Acute and Critical Care

Articles in E-pub version are posted online ahead of regular printed publication.

Original Article

Pulmonary
Awake prone positioning for COVID-19 acute hypoxemic respiratory failure in Tunisia: Khaoula Ben Ismail, Fatma Essafi, Imen Talik, Najla Ben Slimene, Ines Sdiri, Boudour Ben Dhia, Takoua Merhbene; Acute Crit Care. 2023;38(3):271-277. Published online August 21, 2023; DOI: https://doi.org/10.4266/acc.2023.00591 [Epub ahead of print]

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Abstract PDF: Background
In this study, we explored whether awake prone position (PP) can impact prognosis of severe hypoxemia coronavirus disease 2019 (COVID-19) patients.
Methods
This was a prospective observational study of severe, critically ill adult COVID-19 patients admitted to the intensive care unit. Patients were divided into two groups: group G1, patients who benefited from a vigilant and effective PP (>4 hours minimum/24) and group G2, control group. We compared demographic, clinical, paraclinical and evolutionary data.
Results
Three hundred forty-nine patients were hospitalized during the study period, 273 met the inclusion criteria. PP was performed in 192 patients (70.3%). The two groups were comparable in terms of demographic characteristics, clinical severity and modalities of oxygenation at intensive care unit (ICU) admission. The mean PaO2/ FIO2 ratios were 141 and 128 mm Hg, respectively (P=0.07). The computed tomography scan was comparable with a critical >75% in 48.5% (G1) versus 54.2% (G2). The median duration of the daily PP session was 13±7 hours per day. The average duration of spontaneous PP days was 7 days (4–19). Use of invasive ventilation was lower in the G1 group (27% vs. 56%, P=0.002). Healthcare-associated infections were significantly lower in G1 (42.1% vs. 82%, P=0.01). Duration of total mechanical ventilation and length of ICU stay were comparable between the two groups. Mortality was significantly higher in G2 (64% vs. 28%, P=0.02).
Conclusions
Our study confirmed that awake PP can improve prognosis in COVID-19 patients. Randomized controlled trials are needed to confirm this result.

Case Reports

Neurosurgery
Use of droxidopa for blood pressure augmentation after acute spinal cord injury: case reports: Christopher S. Hong, Muhammad K. Effendi, Abdalla A. Ammar, Kent A. Owusu, Mahmoud A. Ammar, Andrew B. Koo, Layton A. Lamsam, Aladine A. Elsamadicy, Gregory A. Kuzmik, Maxwell Laurans, Michael L. DiLuna, Mark L. Landreneau; Received December 3, 2021 Accepted September 14, 2022 Published online December 7, 2022; DOI: https://doi.org/10.4266/acc.2021.01662 [Epub ahead of print]

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Abstract PDF: Hypotension secondary to autonomic dysfunction is a common complication of acute spinal cord injury (SCI) that may worsen neurologic outcomes. Midodrine, an enteral α-1 agonist, is often used to facilitate weaning intravenous (IV) vasopressors, but its use can be limited by reflex bradycardia. Alternative enteral agents to facilitate this wean in the acute post-SCI setting have not been described. We aim to describe novel application of droxidopa, an enteral precursor of norepinephrine that is approved to treat neurogenic orthostatic hypotension, in the acute post-SCI setting. Droxidopa may be an alternative enteral therapy for those intolerant of midodrine due to reflex bradycardia. We describe two patients suffering traumatic cervical SCI who were successfully weaned off IV vasopressors with droxidopa after failing with midodrine. The first patient was a 64-year-old male who underwent C3–6 laminectomies and fusion after a ten-foot fall resulting in quadriparesis. Post-operatively, the addition of midodrine in an attempt to wean off IV vasopressors resulted in significant reflexive bradycardia. Treatment with droxidopa facilitated rapidly weaning IV vasopressors and transfer to a lower level of care within 72 hours of treatment initiation. The second patient was a 73-year-old male who underwent C3–5 laminectomies and fusion for a traumatic hyperflexion injury causing paraplegia. The addition of midodrine resulted in severe bradycardia, prompting consideration of pacemaker placement. However, with the addition of droxidopa, this was avoided, and the patient was weaned off IV vasopressors on dual oral therapy with midodrine and droxidopa. Droxidopa may be a viable enteral therapy to treat hypotension in patients after acute SCI who are otherwise not tolerating midodrine in order to wean off IV vasopressors. This strategy may avoid pacemaker placement and facilitate shorter stays in the intensive care unit, particularly for patients who are stable but require continued intensive care unit admission for IV vasopressors, which can be cost ineffective and human resource depleting.

