Critically ill COVID-19 patients attended by anesthesiologists in northwestern Spain: a multicenter prospective observational study

BACKGROUND AND OBJECTIVES

There are limited information on outcome, complications and treatments of critically ill COVID-19 patients requiring admission to an intensive care unit (ICU). The aim of this study is to describe the clinical ICU course, treatments used, complications and outcomes, of critically ill COVID-19 patients admitted in seven ICU in Galicia region during the 2020 March-April pandemic peak.

METHODS

Between March 21 and April 19, 2020, we evaluated critically ill COVID-19 patients admitted to the ICU of Anesthesia of seven hospitals in Galicia, northwestern Spain. Outcome, complications, and treatments were monitored until May 6, 2020, the final date of follow-up.

RESULTS

A total of 97 critically ill COVID-19 patients were included. During ICU stay, mechanical ventilation became necessary in 80 (82.5%) patients, and tracheostomy in 22 (22.7%) patients. Prone position was used frequently in both intubated (67.5%) and awake (27.8%) patients. Medications consisted of antivirals agents (92.7%), corticosteroids (93.8%), tocilizumab (57.7%), and intermediate or high doses of anticoagulants (83.5%). The most frequent complications were ICU-acquired infection (52.6%), thrombosis events (16.5%), and reintubation (9.3%). After a median follow-up of 42 (34-45) days, 15 patients (15.5%) deceased, 73 patients (75.2%) had been discharged from ICU, and nine patients (9.3%) were still in the ICU.

CONCLUSIONS

A high proportion of our critically ill COVID-19 patients required mechanical ventilation, prone positioning, antiviral medication, corticosteroids, and anticoagulants. ICU complications were frequent, mainly infections and thrombotic events. We had a relatively low mortality of 15,5%.

Endogenous bacterial endophthalmitis. A report of 2cases

CLINICAL CASES

The cases are presented on 2patients with bacterial endogenous endophthalmitis. The first one was caused by Streptococcus bovis, developed after colonoscopy, which had a poor outcome and resulted in evisceration. The second case was caused by a methicillin resistant Staphylococcus aureus from an arthrodesis complicated with a para-spinal abscess. It had an excellent visual outcome.

DISCUSSION

Bacterial endogenous endophthalmitis is a rare, but serious ocular disease that occurs when bacteria reach the eye via the bloodstream. It requires a very early diagnosis based on the clinical symptoms and patient history. A suitable and specific treatment with intravenous and intravitreal antibiotics may prevent a bad visual prognosis in some cases.

Inflammatory responses and side effects generated by several adjuvant-containing vaccines in turbot

Several of the adjuvants used in fish vaccines cause adhesions in internal organs when they are injected intraperitoneally. We describe the damage caused by vaccines containing different adjuvants in the turbot Scophthalmus maximus and show that internal adhesions can be greatly reduced by injecting the fish in a specific way. Injection of fish with the needle directed towards the anterior part of the peritoneal cavity induced formation of a single cell-vaccine mass (CVM) that became attached to the parietal peritoneum. However, injection of the fish with the needle pointing in the opposite direction generated many small CVM that became attached to the visceral and parietal peritoneum and in some cases caused internal adhesions. We describe the structural and cellular changes in the adjuvant-induced CVMs. The CVMs mainly comprised neutrophils and macrophages, although most of the former underwent apoptosis, which was particularly evident from day 3 post-injection. The apoptotic cells were phagocytosed by macrophages, which were the dominant cell type from the first days onwards. All of the vaccines induced angiogenesis in the area of contact between the CVM and the mesothelium. Vaccines containing oil-based adjuvants or microspheres induced the formation of granulomas in the CVM; however, no granulomas were observed in the CVM induced by vaccines containing aluminium hydroxide or Matrix-Q(®) as adjuvants. All of the vaccines induced strong migration of cells to the peritoneal cavity. Although some of these cells remained unattached in the peritoneal cavity, most of them formed part of the CVM. We also observed migration of the cells from the peritoneal cavity to lymphoid organs, indicating bidirectional traffic of cells between the inflamed areas and these organs.

Effects of bonuses for punctuality on the tardiness of industrial workers

This study evaluated the effectiveness of an incentive procedure designed to increase the punctuality of six workers who were chronically late to work in a manufacturing company. The six workers in the experiment received a 2.00 pesos ($0.16 U.S.) bonus for every day that they arrived on time. A reversal design was used. The contingent bonuses increased the workers' rates of punctuality compared to their baseline rates. A control group of six workers observed during the same 77-week period showed a trend toward decreasing punctuality. These results suggest that the use of small daily bonuses is a practical procedure for modifying chronic tardiness among industrial workers.

