging of brain failed to reveal diagnosis. On postoperative day 1, the patient was noted to have magnesium level of 9.2 mg/dL (1.6-2.3 mg/dL), which was thought to be cause of flaccid paralysis and respiratory failure. In view of his acute oliguric kidney injury, he was initiated on intermittent hemodialysis, until his magnesium levels were back to its physiologic limits. His paralysis gradually improved over next 48 to 72 hours and he was liberated from ventilator successfully.

scholarly journals Abdominal Pain, Hyperkalemia, and Elevated Creatinine after Blunt Trauma: Bladder Rupture and Pseudo–Acute-Kidney-Injury.

2018 ◽  
Vol 13 (2) ◽  
Author(s):  
Reza D Mirza ◽  
Eric KC Wong ◽  
Robert Yang ◽  
Catherine Clase
Keyword(s):  
Acute Kidney Injury ◽  
Abdominal Pain ◽  
Kidney Injury ◽  
Organ Injury ◽  
Bladder Rupture ◽  
Free Fluid ◽  
Solid Organ ◽  
Solid Organ Injury ◽  
Elevated Creatinine ◽  
Initial Imaging

A 40-year-old man involved in trauma presented with abdominal pain and ascites. He was referred to nephrology for elevated creatinine and hyperkalemia. Initial imaging showed diffuse free fluid in the abdomen and pelvis without solid organ injury. Paracentesis drained 1.5L of yellow fluid notable for a creatinine of 2259 μmol/L. Intraperitoneal urinary bladder rupture was diagnosed and surgically repaired. Within 24 hours, creatinine had normalized consistent with a presentation of pseudo-acute-kidney-injury. This case and a literature review reveals that this condition is often delayed in diagnosis or misdiagnosed altogether. 

scholarly journals Dobutamine-sparing versus dobutamine-to-all strategy in cardiac surgery: a randomized noninferiority trial

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Rafael Alves Franco ◽  
Juliano Pinheiro de Almeida ◽  
Giovanni Landoni ◽  
Thomas W. L. Scheeren ◽  
Filomena Regina Barbosa Gomes Galas ◽  
...  
Keyword(s):  
Cardiac Output ◽  
Cardiac Surgery ◽  
Prolonged Mechanical Ventilation ◽  
Kidney Injury ◽  
Composite Endpoint ◽  
Tissue Perfusion ◽  
Hospital Length Of Stay ◽  
Low Cardiac Output Syndrome ◽  
Low Cardiac Output ◽  
Noninferiority Trial

Abstract Background The detrimental effects of inotropes are well-known, and in many fields they are only used within a goal-directed therapy approach. Nevertheless, standard management in many centers includes administering inotropes to all patients undergoing cardiac surgery to prevent low cardiac output syndrome and its implications. Randomized evidence in favor of a patient-tailored, inotrope-sparing approach is still lacking. We designed a randomized controlled noninferiority trial in patients undergoing cardiac surgery with normal ejection fraction to assess whether an dobutamine-sparing strategy (in which the use of dobutamine was guided by hemodynamic evidence of low cardiac output associated with signs of inadequate tissue perfusion) was noninferior to an inotrope-to-all strategy (in which all patients received dobutamine). Results A total of 160 patients were randomized to the dobutamine-sparing strategy (80 patients) or to the dobutamine-to-all approach (80 patients). The primary composite endpoint of 30-day mortality or occurrence of major cardiovascular complications (arrhythmias, acute myocardial infarction, low cardiac output syndrome and stroke or transient ischemic attack) occurred in 25/80 (31%) patients of the dobutamine-sparing group (p = 0.74) and 27/80 (34%) of the dobutamine-to-all group. There were no significant differences between groups regarding the incidence of acute kidney injury, prolonged mechanical ventilation, intensive care unit or hospital length of stay. Discussion Although it is common practice in many centers to administer inotropes to all patients undergoing cardiac surgery, a dobutamine-sparing strategy did not result in an increase of mortality or occurrence of major cardiovascular events when compared to a dobutamine-to-all strategy. Further research is needed to assess if reducing the administration of inotropes can improve outcomes in cardiac surgery. Trial registration ClinicalTrials.gov, NCT02361801. Registered Feb 2nd, 2015. https://clinicaltrials.gov/ct2/show/NCT02361801

scholarly journals Surgical tracheostomy in a cohort of COVID-19 patients

HNO ◽  
2021 ◽  
Author(s):  
Patrick J. Schuler ◽  
Jens Greve ◽  
Thomas K. Hoffmann ◽  
Janina Hahn ◽  
Felix Boehm ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Respiratory Failure ◽  
Prolonged Mechanical Ventilation ◽  
Tertiary Care ◽  
Lung Compliance ◽  
Hypoxemic Respiratory Failure ◽  
Surgical Tracheostomy ◽  
Increased Risk ◽  
Open Surgical Tracheostomy ◽  
Sedative Drugs