Pediatrics
Hydranencephaly in a newborn due to occupational toluene exposure during pregnancy: a case report: Banu Aydın, Edin Botan, Bülent Gülensoy, Seda Akyol; Received August 9, 2021 Accepted January 30, 2022 Published online July 15, 2022; DOI: https://doi.org/10.4266/acc.2021.01081 [Epub ahead of print]

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Abstract PDF: The etiopathogenesis of hydranencephaly remains unclear; however, exposure to toxic substances during pregnancy likely increases hydranencephaly risk. Head computed tomography (CT) was performed in a neonate 9 hours post-delivery because the anterior fontanelle was large and there were clinical signs of encephalopathy. Head CT revealed a lack of both cerebral hemispheres and significant cystic enlargement, while the cerebellar hemispheres and pons were found to have developed normally. History-taking revealed that the mother worked in the automotive industry, specifically in the car paint cleaning business and was exposed to toluene during the pregnancy. The patient was diagnosed with hydranencephaly, central diabetes insipidus and central hypothyroidism. Due to the increased head circumference and tense anterior fontanelle, a ventriculoperitoneal shunt was placed. Toluene exposure during pregnancy should be considered among the causes of hydranencephaly. Furthermore, central diabetes insipidus and central hypothyroidism may develop in such cases.

Neurosurgery
A point-of-care evaluation after visual loss following paraclinoid aneurysm repair: the role of sonographic and pupillometer assessment: Giacomo Bertolini, Ernesto Migliorino, Diego Mazzatenta, Carlo Bortolotti, Raffaele Aspide; Received January 9, 2022 Accepted March 17, 2022 Published online July 5, 2022; DOI: https://doi.org/10.4266/acc.2022.00045 [Epub ahead of print]

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Abstract PDF: Visual complications represent common deficits following surgical or endovascular repair of paraclinoid aneurysms. Different etiologies should be investigated to prevent devastating consequences. Herein we present a point-of-care evaluation to investigate sudden visual loss after coiling of a paraclinoid aneurysms. A 20-year-old male were admitted for a sudden headache. Head computed tomography showed a subarachnoid hemorrhage and subsequent angiography revealed a 9-mm left supraclinoid aneurysm of the internal carotid artery treated with endovascular coil embolization. Thirty minutes after intensive care unit admission the patient reported a left amaurosis. To exclude secondary etiologies an immediate evaluation with point-of-care devices (color-doppler and B-mode ultrasound and automated pupillometry) were performed. Sonographic evaluations were negative for ischemic/thrombotic events and neurologic pupil index within physiological ranges provide evidence of third cranial nerve responsiveness. The symptomatology resolved progressively over 120 minutes with low-dose steroid therapy, 30° head-of-bed elevation and blood pressure management. Visual deficits can occur after endovascular procedure and should be investigated. Suspected visual loss is a neurological emergency that deserve a prompt evaluation. Ultrasound and automated pupillometry have proved to be an effective, rapid, reliable and non-invasive combination for a clinical decision-making strategy in the management of post-procedural acute visual deficits.

Neurology
Abducens paralysis—a rare complication of spinal anesthesia at an emergency department: a case report: Mustafa Korkut, Cihan Bedel; Received December 4, 2021 Accepted January 28, 2022 Published online July 5, 2022; DOI: https://doi.org/10.4266/acc.2021.01697 [Epub ahead of print]

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Abstract PDF: The sixth cranial nerve (CN VI) is a rare site of complication associated with spinal anesthesia and can produce secondary symptoms of ocular muscle palsy. A 38-year-old man was admitted to the emergency department with complaint of diplopia and limited lateral gaze in the first week after endoscopic urological surgery under spinal anesthesia. Isolated unilateral CN VI palsy was considered after excluding differential diagnoses. Ocular palsy and diplopia regressed with conservative treatment during follow-up, and the patient was discharged. This article aims to show that CN VI palsy is a rare complication of spinal anesthesia, which can be observed in the emergency department.

Pulmonary
Digital tomography in the diagnosis of a posterior pneumothorax in the intensive care unit: Shauni Wellekens, Nico Buls, Johan De Mey, Vincent Van Nieuwenhove, Jeroen Cant, Joop Jonckheer; Received December 24, 2021 Accepted February 4, 2022 Published online June 10, 2022; DOI: https://doi.org/10.4266/acc.2021.01802 [Epub ahead of print]

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Abstract PDF: Portable chest radiography is a valuable tool in the intensive care unit. However, the supine position causes superposition of anatomical structures resulting in less reliable detection of certain abnormalities. Recently, a portable digital tomosynthesis (pDTS) prototype with a modified motorized X-ray device was developed. Our aim is to compare the diagnostic value of pDTS to standard bedside chest radiography in the diagnosis of a posterior pneumothorax. A modified motorized x-ray device was developed to perform 15 radiographic projections while translating the X-ray tube 25 cm (10 cm ramp up and 15 cm during X-ray exposure) with a total radiation dose of 0.54 mSv. This new technique of pDTS was performed in addition to standard bedside chest X-ray in a patient with a confirmed posterior hydropneumothorax. The images were compared with the standard bedside chest X-ray and computed tomography (CT) images by two experienced radiologists. The posterior hydropneumothorax previously identified with CT was visible on tomosynthesis images but not with standard bedside imaging. Combining the digital tomosynthesis technique with the portable x-ray machine could increase the diagnostic value of bedside chest radiography for the diagnosis of posterior pneumothoraces, while avoiding intrahospital transport and limiting radiation exposure compared to CT.

