Association of ROX Index with Mechanical Ventilator Use in Sepsis Patients in the Emergency Department

Detecting sepsis patients who are at a high-risk of mechanical ventilation is important in emergency departments (ED). The respiratory rate oxygenation (ROX) index is the ratio of tissue oxygen saturation/fraction of inspired oxygen to the respiratory rate. This study aimed to investigate whether the ROX index could predict mechanical ventilator use in sepsis patients in an ED. This retrospective observational study included quick sequential organ failure assessment (qSOFA) ≥ 2 sepsis patients that presented to the ED between September 2019 and April 2020. The ROX and ROX-heart rate (HR) indices were significantly lower in patients with mechanical ventilator use within 24 h than in those without the use of a mechanical ventilator (4.0 [3.2–5.4] vs. 10.0 [5.9–15.2], p < 0.001 and 3.9 [2.7–5.8] vs. 10.1 [5.4–16.3], p < 0.001, respectively). The area under the receiver operating characteristic (ROC) curve of the ROX and ROX-HR indices were 0.854 and 0.816 (both p < 0.001). The ROX and ROX-HR indices were independently associated with mechanical ventilator use within 24 h (adjusted hazard ratio = 0.78, 95% CI: 0.68–0.90, p < 0.001 and adjusted hazard ratio = 0.87, 95% CI 0.79–0.96, p = 0.004, respectively). The 28-day mortality was higher in the low ROX and low ROX-HR groups. The ROX and ROX-HR indices were associated with mechanical ventilator use within 24 h in qSOFA ≥ 2 patients in the ED.

Clinical impact of pneumothorax in patients with Pneumocystis jirovecii pneumonia and respiratory failure in an HIV-negative cohort

Background Pneumocystis jirovecii pneumonia (PCP) with acute respiratory failure can result in development of pneumothorax during treatment. This study aimed to identify the incidence and related factors of pneumothorax in patients with PCP and acute respiratory failure and to analyze their prognosis. Methods We retrospectively reviewed the occurrence of pneumothorax, including clinical characteristics and results of other examinations, in 119 non-human immunodeficiency virus patients with PCP and respiratory failure requiring mechanical ventilator treatment in a medical intensive care unit (ICU) at a tertiary-care center between July 2016 and April 2019. Results During follow up duration, twenty-two patients (18.5%) developed pneumothorax during ventilator treatment, with 45 (37.8%) eventually requiring a tracheostomy due to weaning failure. Cytomegalovirus co-infection (odds ratio 13.9; p = 0.013) was related with occurrence of pneumothorax in multivariate analysis. And development of pneumothorax was not associated with need for tracheostomy and mortality. Furthermore, analysis of survivor after 28 days in ICU, patients without pneumothorax were significantly more successful in weaning from mechanical ventilator than the patients with pneumothorax (44% vs. 13.3%, p = 0.037). PCP patients without pneumothorax showed successful home discharges compared to those who without pneumothorax (p = 0.010). Conclusions The development of pneumothorax increased in PCP patient with cytomegalovirus co-infection, pneumothorax might have difficulty in and prolonged weaning from mechanical ventilators, which clinicians should be aware of when planning treatment for such patients.

Effects of Changes in Inspiratory Time on Inspiratory Flowrate and Airway Pressure during Cardiopulmonary Resuscitation: A Manikin-Based Study

Objectives: Given that cardiopulmonary resuscitation (CPR) is an aerosol-generating procedure, it is necessary to use a mechanical ventilator and reduce the number of providers involved in resuscitation for in-hospital cardiac arrest in coronavirus disease (COVID-19) patients or suspected COVID-19 patients. However, no study assessed the effect of changes in inspiratory time on flowrate and airway pressure during CPR. We herein aimed to determine changes in these parameters during CPR and identify appropriate ventilator management for adults during CPR.Methods: We measured changes in tidal volume (Vt), peak inspiratory flow rate (PIFR), peak airway pressure (Ppeak), mean airway pressure (Pmean) according to changes in inspiratory time (0.75 s, 1.0 s and 1.5 s) with or without CPR. Vt of 500 mL was supplied (flowrate: 10 times/min) using a mechanical ventilator. Chest compressions were maintained at constant compression depth (53 ± 2 mm) and speed (102 ± 2/min) using a mechanical chest compression device.Results: Median levels of respiratory physiological parameters during CPR were significantly different according to the inspiratory time (0.75 s vs. 1.5 s): PIFR (80.8 [73.3 – 87.325] vs. 70.5 [67 – 72.4] L/min, P < 0.001), Ppeak (54 [48 – 59] vs. 47 [45 – 49] cmH₂O, P < 0.001), and Pmean (3.9 [3.6 – 4.1] vs. 5.7 [5.6 – 5.8] cmH₂O, P < 0.001).Conclusions: Changes in PIFR, Ppeak, and Pmean were associated with inspiratory time. PIFR and Ppeak values tended to decrease with increase in inspiratory time, while Pmean showed a contrasting trend. Increased inspiratory time in low-compliance cardiac arrest patients will help in reducing lung injury during adult CPR.