Abstract Background One of the main symptoms of severe infection with the new coronavirus‑2 (SARS-CoV-2) is hypoxemic respiratory failure because of viral pneumonia with the need for mechanical ventilation. Prolonged mechanical ventilation may require a tracheostomy, but the increased risk for contamination is a matter of considerable debate. Objective Evaluation of safety and effects of surgical tracheostomy on ventilation parameters and outcome in patients with COVID-19. Study design Retrospective observational study between March 27 and May 18, 2020, in a single-center coronavirus disease-designated ICU at a tertiary care German hospital. Patients Patients with COVID-19 were treated with open surgical tracheostomy due to severe hypoxemic respiratory failure requiring mechanical ventilation. Measurements Clinical and ventilation data were obtained from medical records in a retrospective manner. Results A total of 18 patients with confirmed SARS-CoV‑2 infection and surgical tracheostomy were analyzed. The age range was 42–87 years. All patients received open tracheostomy between 2–16 days after admission. Ventilation after tracheostomy was less invasive (reduction in PEAK and positive end-expiratory pressure [PEEP]) and lung compliance increased over time after tracheostomy. Also, sedative drugs could be reduced, and patients had a reduced need of norepinephrine to maintain hemodynamic stability. Six of 18 patients died. All surgical staff were equipped with N99-masks and facial shields or with powered air-purifying respirators (PAPR). Conclusion Our data suggest that open surgical tracheostomy can be performed without severe complications in patients with COVID-19. Tracheostomy may reduce invasiveness of mechanical ventilation and the need for sedative drugs and norepinehprine. Recommendations for personal protective equipment (PPE) for surgical staff should be followed when PPE is available to avoid contamination of the personnel.

scholarly journals SAT-LB303 Severe Refractory Volume Overload With Diazoxide in the Treatment of Insulinoma

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Pouneh Pasha ◽  
Graydon S Meneilly ◽  
Jordanna Esther Kapeluto
Keyword(s):  
Surgical Resection ◽  
Myocardial Infarct ◽  
Kidney Injury ◽  
Volume Overload ◽  
Cardiorenal Syndrome ◽  
Intermittent Hemodialysis ◽  
Close Monitoring ◽  
Clinical Pharmacokinetics ◽  
Reduced Ejection Fraction ◽  
Supportive Management

Abstract Background: Insulinoma is the most common neuroendocrine tumor (NET), occurring in 1-4 people per million. Surgical resection remains standard of care for symptomatic control and long-term remission. Where surgery is not feasible medical therapy with diazoxide and somatostatin analogues is used as supportive management. Case: A 88-year-old male with background hypertension, remote myocardial infarct and chronic kidney disease (CKD) (Cr 130-150 umol/L; N 60-115) was diagnosed with insulinoma following a presentation for confusion and CBG of 0.9 mmol/L. Diagnosis was confirmed by 72 hour fast with inappropriate insulin (85 pmol/L; N&lt95) and elevated c-peptide (1875 pmol/L; N 325-1090) with documented hypoglycemia (2.8 mmol/L). CT abdomen localized a 1.2 cm exophytic lesion in the pancreatic tail suggestive of insulinoma. Normal morning cortisol (547 nmol/L) excluded adrenal insufficiency. Initial management included resuscitation with dextrose infusions. Due to advanced age and high cardiac risk profile, the patient was not a candidate for surgical resection of the NET. Endoscopic ultrasound (EUS) ablation was deferred at time of initial hospitalization due to stabilization of hypoglycemia with high glycemic diet. An episode of nocturnal hypoglycemia prompted initiation of diazoxide 100 mg as an outpatient. Subsequent dyspnea (NYHA IV) developed and acute on chronic kidney injury (peak Cr 416 umol/L) with evidence of anasarca secondary to diazoxide use prompted readmission to hospital. With conversion to octreotide, discontinuation of diazoxide and treatment with multiple diuretics, volume overload did not improve. The patient was deemed not a candidate for intermittent hemodialysis and the decision was made to change goals of care. The patient died of complications of volume overload from cardiorenal syndrome 21 days after the initiation of diazoxide. Conclusion: Volume overload has been documented as a complication of diazoxide use in both hypoglycemia and hypertension, occurring in up to 50% of cases, however mortality is not common with supportive management.1, 2 Risk factors for refractory volume overload appear to include reduced ejection fraction, extremes of age and history of CKD3. Possible mechanisms for acute decompensation in CKD include increased unbound diazoxide levels, prerenal effect from hypotension and sodium retention4,5. This case highlights the need for close monitoring with diazoxide use in high risk patients. Clinicians should consider echocardiogram, close monitoring of clinical volume status and renal parameters. References: 1) Goode PN. (1986). World J Surg 10: 586. 2) Komatsu Y. (2016) Endocr J. 63(3): 311. 3) Tarçin O. (2018). Endocrine Abstracts56 EP4. 4) Pearson RM. (1977) Clinical Pharmacokinetics vol 2: 198. 5) Allen WR. (1983). Pharmacology 27: 336.