[Is morphine still the analgesic of choice in acute myocardial infarction?]

Chest pain is the most common symptom of patients who present with ischemic heart disease. Morphine has traditionally been the drug of choice for managing chest pain in acute coronary syndrome (ACS) due to its high analgesic potency, though its physiological effects are poorly understood. Routinely used for managing chest pain, morphine is recommended in the 2002 guidelines of the American College of Cardiology/American Heart Association. This recommendation, however, is not based on a high level of scientific evidence but on expert opinion. Studies have found both for and against the use of morphine in ACS, suggesting that its benefits are perhaps not altogether clear. This review examines the pathophysiological effects of morphine and their cardiac implications, with special attention to a possible negative effect on ACS. We reviewed articles in the MEDLINE database from 1982 to 2006.

[Retinal cholesterol embolization after coronary angiography]

CASE REPORT

We report a patient with multiple cholesterol retinal embolism in both eyes following coronary angiography. She also had associated renal, skin and cardiac manifestations of the Cholesterol Embolization Syndrome (CES) and died 10 weeks later. Autopsy revealed cholesterol crystal emboli in several organs.

DISCUSSION

Atheromatous plaques can be ruptured and displaced during a diagnostic catheterisation, and thus can be a potential source of these massive emboli. Retinal cholesterol crystals help to establish the diagnosis of the syndrome, particularly when other systemic manifestations exist. When this complication occurs, the prognosis can be devastating because of associated multiorgan failure.

Stereocontrolled synthesis of 6-s-cis- and 6-s-trans-locked 9Z-retinoids by hydroxyl-accelerated Stille coupling of (Z)-tri-n-butylstannylbut-2-en-1-ol and bicyclic dienyl triflates

Analogues of 9-cis-retinoic acid with locked 6-s-cis and 6-s-trans conformations have been stereoselectively synthesized using a Stille coupling reaction between bicyclic dienyl triflates (5and 6, respectively) and (Z)-tributylstannylbut-2-en-1-ol (7) to stablish the Z geometry of the polyenic side chain. The mild conditions (25 degrees C, 30 min) of this coupling stand in contrast to the reluctance of the isomeric (E)-tributylstannylbut-2-en-1-ol (18) to react with triflates 5/6. The significant rate differences experimentally observed in Stille reactions between isomeric (Z)- and (E)-tri-n-butylstannylalkenols in favor of the former isomer, even with highly hindered alkenyl triflates, is ascribed to internal coordination of palladium to the heteroatom in the presumably rate-limiting transmetalation step. Dienals and trienals with an E geometry, which are not efficiently available by direct coupling of the corresponding triflates and E-stannanes, can in turn be obtained by isomerization of their Z-isomers.

Modifications induced by atherogenic diet in the capacity of the arterial wall in rats to respond to surgical insult

A study was made of events occurring in the arterial wall of the rat after administration of an atherogenic calcification-inducing diet and of vascular response in a model of combined metabolic aggression (atherogenic, calcification-inducing diet) and surgical aggression (adventitial resection). Female Sprague-Dawley rats were fed an atherogenic, calcification-inducing diet for 24 consecutive days, after which half the rats returned to standard diet (group I, n = 12) and the other half (group II) underwent resection of the adventitia on a segment of common iliac artery on day 25 before returning to standard diet. Normolipemic rats and rats that underwent adventitial resection without the atherogenic, calcification-inducing diet were used as the control groups. The rats were killed at 10 min, 1 and 24 h, 5, 14, 21, 30, 50, 70, 120 and 180 days. Morphologic studies were made with light microscopy and electron microscopy (scanning and transmission), as well as biochemical studies. Monocyte adherence and infiltration of the arterial intima, thickening of the subintimal space, the presence of monocyte-macrophages, calcification in the medial layer, intense adventitial fibrosis, and vacuolization of the endothelial cells of the adventitial microvessels were common findings in the two groups receiving the atherogenic, calcification-inducing diet. However, these groups differed in the intensity of calcification: the deep part of the medial layer did not become calcified when the adventitia was resected. Moreover, adventitial regeneration was delayed in group II with respect to the animals that underwent adventitial resection without atherogenic, calcification-inducing diet. We conclude that this diet induced atherosclerotic lesions in the vessel wall and inhibited adventitial regeneration in the rats that underwent resection.