Cardiology
Successful neural modulation of bedside modified thoracic epidural anesthesia for ventricular tachycardia electrical storm: Ki-Woon Kang; Received November 17, 2021 Accepted March 7, 2022 Published online May 31, 2022; DOI: https://doi.org/10.4266/acc.2021.01683 [Epub ahead of print]

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Abstract PDF: Ventricular tachycardia (VT)/ventricular fibrillation (VF) storm can be hemodynamically compromising and life-threatening. Management of medically refractory VT/VF storm is challenging in the intensive care unit. A 38-year-old male patient was diagnosed with non-ischemic heart failure and acute kidney injury with documented frequent premature ventricular contraction with QT prolongation after recurrent VT/VF. Even though the patient was intubated with sedatives and had taken more than two anti-arrhythmic drugs with external recurrent defibrillation at bedside, the electrical storm persisted for several hours. However, medically refractory VT/VF storm can be successfully and rapidly terminated with a modified thoracic epidural anesthesia at bedside. This case demonstrates that a bedside thoracic epidural anesthesia can be an effective non-pharmacological option to treat medically refractory VT/VF storm in the intensive care unit.

Cardiology
Successful extracorporeal membrane oxygenation treatment of catecholamine-induced cardiomyopathy-associated pheochromocytoma: Sangshin Park, Min Kim, Dae In Lee, Ju-Hee Lee, Sangmin Kim, Sang Yeub Lee, Jang-Whan Bae, Kyung-Kuk Hwang, Dong-Woon Kim, Myeong-Chan Cho, Dae-Hwan Bae; Received August 31, 2021 Accepted December 20, 2021 Published online May 11, 2022; DOI: https://doi.org/10.4266/acc.2021.01158 [Epub ahead of print]

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Abstract PDF Supplementary Material: The main mechanism of Takotsubo cardiomyopathy (TCM) is catecholamine-induced acute myocardial stunning. Pheochromocytoma, a catecholamine-secreting tumor, can cause several cardiovascular complications, including hypertensive crisis, myocardial infarction, toxic myocarditis, and TCM. A 29-year-old woman presented to our hospital with general weakness, vomiting, dyspnea, and chest pain. The patient was nullipara, 28 weeks’ gestation, and had a cachexic morphology. Her cardiac enzyme levels were elevated and bedside echocardiography showed apical akinesia, suggesting TCM. The next day, she could not feel the fetal movement, and an emergency cesarean section was performed. After delivery, the patient experienced cardiac arrest and was transferred to the intensive care unit for cardiopulmonary resuscitation (CPR). Spontaneous circulation returned after 28 minutes of CPR, but cardiogenic shock continued, and extracorporeal membrane oxygenation (ECMO) was initiated. On the third day of ECMO maintenance, left ventricular ejection fraction improved and blood pressure stabilized. On the eighth day after ECMO insertion, it was removed. However, complications of the left leg vessels occurred, and several surgeries and interventions were performed. A left adrenal gland mass was found on computed tomography and was removed while repairing the leg vessels. Pheochromocytoma was diagnosed and left adrenalectomy was performed.

Neurology
Myoclonic status epilepticus after severe hyperthermia in a patient with coronavirus disease 2019: Katherine A Hill, John J Peters, Sara M Schaefer; Received October 6, 2021 Accepted November 22, 2021 Published online March 24, 2022; DOI: https://doi.org/10.4266/acc.2021.01452 [Epub ahead of print]

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Abstract PDF: Myoclonic status epilepticus (MSE) is a sign of severe neurologic injury in cardiac arrest patients. To our knowledge, MSE has not been described as a result of prolonged hyperpyrexia. A 56-yearold man with coronavirus disease 2019 presented with acute respiratory distress syndrome, septic/hypovolemic shock, and presumed community-acquired pneumonia. Five days after presentation, he developed a sustained fever of 42.1°C that did not respond to acetaminophen or ice water gastric lavage. After several hours, he was placed on surface cooling. Three hours after fever resolution, new multifocal myoclonus was noted in the patient’s arms and trunk. Electroencephalography showed midline spikes consistent with MSE, which resolved with 40 mg/kg of levetiracetam. This case demonstrates that severe hyperthermia can cause cortical injury significant enough to trigger MSE and should be treated emergently using the most aggressive measures available. Providers should have a low threshold for electroencephalography in intubated patients with a recent history of hyperpyrexia.

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