[신간의 별자리x] 우리/미술, 그리고 ‘슬픔의 박물관’

Executive Summary Introduction Methodology Used to Prepare the Guideline Epidemiology Incidence Etiology Major Epidemiologic Points Pathogenesis Major Points for Pathogenesis Modifiable Risk Factors Intubation and Mechanical Ventilation Aspiration, Body Position, and Enteral Feeding Modulation of Colonization: Oral Antiseptics and Antibiotics Stress Bleeding Prophylaxis, Transfusion, and Glucose Control Major Points and Recommendations for Modifiable Risk Factors Diagnostic Testing Major Points and Recommendations for Diagnosis Diagnostic Strategies and Approaches Clinical Strategy Bacteriologic Strategy Recommended Diagnostic Strategy Major Points and Recommendations for Comparing Diagnostic Strategies Antibiotic Treatment of Hospital-acquired Pneumonia General Approach Initial Empiric Antibiotic Therapy Appropriate Antibiotic Selection and Adequate Dosing Local Instillation and Aerosolized Antibiotics Combination versus Monotherapy Duration of Therapy Major Points and Recommendations for Optimal Antibiotic Therapy Specific Antibiotic Regimens Antibiotic Heterogeneity and Antibiotic Cycling Response to Therapy Modification of Empiric Antibiotic Regimens Defining the Normal Pattern of Resolution Reasons for Deterioration or Nonresolution Evaluation of the Nonresponding Patient Major Points and Recommendations for Assessing Response to Therapy Suggested Performance Indicators

Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia the official statement of the American Thoracic Society and the Infectious Disease Society of America (特集 救急診療ガイドライン) -- (海外のガイドライン)

The "very old intensive care patients" (abbreviated to VOPs; greater than 80 years old) are probably the fastest expanding subgroup of all intensive care unit (ICU) patients. Up until recently most ICU physicians have been reluctant to admit these VOPs. The general consensus was that there was little survival to gain and the incremental life expectancy of ICU admission was considered too small. Several publications have questioned this belief, but others have confirmed the poor long-term mortality rates in VOPs. More appropriate triage (resource limitation enforced decisions), admission decisions based on shared decision-making and improved prediction models are also needed for this particular patient group. Here, an expert panel proposes a research agenda for VOPs for the coming years.

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The status of intensive care medicine research and a future agenda for very old patients in the ICU

Extrahepatic manifestations of chronic hepatitis C.

Background:Different modes of death are described in selected populations, but few data report the characteristics of death in a general intensive care unit population. This study analyzed the causes and characteristics of death of critically ill patients and compared anticipated death patients to u

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Causes and Characteristics of Death in Intensive Care Units: A Prospective Multicenter Study.

Echocardiography and the N-terminal pro-brain-type natriuretic peptide (NT-proBNP) level are important tests for assessing left ventricular function in patients presenting to the emergency department with acute dyspnea. Chest ultrasound is becoming an important tool in diagnosing acute pulmonary edema. To assess the diagnostic accuracy of chest ultrasound examination using echocardiography and a curvilinear probe for detecting B-lines in patients presenting with acute pulmonary edema compared with assessment using NT-proBNP. This paper reports a prospective observational study of 61 consecutive patients presenting with symptoms and signs of pulmonary edema and B-profile detected by echocardiography with a 5 MHz curvilinear probe. The emergency department physicians ordered NT-proBNP levels, and critical care physicians trained in ultrasound examination performed echocardiography and chest ultrasounds. The findings of the chest ultrasound were reviewed by another senior physician. Sixty-one participants were enrolled over a period of 6 months (49.2 % male, with a mean age 66.8). Forty-seven of the 61 patients had a B-profile. The median NT-proBNP level in the patients with B-profile was 6200, compared with the mean level in the patients with an A-profile of 180 (CI 0.33–0.82). The distributions in the two groups differed significantly (p = 0.034). Based on a threshold level of NT-proBNP in relation to age, the sensitivity and specificity (including the 95 % confidence interval) were determined; the sensitivity of finding B-profile on ultrasound was 92.0 %, and the specificity was 91.0 %. The positive predictive value of the B-profile was 97.0 %, and the negative predictive value was 71.0 %. The systolic function in the subjects with a B-profile was below 50 in 84.3 % of the subjects and normal in 15.7 % of the subjects. An A-profile was present in all of the subjects with systolic function >55 %. In the subjects with a B-profile, 94 % had a Framingham score of CHF >4; the subjects with all A-profile had scores 3 in 96 % of the subjects with a B-profile, and all of the subjects with an A-profile had scores <3 (p < 0.0001). Detecting the B-profile with an echocardiography probe (curvilinear 5 MHz) in lung ultrasound is highly sensitive and specific for elevated NT-proBNP helping in diagnosing pulmonary edema, although of resolution inferior to micro convex probes.

