Hyperacute Gullain Barre Syndrome (GBS); The Catastrophic Variant- A Rare Case Report

Guillain-Barré syndrome (GBS) also known as acute demyelinating polyradiculoneuropathy (AIDP) is an immunologically mediated rare neurological disorder. The basic pathogenic mechanism is regulated by molecular mimicry. Usually there is a history of preceding infection which occurs some weeks before the attack. The infections are gastroenteritis or upper respiratory. The clinical spectrum of ranges from mild weakness to devastating paralysis including respiratory failure. Majority of the cases recover but a few continue to have residual neurodeficit. The usual clinical course of GBS from the starting of weakness to development of maximum neurologic progression usually progresses over 4 weeks. Hyperacute GBS is a term used when the progression of weakness occurs within hours to days to maximum neurologic impairment. In this case report we present a 28 year old female who developed rapidly progressive, areflexic quadriparesis with respiratory muscle involvement requiring mechanical ventilatory support within nine hours. Clinical , laboratory and nerve conduction studies suggested a diagnosis of GBS.

Association of the Verbal Component of the GCS With Mortality in Patients With Encephalopathy Who Are Not Undergoing Mechanical Ventilation

Background and Objectives:The utility of the Glasgow Coma Scale (GCS) in intubated patients is limited due to reliance on language function evaluation. The Full Outline of UnResponsiveness (FOUR) Score was designed to circumvent this shortcoming, instead adding evaluations of brainstem reflexes (FOUR B) and specific respiratory patterns (FOUR R). We aimed to determine if the verbal component of the GCS (GCS V) among encephalopathic non-intubated patients significantly contributes to mortality prediction and to assess GCS vs. FOUR Score performance.Methods:All prospectively consented patients ≥18 years admitted to the Internal Medicine service at Zambia’s University Teaching Hospital from October 3rd, 2017 to May 21st, 2018 with a GCS of ≤10 have undergone simultaneous GCS and FOUR Score assessments. The patients were not eligible for mechanical ventilatory support per local standards. Patients’ demographics and clinical characteristics were presented as either percentage frequencies or numerical summaries of spread. The predictive power of the GSC without Verbal component vs. total GCS vs. FOUR Score on mortality were estimated using the area under the receiver operating characteristic (AU-ROC).Results:235 patients (50% women; mean age 47.5 years) were enrolled. All patients were Black. Presumed etiology was CNS infection (64; 27%), stroke (63; 27%), systemic infection (39; 16.6%), metabolic encephalopathy (3; 14.5 %), 14.9% unknown. In-hospital mortality was 83%. AU ROC for GCS Eye+Motor (0.662) vs. total GCS (0.641) vs. total FOUR Score (0.657) did not differ. Odds ratio mortality for GCS > 6 vs. < 6 was 0.32, 95% CI 0.14-0.72 (p 0.01); for FOUR Score >10 vs. <10 was 0.41, 95% CI 0.19-0.86 (p 0.02).Conclusion:Absence of a verbal component of GCS had no significant impact on total GCS’s performance and either GCS or FOUR Score are acceptable scoring tools for mortality prediction in the resource-limited setting. These findings need further validation in the countries with readily available mechanical ventilatory support.Classification of Evidence:This study provides Class I evidence that the verbal component of the GCS does not significantly contribute to a total GCS score in mortality prediction among encephalopathic patients who are not intubated.

Complex Oncologic Surgeries and Implications for the Intensive Care Unit Nurse

There are many challenges in caring for the postsurgical patient in the intensive care unit. When the postsurgical patient has an active malignancy, this can make the intensive care unit care more challenging. Nutrition, infection, and the need for postoperative mechanical ventilatory support for the patient with cancer present challenges that may increase the patient’s length of stay in the intensive care unit. Critical care nurses must be aware of these challenges as they provide care to this patient population.

