间歇性停用肌肉松弛剂对亚低温治疗的颅脑损伤患者复温后肺部感染的影响

目的探讨间歇性停用肌肉松弛剂降低重型颅脑损伤患者在亚低温治疗复温后肺部感染发生率的作用。方法便利抽样法选取2007年10月至2010年11月在上海市第七人民医院神经外科进行亚低温治疗的重型颅脑损伤患者90例为研究对象,按随机数字表将其分为观察组(n=49)和对照组(n=41),两组患者均采用常规的亚低温治疗方法。观察组患者在亚低温治疗期间根据医嘱每6h停用肌肉松弛剂罗库溴铵30min,对照组患者按照常规持续使用。观察两组患者在复温1周后肺部感染的发生率。结果两组患者亚低温治疗复温1周后肺部感染的发生率分别为16.3%、46.3%,对照组高于观察组,差异有统计学意义(P<0.01)。结论间歇性停用肌肉松弛剂可降低亚低温治疗的重型颅脑损伤患者复温后肺部感染的发生率。     

Renal complications in COVID-19: a systematic review and meta-analysis

Abstract

Purpose

Emerging data suggest that coronavirus disease 2019 (COVID-19) has extrapulmonary manifestations but its renal manifestations are not clearly defined. We aimed to evaluate renal complications of COVID-19 and their incidence using a systematic meta-analysis.     

Renal outcome after vancomycin treatment and renal replacement therapy in patients with severe sepsis and septic shock: A retrospective study

Purpose

Acute kidney injury during systemic infections is common; however, renal outcome is poorly investigated. The increase of multiresistant pathogens leads to the use of potential nephrotoxic antibiotics as vancomycin. We investigated the impact of vancomycin and renal replacement therapy (RRT) for renal recovery during sepsis.

Materials and methods

This is a retrospective data analysis of 1159 patients with severe sepsis or septic shock. Logistic regression models were performed.

Results

In total, 390 (33.6%) patients required RRT during intensive care unit (ICU) stay; 233 (20.1%), at discharge. Admission estimated glomerular filtration rate (eGFR) predicted the need of RRT during stay (odds ratio [OR] 0.969 [0.959-0.979] per increase of 1 mL/min, P < .001) and the prolonged need of RRT at ICU discharge (OR 0.979 [0.967-0.990], P < .001). Survivors without any RRT showed an improvement of eGFR at discharge, whereas patients after RRT did not (7.1 vs 0.8 mL/[min 1.73 m²], P < .001). The use (OR 1.648 [1.067-2.546], P < .05) and duration of vancomycin treatment (OR 1.043 [1.004-1.084] per each additional treatment day, P < .05) were predictors for ongoing RRT at discharge.

Conclusions

Estimated GFR at ICU admission predicts renal outcome, whereas the use of vancomycin increases the probability of a prolonged need for RRT at discharge from ICU. The use of alternative antibiotics for certain patients, indicated by eGFR at admission, might be considered.     

Prediction of Tubulointerstitial Injury in Chronic Kidney Disease Using a Non-Invasive Model: Combination of Renal Sonography and Laboratory Biomarkers

The goal of the study described here was to evaluate the degree of tubulointerstitial injury in patients with chronic kidney disease (CKD) using a more accurate model that combines renal sonographic parameters and laboratory biomarkers. A total of 308 patients were enrolled. The study protocol included conventional ultrasound, contrast-enhanced ultrasonography and renal biopsy. CKD patients were divided into normal and mild (≤25%), moderate (26%–50%) and severe (>50%) tubulointerstitial injury groups. We created a model comprising peak intensity, time to peak, urinary retinol-binding protein and β₂-microglobulin that could discriminate severe (>50%) tubulointerstitial injury. The area under the receiver operating characteristic curve of this model was 0.832, which had better accuracy than other individual indexes, and the sensitivity and specificity were 74.2% and 82.8%, respectively. Therefore, this model may be used to evaluate the severity of tubulointerstitial injury and may have the potential to serve as an effective auxiliary method to help nephrologists evaluate patients with CKD.     

Clinical use of renal perfusion imaging by means of harmonic sonography with a microbubble contrast agent in patients after renal transplantation: preliminary study.