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Sonographic chest B-lines anticipate elevated B-type natriuretic peptide level, irrespective of ejection fraction

A case of ST elevation myocardial infarction reported post Coronavirus disease 2019 (COVID-19) vaccine. Probably premature to draw a link between COVID-19 vaccine and myocardial infarction.

Myocardial infarction post COVID-19 vaccine - coincidence, Kounis syndrome or other explanation - time will tell.

Background and aims Chest radiography (CXR) and computerized tomography (CT) scan are the preferred methods for lung imaging in diagnosing pneumonia in the intensive care unit, in spite of their limitations. The aim of this study was to assess the performance of bedside lung ultrasound examination by a critical care physician, compared with CXR and chest CT, in the diagnosis of acute pneumonia in the ICU. Materials and methods This was an observational, prospective, single-center study conducted in the intensive care unit of Ahmadi General Hospital. Lung ultrasound examinations (LUSs) were performed by trained critical care physicians, and a chest radiograph was interpreted by another critical care physician blinded to the LUS results. CT scans were obtained when clinically indicated by the senior physician. Results Out of 92 patients with suspected pneumonia, 73 (79.3%) were confirmed to have a diagnosis of pneumonia based on radiological reports, clinical progress, inflammatory markers, and microbiology studies. Of the 73 patients, 31 (42.5%) were male, with a mean age of 68.3 years, and a range of 27 to 94 years. Eleven (15%) patients had community-acquired pneumonia, and 62 (85%) had hospital-acquired pneumonia. In the group of patients with confirmed pneumonia, 72 (98.6%) had LUSs positive for consolidation (sensitivity 98.6%, 95% CI 92.60%-99.97%), and in the group without pneumonia, 16 (85%) had LUS negative for consolidation (specificity 84.2%, 95% CI 60.42%-96.62%), compared with 40 (55%) with CXRs positive for consolidation (sensitivity 54.8%, 95% CI 42.70%-66.48%) and 33 (45%) with CXRs negative for consolidation (specificity 63.16%, 95% CI 38.36%-83.71%).A chest CT was performed in 38 of the 92 enrolled patients and was diagnostic for pneumonia in 32 cases. LUSs were positive in 31 of 32 patients with CT-confirmed pneumonia (sensitivity 96%), and CXR was positive in 5 of 32 patients with CT-confirmed pneumonia (sensitivity 15.6%). Conclusion Bedside lung ultrasound is a reliable and accurate tool that appears to be superior to CXR for diagnosing pneumonia in the ICU setting. LUS allows for a faster, non-invasive, and radiation-free method to diagnose pneumonia in the ICU.

https://www.onlinelibrary.wiley.com/doi/pdf/10.1002/hsr2.102

Diagnostic accuracy of chest ultrasound in patients with pneumonia in the intensive care unit: A single-hospital study.