Bradyarrhythmic Cardiac Arrest—A Rare Manifestation of Fexofenadine Cardiotoxicity

A 66-year-old diabetic, hypertensive, and hypothyroid female presented in the emergency department with cardiac arrest, for which cardiopulmonary resuscitation was immediately initiated. She had been on oral fexofenadine for 36 h prior to the event. Post successful resuscitation, her cardiac rhythm showed high-grade atrioventricular block. Patient was treated with mechanical ventilatory support and temporary transvenous pacing. No treatable cause could be identified, and she recovered completely following fexofenadine discontinuation, without need for a permanent pacemaker. She has remained asymptomatic during 1 year of follow-up with no documented arrhythmias. An electrophysiological study at 6 months revealed prolonged HV interval (70 ms) with 1:1 AV conduction and no inducible arrhythmias. This is probably the first reported case of fexofenadine-induced cardiac arrest in a patient without previous history of heart disease.

Severe Esophagitis and Chemical Pneumonitis as a Consequence of Dilute Benzalkonium Chloride Ingestion: A Case Report

Background: Benzalkonium chloride (BAC) has been used as an active ingredient in a wide variety of compounds such as surface disinfectants, floor cleaners, pharmaceutical products and sanitizers. Solutions containing <10% concentration of BACs typically do not cause serious injury. As the available data regarding acute BAC toxicity is limited, we report a case of dilute benzalkonium chloride ingestion resulting in bilateral chemical pneumonitis and significant gastrointestinal injury requiring mechanical ventilatory support. The Case: A 42-year-old male presented with complaints of nausea, vomiting and excessive amount of blood mixed oral secretions after accidental ingestion of approximately 100ml of BAC solution (<10%). Later he developed respiratory distress with falling oxygen saturation for which he was intubated and mechanical ventilatory support was administered. Computed tomography (CT) chest was suggestive of bilateral chemical pneumonitis and upper gastrointestinal (GI) endoscopy revealed diffuse esophageal ulcerations. The patient was managed with intravenous fluids, corticosteroids, proton pump inhibitor, empiric antibiotics, and total parenteral nutrition. Conclusion: The present case report emphasizes that dilute BAC compounds can cause severe respiratory and gastrointestinal injuries. Immediate and aggressive medical treatment is crucial for improving patient outcomes and reducing complication rates.

Large airway complications in COVID-19 pneumonia

COVID-19 pneumonia can cause respiratory failure which requires specialist management. However the inflammatory nature of the condition and the interventions necessary to manage these patients such as endotracheal intubation and tracheostomy can lead to large airway pathology which may go unrecognised. We describe five of the 44 (11%) consecutive patients referred to our specialist ARDS team between April and June 2020 with confirmed COVID-19 pneumonia who developed diverse large airway pathology which comprised of: supraglottic oedema, tracheal tear, tracheal granulation tissue formation, bronchomalacia, and tracheal diverticulum. Large airway pathology may be underappreciated in severely ill patients with COVID-19 pneumonia and should be considered in patients with unexplained air leak, prolonged need for mechanical ventilatory support, and repeated failed extubation or decannulation. If suspected, such patients should be managed by a team with expertise in large airway intervention and early specialist advice should be sought.

Mortality Data in Mechanically Ventilated COVID-19 patients admitted to ICU: A Retrospective Study in Brooklyn

Background: High mortality rates are predominant even in COVID-19 patients requiring minimal supportive therapy, with a short-coming of data on COVID-19 patients requiring mechanical ventilation.Objectives/Design: We performed a single-center, retrospective, cohort study at a tertiary care, community-based teaching hospital with patient who required invasive mechanical ventilatory support and were COVID-19 positive. All patients were treated according to the ARDSnet protocol. The primary outcome was overall mortality, and secondary outcome was successful extubation.Results: A total of 72 COVID-19 positive intubated patients were included. Twenty-six (66.6%) patients died within the first 15 days of hospital admission; thirty-eight (52.7%) died within 28 days, and thirty-nine (54.2%) died within 29 days. A total of 22 patients (30.5%) were successfully extubated. 15 patients (20.8%) who required reintubation or could not be extubated further underwent tracheostomy.Conclusions: Mortality of critically ill COVID-19 patients requiring mechanical ventilatory support is high, our observed mortality rate (54.2%) was significantly lower than currently published reports. We believe our rate to be a consequence of early intubation in conjunction with adherence to ARDSnet protocol. We also observed patients with hyperlipidemia, higher CRP, renal failure, or those requiring vasopressor use had worse outcomes.