[Percutaneous pulmonary valvuloplasty with balloon catheter in a patient with severe pulmonary stenosis. First case carried out in Panamá]

The authors report the clinical history of a 15 years old young man with severe congenital pulmonary valvular stenosis who was treated, for the first time in Panama, with percutaneous balloon pulmonary valvuloplasty (PBPV). The patient presented with an episode of syncope at rest. The EKG showed right ventricular hypertrophy (RVH) and suggested the presence, with the echocardiogram, of pulmonary systolic pressures higher than the systolic systemic pressures. The diameter of the interior pulmonary ring was estimated to 20 mm. The chest X-ray suggested the presence of RVH. Multiple premature ventricular systoles were detected by the Holter monitoring. Cardiac catheterization showed pressures of 150/12 mm Hg in the right ventricle (RV) and 24/9 mm Hg in the pulmonary artery (PA) with a transvalvular gradient of 126 mm Hg. PBPV was successfully done on 19 june 1993. The pressures in the RV were then 38/5 mm Hg and in the PA 25/7 mm Hg with a residual gradient of 13 mm Hg. Twenty minutes after completion of the procedure the patient experienced a hypertensive crisis and pulmonary edema, a complication of PBPV not previously reported in the literature.

[Experience with amlodipine (Norvasc) in the management of arterial hypertension]

The authors report the results of therapy with amlodipine in 20 patients with mild or moderate hypertension (diastolic pressure between 95 and 115 mmHg). Amlodopine was administered in a dose of either 5 or 10 mg once a day for 12 weeks. None of the patients had a history of congestive heart failure. Eleven patients were men between 27 and 89 years of age (average age was 52.6 years). There was a significant decrease in systolic blood pressure (from 161 to 141 mm Hg or -12.4%) and in diastolic blood pressure (from 103 to 86 mm Hg or -16.5%). Heart rate remained between 78 and 77 beats per minute. Only one patient experienced palpitations and two complained of mild, transient giddiness while on this therapy.

[Myocardial bridging as a cause of coronary insufficiency]

The authors studied the clinical and angiographic findings in two patients who had a myocardial bridge (MB) in the right anterior descending coronary artery and did not have any arteriosclerotic lesions in the coronary arteries. The two patients were men, 57 and 58 years old. Both had a history of arterial hypertension (for 19 years and 6 months, respectively) and angina pectoris (for 7 years and 6 months, respectively). The resting EKG showed subepicardial ischemia in one and was normal in the other. The stress test was positive in both. Coronary artery angiography showed an MB in the right anterior descending coronary artery which caused a systolic constriction of 90% and 80%, 3 and 2 cm. long. Both patients had left ventricular hypertrophy. The authors conclude that MB is a frequent cause of coronary insufficiency and that the appearance of symptoms and their severity depends on the degree of systolic constriction, greater than 75%, and on the presence of left ventricular hypertrophy. The majority of patients are controlled with medical treatment and only a small number require surgical therapy.

[Epidemiological study of prisoners at risk for AIDS in a Spanish prison]

Different proportions of the several AIDS risk practices in a Spanish prison during 1988 were studied. Also a epidemiologic study of the infectious diseases of the prisoners with some risk of this type was carried out. Of 135 prisoners with risk of AIDS, it was found that 91.2% of them were drug addicts. The index of positive HIV in all the population study was of 65.2%. 81.5% of the sample had at least one B hepatitis marker and 11.1% had HBs-Ag. 15.4% of the last group also showed HBe-Ag positive. Histories of non-A, non-B hepatitis were not evaluated in 9.6% of all the patients studied. 53.3% had sexually transmitted diseases. It is important to mention the high index of active tuberculosis found (12.6% of the sample), which is higher than the maximum values found in various similar papers. We did not find any differences in the grade of affectation between HIV+ and HIV-.

[Tetanus in adults: mortality. Study in 130 cases]

Out of the 557 cases of tetanus in adult patients seen in our institution over 61 years, we have selected for analysis the 130 patients who where admitted to our service since its creation in 1968. We have found a trend toward older patient age in recent years. The age distribution showed a bimodal curve which was maintained in the different periods and was due, in the last one to the population of parenteral drug abusers. In the last 20 years there has been an increase in severe forms (p less than 0.001). The mortality was statistically associated with clinical severity (p less than 0.001) and with the surgical portal of entry (p less than 0.05). The development of intensive care reduced the mortality rate from 58.3% in the period before ICU to 24.6% in the 130 patients cared for since the service was created (p less than 0.001). In the last 10 years, the mortality rate of 41 patients was 9.7%. The most common cause of death was cardiac arrest (68.7%). Superinfection was the second cause (25%). The use of beta-blockers in patients with severe tetanus, with significant autonomic abnormalities, reduced the mortality from 72.7% to 14.8% (p less than 0.001). The mortality of superinfection has been maintained, without statistically significant changes.