The Double Gut Point: A Novel Sonographic Sign of Pneumoperitoneum

Pneumoperitoneum is a life-threatening condition, caused by hollow organ perforation. The diagnosis is often difficult, and Point-of-care ultrasound can be useful to distinguish from different conditions, and early set the indication of urgent surgery. We report a critically ill patient presented to the Emergency Department with sudden increase in upper abdominal pain and distension with a diagnosis of small bowel obstruction on ultrasound using a curvilinear probe. After repeating the ultrasound using a linear probe, two dynamic points at mesogastrium very similar to the “double lung point” seen in thoracic ultrasound was detected. This “double gut point” due to bowel ischemia and perforation was confirmed on a computed tomography scan. In this case, the finding of an abdominal “double gut point” allowed us to diagnose pneumoperitoneum, being a novel sign not previously described, that could aid to diagnose small amounts of free air in the peritoneal cavity.

A New Subform? Fast-Progressing, Severe Neurological Deterioration Caused by Spinal Epidural Lipomatosis

Spinal epidural lipomatosis (SEL) is a rare condition caused by hypertrophic growth of epidural fat. The prevalence of SEL in the Western world is approximately 1 in 40 patients and is likely to increase due to current medical and socio-economic developments. Rarely, SEL can lead to rapid severe neurological deterioration. The pathophysiology, optimal treatment, and outcome of these patients remain unclear. This study aims to widen current knowledge about this “SEL subform” and to improve its clinical management. A systematic literature review according to the PRISMA guidelines using PubMed, Scopus, Web of Science, and Cochrane Library was used to identify publications before 7 November 2021 reporting on acute/rapidly progressing, severe SEL. The final analysis comprised 12 patients with acute, severe SEL. The majority of the patients were male (9/12) and multimorbid (10/12). SEL mainly affected the thoracic part of the spinal cord (11/12), extending a median number of 7 spinal levels (range: 4–19). Surgery was the only chosen therapy (11/12), except for one critically ill patient. Regarding the outcome, half of the patients regained independence (6/11; = modified McCormick Scale ≤ II). Acute, severe SEL is a rare condition, mainly affecting multimorbid patients. The prognosis is poor in nearly 50% of the patients, even with maximum therapy. Further research is needed to stratify patients for conservative or surgical treatment.

ABO Blood Group and RhD status Are Not Associated with Mortality and Morbidity in Critically Ill Patients; a Multicentre Observational Study of 29 512 Patients

Background. Previous studies have demonstrated an association between ABO blood groups and many types of disease. The present study primarily aimed to identify associations between ABO blood groups, RhD groups and mortality/morbidity outcomes in critically ill patients both in a main cohort and in six pre-defined subgroups. The secondary aim was to investigate any differences in transfusion requirement between the different ABO blood groups and RhD status.Methods. Adult patients admitted to any of the five intensive care units (ICUs) in Skåne, Sweden, between February 2007 and April 2021 were eligible for inclusion. The outcomes were mortality analysed at 28– and 90–days as well as at the end of observation and morbidity measured using days alive and free of (DAF) invasive ventilation (DAF ventilation) and DAF circulatory support, including vasopressors or inotropes (DAF circulation), maximum Sequential Organ Failure Assessment score (SOFAmax) the first 28 days after admission and length of stay. All outcomes were analysed in separate multivariable regression models (adjusted for age and sex), generating odds or hazard ratios for each blood group and RhD status using blood group O and RhD negative as reference. Transfusion requirements were also investigated.Results. In total, 29 512 unique patients were included in the analyses. There were no significant differences for any of the outcomes between non-O blood groups and blood group O, or between RhD groups. In five pre-defined subgroups (sepsis, septic shock, acute respiratory distress syndrome, cardiac arrest and trauma) there were no differences in mortality between non-O blood groups and blood group O or between the RhD groups. The Covid-19 cohort was not investigated given the low number of patients. Furthermore, we could not demonstrate any differences in the number of transfused patients between the ABO blood groups or between the RhD groups.Conclusions. ABO blood type and RhD status do not appear to influence mortality or morbidity in a general critically ill patient population. There were no differences in the number of transfused patients between the ABO blood groups or between the RhD status groups.

Acquired pyroglutamic acidaemia in a critically ill patient with chronic paracetamol use: A case report

Pyroglutamic acid is an endogenous organic acid and a metabolite in the γ-glutamyl cycle, involved in glutathione metabolism. Accumulation of pyroglutamic acid is a rare cause of high anion gap metabolic acidosis. There are multiple risk factors for pyroglutamic acid accumulation, such as chronic paracetamol use and sepsis. In this case report, we discuss how we came to this diagnosis, how it was subsequently managed and why it is an important consideration for critically ill patients with risk factors who are likely to end up in an intensive care setting. Pyroglutamic acid recognition and treatment could benefit patients in the critically ill population as pyroglutamic acid is a rare cause of high anion gap metabolic acidosis, which is likely under-recognised and easily treated. Inappropriate management of metabolic disorders can contribute to patient morbidity and mortality. Therefore, the recognition and appropriate management of pyroglutamic acidaemia could benefit patients with risk factors for its development in a critical care setting.

Continuous Renal Replacement Therapy in the Critically Ill Patient: From Garage Technology to Artificial Intelligence

The history of continuous renal replacement therapy (CRRT) is marked by technological advances linked to improvements in the knowledge of the mechanisms and kinetics of extracorporeal removal of solutes, and the pathophysiology of acute kidney injury (AKI) and other critical illnesses. In the present article, we review the main steps in the history of CRRT, from the discovery of continuous arteriovenous hemofiltration to its evolution into the current treatments and its early use in the treatment of AKI, to the novel sequential extracorporeal therapy. Beyond the technological advances, we describe the development of new medical specialties and a shared nomenclature to support clinicians and researchers in the broad and still evolving field of CRRT.

COVID-19–Associated Pulmonary Aspergillosis in the Critical Care Setting

The first confirmed case of COVID-19 in the United States was reported on January 20, 2020. Most infected individuals experience a mild illness with loss of taste and smell, body aches, fatigue, cough, and fever. However, about 5% of patients become critically ill and experience more serious symptoms such as respiratory distress, pulmonary emboli, or even multisystem organ failure. Those who become critically ill with COVID-19 are at high risk for superinfections, including pulmonary, bloodstream, and urinary tract infections. Invasive aspergillosis is emerging as a serious secondary pulmonary infection in patients with COVID-19 who experience respiratory distress syndrome. If these patients are not accurately diagnosed and subsequently treated, the infection can be fatal. This case study describes COVID-19–associated pulmonary aspergillosis in the critically ill patient.