Kavi Haji

High-flow nasal oxygen vs high-flow face mask: A randomized crossover trial in extubated patients

PURPOSE Oxygen delivery after extubation is critical to maintain adequate oxygenation and to avoid reintubation. The delivery of oxygen in such situations is usually by high-flow face mask (HFFM). Yet, this may be uncomfortable for some patients. A recent advance in oxygen delivery technology is high-flow nasal prongs (HFNP). There are no randomized trials comparing these 2 modes. METHODS Patients were randomized to either protocol A (n = 25; HFFM followed by HFNP) or protocol B (n = 25; HFNP followed by HFFM) after a stabilization period of 30 minutes after extubation. The primary objective was to compare the efficacy of HFNP to HFFM in maintaining gas exchange as measured by arterial blood gas. Secondary objective was to compare the relative effects on heart rate, blood pressure, respiratory rate, comfort, and tolerance. RESULTS Patients in both protocols were comparable in terms of age, demographic, and physiologic variables including arterial blood gas, blood pressure, heart rate, respiratory rate, Glasgow Coma Score, sedation, and Acute Physiology and Chronic Health Evaluation (APACHE) III scores. There was no significant difference in gas exchange, respiratory rate, or hemodynamics. There was a significant difference (P = .01) in tolerance, with nasal prongs being well tolerated. There was a trend (P = .09) toward better patient comfort with HFNP. CONCLUSIONS High-flow nasal prongs are as effective as HFFM in delivering oxygen to extubated patients who require high-flow oxygen. The tolerance of HFNP was significantly better than in HFFM.

Stress hyperglycemia may not be harmful in critically ill patients with sepsis

BACKGROUND Stress hyperglycemia (SH) is commonly seen in critically ill patients. It has been shown to be associated with adverse outcomes in some groups of patients. The effects of SH on critically ill patients with sepsis have not been well studied. We aimed to evaluate the effects of SH in critically ill patients with sepsis. METHODS In this retrospective study, patients with sepsis admitted to intensive care unit (ICU) over a 5-year period were included. RESULTS Of 297 patients, 204 (68.7%) had SH during the study period. The mean blood glucose level in patients with SH was 8.7 mmol/L compared with 5.9 mmol/L in those without SH (P < .05). There were no statistically significant differences in age; sex; sepsis severity; cardiovascular, respiratory, and renal comorbidities; requirement of mechanical ventilation; inotropes; and Acute Physiology, Age, and Chronic Health Evaluation III and Simplified Acute Physiology 2 scores on ICU admission. Intensive care unit mortality was significantly lower in patients who had SH. The median duration of ICU and hospital length of stay was longer in patients with SH. On logistic regression analysis, the presence of SH was associated with reduced ICU mortality. Subgroup analysis revealed SH to be protective in patients with septic shock. CONCLUSION Stress hyperglycemia may not be harmful in critically ill patients with sepsis. Patients with SH had lower ICU mortality.

Diaphragmatic regional displacement assessed by ultrasound and correlated to subphrenic organ movement in the critically ill patients—an observational study

INTRODUCTION The objectives of the study are to identify the most reliably imaged regions of the diaphragm, to evaluate the correlation of movement between different parts of each hemidiaphragm, and to assess the agreement between liver or spleen displacement and movement of the ipsilateral hemidiaphragm. METHODS Images of the diaphragm, liver, and spleen were obtained using 2-dimensional ultrasound. Acceptable agreement between regions of the diaphragm, liver, and spleen was defined as an absence of fixed or proportional bias using Deming regression analysis and limits of agreement of 2 SDs of the difference less than 30% of the mean value. RESULTS We included 90 critically ill patients. The medial (87%) and middle (73%) regions of the right hemidiaphragm, liver (87.7%), and spleen (81%) and medial (71%) and middle regions (51%) of the left hemidiaphragm were most frequently imaged. In nonintubated patients, acceptable agreement was present for comparisons of the left middle and medial, right middle and medial, and left middle regions and spleen displacement. In intubated patients and in all patients when combined, acceptable agreement was only present for comparisons of the left middle and medial and right middle and medial regions of the diaphragm. Acceptable agreement was not present for intubated and all patients for diaphragmatic and solid organ movement. CONCLUSION The diaphragm medial part is visualized in the majority of studied patients. The medial and middle thirds may be used interchangeably to assess hemidiaphragm movement. Acceptable agreement does not exist for diaphragm and solid organ movement, other than for the left middle region and the spleen.

Severe Rhabdomyolysis due to Presumed Drug Interactions between Atorvastatin with Amlodipine and Ticagrelor

Atorvastatin and ticagrelor combination is a widely accepted therapy for secondary prevention of ischaemic heart disease. However, rhabdomyolysis is a well-known rare side effect of statins which should be considered when treatments are combined with cytochrome P450 3A4 enzyme inhibitors. We report a case of atorvastatin and ticagrelor associated severe rhabdomyolysis that progressed to multiorgan failure requiring renal replacement therapy, inotropes, intubation, and mechanical ventilation. Despite withdrawal of the precipitating cause and the supportive measures including renal replacement therapy, creatinine kinase increased due to ongoing rhabdomyolysis rapidly progressing to upper and lower limbs weakness. A muscle biopsy was performed to exclude myositis which confirmed extensive myonecrosis, consistent with statin associated rhabdomyolysis. After a prolonged ventilatory course in the intensive care unit, patients condition improved with recovery from renal and liver dysfunction. The patient slowly regained her upper and lower limb function; she was successfully weaned off the ventilator and was discharged for rehabilitation. To our knowledge, this is a second case of statin associated rhabdomyolysis due to interaction between atorvastatin and ticagrelor. However, our case differed in that the patient was also on amlodipine, which is considered to be a weak cytochrome P450 3A4 inhibitor and may have further potentiated myotoxicity.

