Background
Ultrasound (US) examination of the eye can be used to detect and monitor elevated intracranial pressure (ICP) and its consequences. Elevated ICP is transmitted to the contiguous optic ...nerve and its sheath (dura mater), thus underlying the development of papilledema and a widened sheath diameter. The US measurement of the optic nerve sheath diameter (ONSD) has previously been validated to diagnose and monitor raised ICP. The occurrence of vitreous hemorrhage in association with subarachnoid hemorrhage (SAH)—i.e., Terson syndrome—can also be easily diagnosed using ophthalmic US. Because of its relevance in anesthesia and critical care, we describe how to perform the technique illustrated by two cases.
Case presentations
A 72-yr-old man with hydrocephalus secondary to a SAH developed raised ICP following the removal of an external ventricular drainage (EVD) system. Daily ONSD measurements using handheld US allowed us to diagnose and monitor the progression and resolution of the intracranial hypertension following the placement of a second EVD system. We also describe the steps used to obtain ONSD measurements during the ophthalmic US examination of a 53-yr-old woman who presented with a stage IV SAH with concomitant bilateral vitreous hemorrhages or Terson syndrome.
Conclusion
Ophthalmic US using a handheld device to measure and monitor ONSD at the bedside is useful in diagnosing and monitoring the progression of intracranial hypertension following EVD removal in a patient with hydrocephalus secondary to SAH. Ophthalmic US can also be used to identify concomitant vitreous hemorrhage that is associated with a worse prognosis.
Pulmonary complications are the most common clinical manifestations of coronavirus disease (COVID-19). From recent clinical observation, two phenotypes have emerged: a low elastance or L-type and a ...high elastance or H-type. Clinical presentation, pathophysiology, pulmonary mechanics, radiological and ultrasound findings of these two phenotypes are different. Consequently, the therapeutic approach also varies between the two. We propose a management algorithm that combines the respiratory rate and oxygenation index with bedside lung ultrasound examination and monitoring that could help determine earlier the requirement for intubation and other surveillance of COVID-19 patients with respiratory failure.
To prospectively compare three methods of apnea testing for the confirmation of brain death.
Prospective, randomized, crossover study.
Intensive care unit of a tertiary care university hospital.
...Twenty adult patients requiring apnea testing for confirmation of brain death.
Ten minute apnea testing was repeated in random order for every patient with the three oxygenation systems: oxygen catheter inserted through the endotracheal tube (oxygen 6 L/min), T-piece system (oxygen 12 L/min), and continuous positive airway pressure (CPAP) system 10 cm H2O (oxygen 12 L/min).
Arterial blood was drawn at 0, 2, 5, and 10 mins of each test. Compared with baseline, Paco2 increased by 30.6 +/- 7.4, 30.0 +/- 7.3 and 30.2 +/- 7.5 mm Hg during the apnea period (p = .96), reaching 73.3 +/- 8.3, 71.6 +/- 11.1, and 72.7 +/- 9.0 mm Hg at the end of the apnea test (p = .73) for the oxygen catheter, the T-piece, and the CPAP, respectively. Pao2 decreased less with the CPAP compared with the oxygen catheter or the T-piece (-22.4 +/- 76, -99.1 +/- 158, and -91.6 +/- 133 mm Hg, respectively, p < .01). In two patients, apnea testing could not be completed with the oxygen catheter and the T-piece because of desaturation, although it could be completed with the CPAP.
The T-piece and the CPAP systems are effective alternatives to the standard oxygen catheter technique for apnea testing. Oxygenation was best maintained with the CPAP system, which can be useful in some patients.
Abstract Background Heparin-induced thrombocytopenia (HIT) is commonly considered but rarely confirmed in critically ill patients. The 4Ts score ( T hrombocytopenia, T iming of thrombocytopenia, T ...hrombosis, and o T her reason) might identify individual patients at risk of having this disorder. Objective The aim of the study was to evaluate the value of the 4Ts HIT score in comparison with the serotonin-release assay (SRA) in critically ill patients. Methods This study describes the combined results of 3 prospective studies enrolling critically ill patients who were investigated for HIT if platelets fell to less than 50 × 109 /L or if platelet counts decreased to less than 50% of the value upon intensive care unit admission. We confirmed HIT by a positive platelet SRA. We assigned a 4Ts score blinded to SRA results to all 50 patients investigated for HIT; those with positive SRA results were scored in duplicate. Results Of 528 patients, 50 (9.5%) were investigated for HIT; 39 (78%) of 50 (64%-88%) of these patients were scored as “low probability” by 4Ts score and none had a positive SRA. Of 49 patients who underwent SRA testing because of thrombocytopenia, only 2 (4.1%; 0.5-14.0) had a positive SRA (1 with a moderate 4Ts score and 1 with a high 4Ts score). Therefore, the overall incidence of HIT confirmed by SRA was 2 (0.4%) of 528 (0.04%-1.4%). Conclusions Significant thrombocytopenia during heparin administration occurred in 9.5% of critically ill patients, but HIT was confirmed in only 4.1% of those undergoing testing, for an overall incidence of 0.4%. A low 4Ts score occurred in 78% of patients investigated for HIT; none of these patients had a positive SRA. We conclude that HIT is uncommon in critically ill patients and that the 4Ts score is worthy of further evaluation in this patient population.
Diaphragmatic plication to help ventilation weaning of an adult obese patient after cardiac surgery is very uncommon. Diaphragm paralysis is usually treated with conservative measures and ventilator ...support, after which surgical management is considered after months of medical monitoring.
We report the case of a morbidly obese patient to whom ventilation weaning was unsuccessful following coronary artery bypass graft operation with mitral valve replacement. A de novo right hemidiaphragm elevation was seen on the chest X-ray. Diaphragmatic plication was performed promptly to treat severe respiratory insufficiency and generated favorable outcomes.
Early diaphragmatic plication could be considered in the postoperative period of cardiothoracic surgery to facilitate management and ventilation weaning in the context of de novo diaphragm paralysis.
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