Indications for Dialysis in Acute Kidney Injury

2020 ◽  
Author(s):  
Ankit Patel ◽  
Kenneth B Christopher
Keyword(s):  
Acute Kidney Injury ◽  
Renal Replacement Therapy ◽  
Replacement Therapy ◽  
High Efficiency ◽  
Kidney Injury ◽  
Intermittent Hemodialysis ◽  
Continuous Venovenous Hemofiltration ◽  
Continuous Venovenous Hemodialysis ◽  
Low Efficiency ◽  
The Impact

Renal replacement therapy (RRT) can be used to support patient’s kidney function in cases of acute kidney injury (AKI). However, timing, modality, and dosing of RRT continue to remain in question. Recent studies have begun to provide data to help guide clinicians on when to initiate RRT, what form of RRT to use ranging from continuous venovenous hemofiltration (VVH) to intermittent hemodialysis, and the impact of high versus low-intensity dosing. Additionally, the risks associated with temporary vascular access with regard to thrombosis and infection, the impact of high efficiency and flux versus low efficiency and flux membranes, and options for anticoagulation in RRT for AKI are also discussed. This review contains 75 references.  Key words: acute kidney injury, chronic kidney disease, continuous venovenous hemofiltration, continuous venovenous hemodialysis, renal replacement therapy, venovenous hemofiltration, 

scholarly journals Outcomes of Percutaneous Tracheostomy for Patients with SARS-CoV-2 Respiratory Failure

2021 ◽  
Author(s):  
Jason Arnold ◽  
Catherine A. Gao ◽  
Elizabeth Malsin ◽  
Kristy Todd ◽  
A. Christine Argento ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Respiratory Failure ◽  
Median Time ◽  
Prolonged Mechanical Ventilation ◽  
Percutaneous Tracheostomy ◽  
Tertiary Care ◽  
Severe Respiratory Failure ◽  
Spearman Correlation ◽  
Early Tracheostomy ◽  
Lengths Of Stay

ABSTRACTBackgroundSARS-CoV-2 can cause severe respiratory failure leading to prolonged mechanical ventilation. Data are just emerging about the practice and outcomes of tracheostomy in these patients. We reviewed our experience with tracheostomies for SARS-CoV-2 at our tertiary-care, urban teaching hospital.MethodsWe reviewed the demographics, comorbidities, timing of mechanical ventilation, tracheostomy, and ICU and hospital lengths-of-stay (LOS) in SARS-CoV-2 patients who received tracheostomies. Early tracheostomy was considered <14 days of ventilation. Medians with interquartile ranges (IQR) were calculated and compared with Wilcoxon rank sum, Spearman correlation, Kruskal-Wallis, and regression modeling.ResultsFrom March 2020 to January 2021, our center had 370 patients intubated for SARS-CoV-2, and 59 (16%) had percutaneous bedside tracheostomy. Median time from intubation to tracheostomy was 19 (IQR 17 – 24) days. Demographics and comorbidities were similar between early and late tracheostomy, but early tracheostomy was associated with shorter ICU LOS and a trend towards shorter ventilation. To date, 34 (58%) of patients have been decannulated, 17 (29%) before hospital discharge; median time to decannulation was 24 (IQR 19-38) days. Decannulated patients were younger (56 vs 69 years), and in regression analysis, pneumothorax was associated was associated with lower decannulation rates (OR 0.05, 95CI 0.01 – 0.37). No providers developed symptoms or tested positive for SARS-CoV-2.ConclusionsTracheostomy is a safe and reasonable procedure for patients with prolonged SARS-CoV-2 respiratory failure. We feel that tracheostomy enhances care for SARS-CoV-2 since early tracheostomy appears associated with shorter duration of critical care, and decannulation rates appear high for survivors.

Intensity of Renal Support in Critically Ill Patients with Acute Kidney Injury

2018 ◽  
pp. 221-226
Author(s):  
Eric Ehieli ◽  
Yuriy Bronshteyn
Keyword(s):  
Acute Kidney Injury ◽  
Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Statistical Difference ◽  
Kidney Injury ◽  
Intermittent Hemodialysis ◽  
Replacement Strategy ◽  
Therapy Regimen ◽  
Continuous Venovenous Hemodiafiltration ◽  
Multicenter Prospective Study

Patients with severe acute kidney injury who require renal replacement therapy have high mortality rates. Controversy exists over whether a mortality benefit occurs with use of a more intensive renal replacement therapy regimen. In this multicenter, prospective study, 1124 patients requiring renal replacement therapy for severe acute kidney injury were randomized to a more and a less intensive renal replacement therapy regimen and were followed for 60 days. There was no statistical difference in mortality at 60 days (53.6% intensive, 51.5% less intensive, P = 0.47) and no difference in kidney recovery or non-renal organ failure. Hypotension and electrolyte abnormalities were more common in the intensive renal replacement regimen. A less intensive renal replacement regimen (intermittent hemodialysis 3 times a week or continuous venovenous hemodiafiltration at 20ml/kg/hour) was found noninferior to a more intensive renal replacement strategy (dialysis 6 times per week or continuous venovenous hemodiafiltration at 35 ml/kg/hour).

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