Interpreting diaphragmatic movement with bedside imaging, review article

The diaphragm is the most important muscle of respiration. At equilibrium, the load imposed on the diaphragmatic muscles from transdiaphragmatic pressure balances the force generated by diaphragmatic muscles. However, procedural and nonprocedural thoracic and abdominal conditions may disrupt this equilibrium and impair diaphragmatic function. Diaphragmatic dysfunction is associated with respiratory insufficiency and poor outcome. Therefore, rapid diagnosis and early intervention may be useful. Ultrasound imaging provides quick and accurate bedside assessment of the diaphragm. Various imaging techniques have been suggested, using 2-dimensional and M-mode technology. Diaphragm viewing depends on the degree of robe movement, determined by the angle of incidence of the ultrasound beam and by the direction of probe movement. In this review, we will discuss the function of the diaphragm focusing on clinically important anatomical and physiological properties of the diaphragm. We will review the literature regarding various sonographic techniques for diaphragm assessment. We will also explore the evidence for the role of the tidal displacement of subdiaphragmatic organs as a surrogate for diaphragm movement.

Low-flow veno-venous extracorporeal carbon dioxide removal in the management of severe status asthmatics: a case report.

Status asthmaticus is a life‐threatening condition that requires intensive care management. Most of these patients have severe hypercapnic acidosis that requires lung protective mechanical ventilation. A small proportion of these patients do not respond to conventional lung protective mechanical ventilation or pharmacotherapy. Such patients have an increased mortality and morbidity. Successful use of extracorporeal membrane oxygenation (ECMO) is reported in such patients. However, the use of ECMO is invasive with its associated morbidity and is limited to specialised centres. In this report, we report the use of a novel, minimally invasive, low‐flow extracorporeal carbon dioxide removal device in management of severe hypercapnic acidosis in a patient with life threatening status asthmaticus.

A case of chronic inflammatory demyelinating polyneuropathy with reversible alternating diaphragmatic paralysis: case study

Respiratory failure requiring mechanical ventilation has been reported in patients with bilateral diaphragmatic paralysis due to CIDP. We report a case of CIDP that progressed to respiratory failure with normal chest radiography despite unilateral diaphragmatic paralysis. This manifestation would have been missed if ultrasound was not employed.

Sonographic evaluation of the diaphragm morphology and function in the critically ill

Diaphragmatic dysfunction is associated with adverse events and outcome. Respiratory insufficiency, hypoxia, prolonged mechanical ventilation, and longer hospital length of stay (1,2) have been reported. Diaphragm disuse and atrophy begins early in mechanically ventilated patients (3). Although the aetiology is poorly defined, myofibril and mitochondrial disruption have been suggested in animal literature (4). Surface ultrasound is a feasible, rapid and a reproducible tool for assessing diaphragmatic function and may be the method of choice for investigating diaphragmatic kinetics (5). But the inability to obtain images in some patients due to anatomical, pathologic, and technical reasons remains a major limitation.

Lung Ultrasound in Anaesthesia and Critical Care Medicine

Lung ultrasound (respiratory or thoracic ultrasound) has traditionally been used for evaluation and guidance of drainage of pleural effusion, where it has been shown to reduce iatrogenic injuries from intercostal catheter insertion into adjacent organs. Only recently has its use in bedside diagnosis of respiratory disease become popular. Lung ultrasound is more accurate than chest radiography and approaches the accuracy of computed tomography in diagnosis of pleural effusion, pneumothorax, pulmonary oedema, consolidation and collapse, abscess, emphysema, and even pulmonary embolus. Improved accuracy and speed of diagnosis may also reduce the need for chest radiography and CT, reducing exposure of patients and staff to ionising radiation and the requirement to transport the critically ill. This useful technique is becoming incorporated into clinical practice and training in emergency and critical care medicine, where it has been shown to be effective in rapid diagnosis of the cause of respiratory distress. Additional potential uses for in anaesthetic practice include preoperative assessment in patients with dyspnoea, and rapid assessment of respiratory failure that may occur intra or postoperatively, for example from pneumothorax, acute pulmonary oedema and massive atelectasis or consolidation. Rapid bedside exclusion of pneumothorax may be useful after insertion of central line or paravertebral catheter, or prior to or during mechanical ventilation. There is also an emerging role of lung ultrasound in guidance of endotracheal and subglottic airway management. Lung ultrasound is relatively easy to learn using portable ultrasound machines and can be integrated into routine clinical ‘ultrasound-assisted examination’.