Critical care explorations
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Previous studies demonstrated that extensive fluid loading and consequently positive fluid balances during sepsis resuscitation are associated with adverse outcome. Yet, the association between fluid balance and mortality after reversal of shock, that is, during deresuscitation, is largely unappreciated. Our objective was to investigate the effects of fluid balance on mortality in the days after septic shock reversal. ⋯ A higher fluid balance in the days after septic shock reversal was associated with increased mortality. This stresses the importance of implementing restrictive and deresuscitative fluid management strategies after initial hemodynamic resuscitation. Prospective interventional studies are needed to confirm our results.
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Although significant disease burden in the severe acute respiratory syndrome coronavirus 2 pandemic has been relatively uncommon in children, worldwide cases of a postinfectious multisystem inflammatory syndrome in children and possible atypical Kawasaki-like disease attributing to severe acute respiratory syndrome coronavirus 2 infection have arisen. Original thinking for coronavirus disease-19 disease was that an overwhelming proinflammatory response drove disease pathogenesis. ⋯ Recently reported data on children with multisystem inflammatory syndrome in children have demonstrated a heterogeneity of immune phenotypes among these patients, with concern for a strong initial proinflammatory state; however, data are lacking to support this. Likewise, understanding development of certain clinical findings to changes in the immune system is lacking.
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During training, fellows serve as teachers and role models for junior colleagues. Fellows-as-teachers curricula may support these roles, but little is known about their effectiveness and durability. We sought to measure the long-term effects on ICU rounds after administering fellows-as-teachers workshops.
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Limited evidence is available regarding the role of high-flow nasal oxygen in the management of acute hypoxemic respiratory failure secondary to coronavirus disease 2019. Our objective was to characterize outcomes associated with high-flow nasal oxygen use in critically ill adult patients with coronavirus disease 2019-associated acute hypoxemic respiratory failure. ⋯ We observed an overall high usage of high-flow nasal oxygen in our cohort of critically ill patients with acute hypoxemic respiratory failure secondary to coronavirus disease 2019. Rates of endotracheal intubation and mortality in this cohort were on par with and certainly not higher than other published series. These findings should prompt further considerations regarding the use of high-flow nasal oxygen in the management algorithm for coronavirus disease 2019-associated acute hypoxemic respiratory failure.
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Case Reports
Rescue of Nimodipine-Induced Refractory Vasoplegia With Hydroxocobalamin in Subarachnoid Hemorrhage: A Case Report.
We report a case of refractory vasoplegia after nimodipine administration that was unresponsive to triple vasopressor therapy and was rescued by IV hydroxocobalamin. ⋯ Nimodipine administration is a standard practice for patients with aneurysmal subarachnoid hemorrhage to reduce unfavorable outcomes from cerebral vasospasm. Although mild hypotension is a common side effect of nimodipine, in rare cases, it may become profound, leading to refractory vasoplegia. There is no evidence-base for reversal agents for nimodipine-induced vasoplegia, and this case is the first to demonstrate successful use of hydroxocobalamin as a potential rescue therapy. We also propose an algorithm for treatment of vasoplegia with consideration of medications that act on nitric oxide-mediated vasodilation and their side-effect profiles.