OBJECTIVE: The purpose of this research was to determine the feasibility of renal perfusion imaging by means of harmonic sonography with a microbubble contrast agent for the evaluation of renal perfusion after renal transplantation compared with technetium Tc 99m diethylenetriamine pentaacetic acid ((99m)Tc-DTPA) scans. METHODS: During a 10-month period, 100 patients with renal transplantation that included normal perfusion (n=68) and delayed perfusion including chronic rejection (n=19), acute rejection (n=9), arterial stenosis (n=2), and urinary stricture (n=2) underwent sonographic renal perfusion imaging and (99m)Tc-DTPA scans. Sonographic images were obtained every 3 seconds for a total of 3 minutes after administration of a bolus injection of 4 g of the microbubble contrast agent at a concentration of 300 mg/mL. Sonographic renal perfusion images were converted into a renal perfusion curve, and the calculated time at the peak of the curve (T(peak)) was compared with that of the (99m)Tc-DTPA scan. RESULTS: The T(peak) with the (99m)Tc-DTPA scan was 14.9 seconds in the normal group and 33 seconds in the delayed perfusion group. The T(peak) on sonographic renal perfusion images was 25 seconds in the normal group and 44.8 seconds in the delayed perfusion group. Sonographic renal perfusion images showed good correlation with the (99m)Tc-DTPA scan (r=0.74; P=.0001). The cutoff value of the T(peak) on sonographic renal perfusion images was 35 seconds (sensitivity=85%; specificity=90%). CONCLUSIONS: The renal perfusion images obtained by means of harmonic sonography with a microbubble contrast agent constitute an effective sonographic technique for the evaluation of renal perfusion abnormalities after renal transplantation compared with a (99m)Tc-DTPA scan.     

Effect of Adding Neural Mobilization Versus Myofascial Release to Stabilization Exercises after Lumbar Spine Fusion: A Randomized Controlled Trial

ObjectivesTo test the effect of adding neural mobilization (NM) versus myofascial release (MFR) to stabilization exercises (SE) on disability, pain, and lumbar range of motion (ROM) in patients with lumbar spine fusion (LSF).DesignA single blinded, parallel groups, randomized controlled trial.SettingOutpatient public and governmental hospital clinics.ParticipantsPatients (N=60) who had undergone LSF were randomly assigned into 3 equal groups.InterventionGroup I received NM plus SE, group II received MFR and SE, and group III received SE only. Each group visited the hospital 3 times a week for 4 weeks.Main Outcome MeasuresOswestry disability index (ODI), visual analog scale, and back range of motion (BROM) were assessed before starting treatment, immediately after finishing treatment, and 1 month later.ResultsThere were statistically significant differences among the groups regarding the ODI and pain (P<.05) in favor of the study groups, but no statistically significant differences were found among groups regarding the BROM outcome (P>.05). Regarding the within-group effect, statistically significant differences were found in all outcomes after 1 month of treatment, as well as after 1 month of follow-up in each group (P<.05).ConclusionsPatients who received NM or MFR combined with SE demonstrated better improvement, in favor of the NM group, regarding disability and pain than patients who received SE alone after LSF. No differences were found among the groups regarding lumbar ROM.     

Investigation of a New Couples Intervention for Individuals With Brain Injury: A Randomized Controlled Trial

Objectives

This study aimed to (1) examine the efficacy of a treatment to enhance a couple’s relationship after brain injury particularly in relationship satisfaction and communication; and (2) determine couples’ satisfaction with this type of intervention.

Use of a Standardized Order Set for Achieving Target Temperature in the Implementation of Therapeutic Hypothermia after Cardiac Arrest: A Feasibility Study