Direct-acting oral anticoagulants (DOACs) are used to prevent and treat systemic and cerebral embolisms in patients with non-valvular atrial fibrillation (NV-AF). The use of DOACs with herbal products without consulting healthcare professionals increases the possibility of drug–herb interactions and their adverse effects. An 80-year-old man on dabigatran with a known history of NV-AF presented with a 1-day history of haematemesis and black stool which began 3 days after he had started taking a boiled mixture of ginger and cinnamon. The patient was hypotensive and treated as a case of gastrointestinal bleeding and haemorrhagic shock. Despite continuous aggressive resuscitation measures including administration of a reversal agent for dabigatran, we were unable to control bleeding and the patient died within 24 hours. The interaction of ginger and cinnamon with dabigatran led to fatal bleeding.

LEARNING POINTS

Direct-acting oral anticoagulants (DOACs) are frequently prescribed for patients with non-valvular atrial fibrillation.


Combining herbal products (ginger and cinnamon) with DOACs can be fatal.


Physicians should alert patients and caregivers about dangerous combinations and interactions.





Keywords: Ginger, cinnamon, dabigatran


INTRODUCTION
In January 2019, the American Heart Association/American College of Cardiology/Heart Rhythm Society (AHA/ACC/HRS) recommended direct-acting oral anticoagulants (DOACs) rather than warfarin in patients with non-valvular atrial fibrillation (NV-AF)[1].

The use of herbal products has become increasingly popular, especially in combination with conventional medicines and usually without the advice of a healthcare professional[2,3]. However, it is difficult to predict the pharmacokinetic and/or pharmacodynamic interactions when herbal products, such as ginger and cinnamon, are combined with DOACs. Here we present a case where self-administration of ginger and cinnamon together with dabigatran in an 80-year-old man caused fatal bleeding.

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Adding Herbal Products to Direct-Acting Oral Anticoagulants Can Be Fatal.

BACKGROUND There is scarce literature on point-of-care ultrasound (POCUS) assessment characteristics in coronavirus disease 2019 (COVID-19) pneumonia with hypoxic respiratory failure. METHODS This study was an observational, prospective, single-center study, including adults suspected to have COVID-19 who were transferred to the intensive care unit (ICU). An intensivist in critical care ultrasound performed lung ultrasound (LUS) and echocardiology within 12 hours of patients' admission to the ICU. We calculated the trans mitral E/A ratio, E/e', left ventricular ejection fraction (EF), inferior vena cava (IVC) diameter, right ventricle (RV) size and systolic function. RESULTS In the group of patients with confirmed COVID-19 pneumonia, echocardiographic findings revealed normal E/e', deceleration time (DT), and transmittal E/A ratio compared to those in the non-COVID-19 patients (p = 0.001, 0.0001, and 0.0001, respectively). IVC diameter was 50% collapsibility in 62 (81%) patients with COVID-19 pneumonia; a diameter of > 2 cm and < 50% collapsibility was detected among those with non-COVID-19 pneumonia (p-value of 0.001). In patients with COVID-19 pneumonia, there were 3 cases of myocarditis (3.9%) with poor EF, severe RV systolic dysfunction was seen in 9 cases (11.6%), and 3 cases exhibited RV thrombus. Lung US revealed 4 signs suggestive of COVID-19 pneumonia in 77 patients (98.6%) (sensitivity 96.9%; confidence interval, 85%-99.5%) when compared with reverse transcriptase-polymerase chain reaction results. CONCLUSIONS POCUS plays an important role in the bedside diagnosis, hemodynamic assessment and management of patients with acute hypoxic respiratory and circulatory failure with COVID-19 pneumonia.

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Ossama Sajeh Maadarani

Papers

Sonographic chest B-lines anticipate elevated B-type natriuretic peptide level, irrespective of ejection fraction

Myocardial infarction post COVID-19 vaccine - coincidence, Kounis syndrome or other explanation - time will tell.

Diagnostic accuracy of chest ultrasound in patients with pneumonia in the intensive care unit: A single-hospital study.

Adding Herbal Products to Direct-Acting Oral Anticoagulants Can Be Fatal.

Point-of-Care Ultrasound for COVID-19 Pneumonia Patients in the ICU