Hemophagocytosis, hyper-inflammatory responses, and multiple organ damages in COVID-19-associated hyperferritinemia

Hyperferritinemia comes to light frequently in general practice. However, the characteristics of COVID-19-associated hyperferritinemia and the relationship with the prognosis were not well described. The retrospective study included 268 documented COVID-19 patients. They were divided into the hyperferritinemia group (≥ 500 µg/L) and the non-hyperferritinemia group (< 500 µg/L). The prevalence of fever and thrombocytopenia and the proportion of patients with mechanical ventilator support and in-hospital death were much higher in the hyperferritinemia group (P < 0.001). The hyperferritinemia patients showed higher median IL-6, D-dimer, and hsCRP (P < 0.001) and lowered FIB level (P = 0.036). The hyperferritinemia group had a higher proportion of patients with AKI, ARDS, and CSAC (P < 0.001). According to the multivariate analysis, age, chronic pulmonary disease, and hyperferritinemia were found to be significant independent predictors for in-hospital mortality [HR 1.041 (95% CI 1.015–1.068), P = 0.002; HR 0.427 (95% CI 0.206–0.882), P = 0.022; HR 6.176 (95% CI 2.447–15.587), P < 0.001, respectively]. The AUROC curve was 0.88, with a cut-off value of ≥ 971 µg/L. COVID-19 patients with hyperferritinemia had a high proportion of organ dysfunction, were more likely to show hyper-inflammation, progressed to hemophagocytic lymphohistiocytosis, and indicated a higher proportion of death.

Should Vitamin D Supplements be Used as Adjunct Treatment for COVID-19: A Rapid Review

Background. Pooled data from observational studies suggest that patients with serum vitamin D levels below 30 ng/mL had an increased risk of infection and mortality from COVID-19. This rapid review aimed to determine the efficacy and safety of vitamin D as an adjunct treatment for COVID-19. Methods. We searched MEDLINE (PubMed) and CENTRAL up to July 18, 2021. We also searched trial registries, gray literature, and reference lists of included and excluded studies in the search as well as COVID-19 guidelines. Two reviewers independently screened titles and abstracts, collected data, and assessed for risk of bias. Meta-analysis was conducted, and an evidence profile table using GRADEpro was generated. Outcomes included were mortality, need for mechanical ventilator or progression of oxygen support, duration of mechanical ventilation, ICU admission, hospital length of stay, SARS-CoV-2 positivity at day 21, and adverse events. Results. We found four RCTs (3 low risk of bias and 1 high risk of bias). The sources of bias among the RCTs were unclear allocation, lack of blinding of patients, caregivers, and outcome assessors, and high drop-out rate. This rapid review found that the effects of vitamin D are inconclusive for the following outcomes: mortality (pooled RR 0.62, 95% CI [0.16 to 2.41], I2=49%; n=443, 3 RCTs, very low certainty of evidence), need for mechanical ventilator or progression of oxygen support (RR 0.52, 95% CI [0.24 to 1.13], n=237, 1 RCT, low certainty of evidence), and ICU admission (pooled RR 0.37, 95% CI [0.09 to 1.61], I2=78%; n=443, 3 RCTs, very low certainty of evidence. No significant reduction in hospital length of stay was found among those treated with vitamin D (MD 0 days, 95% CI [-1.19 to 1.09], low certainty of evidence). The duration of mechanical ventilation was also was also not significantly shortened in the treatment group (15 days) compared with placebo (12.8 days), MD 2.2 days, 95% CI [-8.4 to 12.8], low certainty of evidence. Interestingly, a higher proportion of those supplemented with vitamin D showed virologic clearance for COVID-19 on day 21 (RR 3.0, 95% CI [1.26 to 7.14], n=40, 1 RCT). At dosages between 60,000 to 200,000 IU of cholecalciferol, only one episode of vomiting (0.8%) was reported. Conclusion. Based on the evidence found, we are uncertain whether vitamin D is beneficial or harmful for patients with COVID-19. There is very low certainty of evidence to recommend the use of vitamin D supplements as an adjunct treatment for patients with COVID-19. Vitamin D supplementation for patients with COVID-19 should be limited to clinical trials or among those with proven vitamin D deficiency. More published studies are awaited to explore the benefit or harm of vitamin D for COVID-19.

Massive Pleural Effusion as a Rare Manifestation in Severe Neonatal Sepsis

BACKGROUND: Neonatal sepsis can be severe and has mortality rate. The pleural effusion is a rare sign of severe sepsis in newborn and only few studies that reported it. CASE PRESENTATION: We report a case of newborn who referred to our hospital because of dependent mechanical ventilator and severe sepsis. We found a massive pleural effusion and did the pleural drainage. After the drainage, the baby was extubate and discharge well with no signs of respiratory distress. CONCLUSION: Massive pleural effusion might be considered as a cause of dependent ventilator in severe neonatal sepsis.