Objectives:  Induced hypothermia (HT) after cardiac arrest improved outcomes in randomized trials. Current post–cardiac arrest treatment guidelines advocate HT; however, utilization in practice remains low. One reported barrier to adoption is clinician concern over potential technical difficulty of HT. We hypothesized that using a standardized order set, clinicians could achieve HT target temperature in routine practice with equal or better efficiency than that observed in randomized trials.
Methods:  After a multidisciplinary HT education program, we implemented a standardized order set for HT induction and maintenance including sedation and paralysis, intravenous cold saline infusion, and an external cooling apparatus, with a target temperature range of 33–34°C. We performed a retrospective analysis of a prospectively compiled and maintained registry of cardiac arrest patients with HT attempted (intent-to-treat) over the first year of implementation. The primary outcome measures were defined a priori by extrapolating treatment arm data from the largest and most efficacious randomized trial: 1) successful achievement of target temperature for ≥85% of patients in the cohort and 2) median time from return of spontaneous circulation (ROSC) to achieving target temperature <8 hours.
Results:  Clinicians attempted HT on 23 post–cardiac arrest patients (arrest location: 78% out-of-hospital, 22% in-hospital; initial rhythm: 26% ventricular fibrillation/tachycardia, 70% pulseless electrical activity or asystole) and achieved the target temperature in 22/23 (96%) cases. Median time from ROSC to target temperature was 4.4 (interquartile range 2.8–7.2) hours. Complication rates were low.
Conclusions:  Using a standardized order set, clinicians can achieve HT target temperature in routine practice.     

Adding Long-acting β-agonists to Inhaled Corticosteroids after Discharge from the Emergency Department for Acute Asthma: A Randomized Controlled Trial

Background: Relapses of asthma following emergency department discharge can be reduced with oral and inhaled corticosteroids (ICSs), but the benefits of long-acting β-agonists (LABAs) are unclear.
Objectives: To determine whether the addition of a LABA reduces relapses in patients with acute asthma.
Methods: This was a randomized, controlled, double-blind trial of 137 patients, aged 18–55 years, conducted in four Canadian EDs. Patients receiving high-dose ICSs or oral corticosteroids, and those who were medically unstable, were excluded. Patients were randomized to either fluticasone 1,000 μg/day with salmeterol 100 μg/day or fluticasone 1,000 μg/day alone. All patients were discharged on seven days of oral prednisone. The main outcome measure was relapse at 21 days.
Results: Both groups had similar baseline characteristics. After 21 days, seven of 69 patients (10.1%) treated with fluticasone/salmeterol and ten of 68 patients (14.7%) treated with fluticasone experienced a relapse (p = 0.42). Prior intubation, female gender, and prior use of ICSs were associated with relapse. There were no clinically or statistically significant differences in overall quality of life and individual domain scores. Fluticasone/salmeterol improved quality of life (p < 0.05) and relapses (24% to 13%; p = 0.35) in patients receiving ICSs at the time of emergency admission.
Conclusions: Outpatient treatment with a short course of systemic corticosteroids combined with ICSs is adequate for most patients with asthma discharged from the emergency department; those already receiving ICS agents may benefit from ICS/LABA combination therapy to improve quality of life. Larger studies are needed to confirm the role of inhaled LABAs in acute asthma.     

Trauma and donation after circulatory death: a case series from a major trauma center

Even with encouraging recipient outcomes, transplantation using donation after circulatory death (DCD) is still limited. A major barrier to this type of transplantation is the consequences of warm ischemia on graft survival; however, preservation techniques may reduce the consequences of cardiac arrest and provide better organ conservation. Furthermore, DCD in trauma patients could further expand organ donation. We present five cases in which organs were retrieved and transplanted successfully using normothermic regional perfusion (NRP) in trauma patients. Prompt critical care support and surgical treatment allowed us to overcome the acute phase. Unfortunately, owing to the severity of their injuries, all of the donors died. However, the advanced and continuous organ-specific supportive treatment allowed the maintenance of general clinical stability and organ preservation. Consequently, it was possible to retrieve and transplant the donors’ organs. Death was ascertained in accordance with cardio-circulatory criteria, which was followed by NRP. We consider that DCD in trauma patients may represent an important source of organs.     

Renal artery stenosis due to fibromuscular dysplasia in a transplanted kidney from a deceased donor: A difficult diagnosis at color doppler ultrasonography

Atherosclerotic renal artery stenosis is a frequent cause of arterial hypertension and/or allograft dysfunction after kidney transplantation and is usually located at the iliac artery anastomosis. Fibromuscular dysplasia is a less frequent, nonatherosclerotic, vascular disease, inducing stenosis at the proximal/mid‐distal part of the renal artery. We report the case of a 44‐year‐old woman, in whom serum creatinine concentration increased and arterial hypertension developed 3 months after renal transplantation. Color Doppler ultrasonography showed a low arterial resistance index and prolonged acceleration time in the interlobar arteries, and a significantly increased peak systolic velocity at the mid third of the renal artery, demonstrating hemodynamically significant stenosis. Percutaneous transluminal angioplasty allowed stenosis correction and was followed by creatinine concentration and arterial blood pressure normalization. © 2013 Wiley Periodicals, Inc. J Clin Ultrasound 42 :116–120, 2014     

Survival after multiple nail gun injuries to the brain,lung, and heart: a case report and a review of the literature

Most nail gun injuries involve the extremities and result from work-related accidents. Injuries to the brain or thorax are relatively rare, and cases with injuries to both regions are even rarer and often lethal. Initial evaluation, resuscitation, and surgical planning can be challenging for emergency physicians and surgeons. We present the details of a man with multiple nail gun injuries to the brain, lung, and heart following a suicide attempt. The patient presented to the emergency department in shock. After immediate resuscitation, emergent sternotomy, and subsequent craniotomy, he was discharged without significant morbidity. According to the literature, this is the only reported case involving multiple nail gun injuries to the brain, lungs, and heart. The mortality rate of multiple nail gun injuries involving the head and chest is approximately 20%. Rapid evaluation, immediate resuscitation, and appropriate imaging and surgery are crucial for increasing survival and achieving a good prognosis. Emergency sternotomy for cardiac injury is the foremost priority, and the timing of craniotomy depends on the patient’s vital sign status and whether brain injury is evident.A preprint of this article is available online: DOI: 10.21203/rs.3.rs-35448/v1.     

Acute kidney injury after cardiac surgery according to Risk/Injury/Failure/Loss/End-stage,Acute Kidney Injury Network,and Kidney Disease: Improving Global Outcomes classifications

Purpose

The epidemiology of acute kidney injury (AKI) after cardiac surgery depends on the definition used. Our aims were to evaluate the Risk/Injury/Failure/Loss/End-stage (RIFLE) criteria, the AKI Network (AKIN) classification, and the Kidney Disease: Improving Global Outcomes (KDIGO) classification for AKI post–cardiac surgery and to compare the outcome of patients on renal replacement therapy (RRT) with historical data.

Methods

Retrospective analysis of 1881 adults who had cardiac surgery between May 2006 and April 2008 and determination of the maximum AKI stage according to the AKIN, RIFLE, and KDIGO classifications.

Results

The incidence of AKI using the AKIN and RIFLE criteria was 25.9% and 24.9%, respectively, but individual patients were classified differently. The area under the receiver operating characteristic curve for hospital mortality was significantly higher using the AKIN compared with the RIFLE criteria (0.86 vs 0.78, P = .0009). Incidence and outcome of AKI according to the AKIN and KDIGO classification were identical. The percentage of patients who received RRT was 6.2% compared with 2.7% in 1989 to 1990. The associated hospital mortality fell from 82.9% in 1989 to 1990 to 15.6% in 2006 to 2008.

Conclusions

The AKIN classification correlated better with mortality than did the RIFLE criteria. Mortality of patients needing RRT after cardiac surgery has improved significantly during the last 20 years.     

Cricotracheal Separation after Gunshot to the Neck: Report of a Survivor with Recovery of Bilateral Vocal Fold Function

Background

Traumatic tracheal injury via blunt or penetrating mechanism comes with a grave prognosis. Cricotracheal separation is a rare entity among these injuries and even more infrequent by means of penetrating trauma. Resultant airway discontinuity subsequent to these insults causes immense global hypoxia and tends to be uniformly fatal.

Objective

Our aim was to discuss emergent and surgical management of traumatic airway injury.

Case Report

We report the case of a 28-year-old male who sustained a gunshot wound to the neck resulting in laryngeal fracture and cricotracheal separation. We review the initial stabilization of his airway and detail the successive surgical management of his injury in the context of the current available literature, with an emphasis on timely airway stabilization when high suspicion for cricotracheal separation exists based on traumatic mechanism.

Conclusions

Emergent management and stabilization of the airway is critical to survival in the context of trauma involving the neck and airway structures.