Surgical adrenalectomy during rescue Extracorporeal Life Support for pheochromocytoma induced cardiogenic shock: a case report

Introduction : Pheochromocytoma, a rare catecholamine-producing tumor, has been described to provoke stress-induced Takotsubo-like cardiomyopathy and even severe refractory cardiogenic shock. In this case report, venoarterial extracorporeal membrane oxygenation (VA-ECMO) was used for hemodynamic stabilization and was continued during the resection of a large neuroendocrine tumor. Description : A 69-year old male, recently diagnosed with a pheochromocytoma, was referred to our center because of severe cardiogenic shock after induction of anesthesia for resection of the mass. Despite adequate alpha-and beta-adrenergic blockade for one month, he developed malignant hypertension with subsequently hemodynamic collapse. After successful cardiopulmonary resusci-tation he developed pulmonary oedema with severe hypoxemia and persistent hemodynamic lability. On arrival in our hospital, echocardiography revealed significant left ventricular impairment. Decision was made to commence him on VA-ECMO for a refractory cardiogenic shock with severe pulmonary oedema. Because of persistent blood pressure swings despite VA-ECMO and beta-adrenergic blockade, we decided to remove the tumor on mechanical circulatory support by an open surgical approach the next day. After clamping of the adrenal circulation, the patient experienced profound hypotension requiring high doses of epinephrine and a methylene blue infusion. Surgical resection was successful but complicated by a postoperative bleeding for which the patient underwent an emergent endovascular embolization of an adrenal artery. Over the next days, there was progressive cardiac recovery and the patient was weaned off VA-ECMO on the fourth postoperative day. The patient was discharged from the intensive care 27 days after admission and left the hospital on day 30. Discussion: VA-ECMO seems to be a feasible last resort therapy in refractory cardiogenic shock induced by pheochromocytoma crisis as suggested by a high survival rate in literature. Despite its support benefit during this type of shock, surgical removal of the tumor is rarely done with mechanical circulatory support and heparinization.

Perception and knowledge of anesthesia and the role of anesthesiologists : a Belgian single-center cross-sectional survey

Study Objective : To assess the knowledge of anesthesia and the role of anesthesiologists and evaluate the prevalence of concerns of certain risks of anesthesia and surgery in Belgian patients. Design : Observational mono-center cross-sectional survey. Setting : Preoperative patients planned for elective surgery in Jessa Hospital, Belgium. Interventions : An observational survey in Dutch. Measurements : Patient demographics and characteristics, perception of the patient of the expertise, role, and responsibility of the anesthesiologist, knowledge of the patient regarding anesthesia, and patients´ fear of specific risks and side effects of anesthesia and surgery. Associations were analyzed with the Pearson correlation coefficient or the Spearman rank’s correlation coefficient. Main Results : In total 361 patients completed the survey. Patient demographics were as follows : 54.8% males, mean age (± SD) 58,84 ± 16,38 years. Most patients (87.3%) recognized anesthesiologists as specially trained medical doctors but more than 50% underestimated their different perioperative responsibilities. Patients underestimated the dura-tion of education of an anesthesiologist in 84.2%. Their role at the intensive care unit (69.3%), the emergency department (71.2%), and the delivery room (71.2%) were relatively well known. Their role at the chronic pain management clinic (44.8%) and the preoperative anesthesia consultation (40.7%) was less well known. Some patients thought that general anesthesia frequently results in brain damage (22.7%). Older age and lower educational level were associated with lower knowledge. In general, 8.3% of all patients were very anxious about anesthesia, 22.7% somewhat, and 69% not at all. Female gender and lower educational level were positively correlated with a higher risk of fear. : Most patients in this single-center Belgian cohort were aware that anesthesiologists are specialized medical doctors. Overall, the patient´s knowledge of the anesthesiologist’s expertise and responsibilities and anesthesia was rather limited.

Cardiac function during COVID-19 intensive care unit hospitalisation - deformation analysis and outcomes

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Horizon 2020 European Commission Project H2020-MSCA-ITN-2016

Background

Although the cardiac burden of COVID-19 has been demonstrated, follow-up imaging studies are scarce. The aim was to use speckle-tracking deformation imaging (STE) to prospectively assess cardiac function during intensive care unit (ICU) hospitalisation, comparing ventricular and atrial function of COVID-10 patients that died and those that were discharged.

Methods

In a single-centre, COVID-19 patients (n = 41) (71% male, aged 65 ± 11 years) were prospectively followed with echocardiography as part of ICU treatment. The left and right ventricles (LV, RV, respectively) were studied with STE in the 4-chamber cardiac view. The endpoint was defined as death or ICU discharge. Average values of the strain parameters from the first and final scans in the ICU, respectively, were calculated for the two outcome groups.

Results

Endpoint was not reached in 15% (n = 6) at the time of analysis. The remaining patients (n = 32) were 69% male, aged 66 (interquartile range (IQR) 60-72) years, and with an ICU mortality 26% (n = 9). The median spent in ICU was 24 (IQR 15-43) days. On average, echocardiography was performed three times during ICU hospitalisation, amounting to 103 examinations. The changes in cardiac strain are shown in Table 1. The change in LV longitudinal strain during ICU hospitalisation is shown in Figure 1.

Conclusion

Worsening of LV strain and lack of improvement of RV strain is linked to higher mortality in the ICU. The assessment of cardiac function might contain prognostic information in COVID-19 patients that are admitted to the ICU.

	Patients discharged from thee OCU (n = 23)	Patients that died in the ICU (n = 9)	P value
Initial echo in the ICU
LV strain, % (IQR)	18.00 (15.6-19.95)	14.4 (10.56-20.42)	0.158
RV strain, % (IQR)	16.00 (14.70-20.05)	15.50 (10.38-23.70)	0.712
Final echo before discharge
LV strain, % (IQR)	17.35 (15.13-18.98)	13.20 (10.75-15.40)	0.007
RV strain, % (IQR)	17.65 (16.83-19.60)	15.75 (10.68-20.43)	0.438

ICU - intensive care unit; IQR-inter-quartile range

Evolution of cardiac function in COVID 19 patients in the intensive care unit: insights from machine learning

Funding Acknowledgements

Type of funding sources: None.

Background

Repeated echocardiographic assessment of cardiac function is integral in management of intensive care units (ICU) patients. Machine learning (ML) can assist by integrating whole-cardiac cycle echo data derived from flow assessment and deformation imaging, and grouping patients on the basis of patterns of cardiac dysfunction and its evolution over time. Cardiac involvement has been suggested to be important in COVID-19 outcome and echo evaluation can inform on cardiac status. We use unsupervised ML to investigate and integrate longitudinal data from the COVID-HO study (NCT04371679) to determine the potential of tracking changes in cardiac function during ICU hospitalization. 

Methods

In a single-centre, COVID-19 patients (n = 38) were prospectively followed with echocardiography as part of ICU management. The endpoint was defined as death or ICU discharge. LV myocardial deformation, as well as aortic, mitral and pulmonary artery blood-pool Doppler velocity profiles were used as input for ML. Clinical data was used to validate the ML derived phenotypes. Echo data from the initial and final echo examination were used to create an output space where participants were positioned based on cardiac function blinded to outcome status. Regression was used to estimate the echo and clinical characteristics of different regions in the space. Patient trajectories in the output space were investigated for each patient.

Results

Endpoint was not reached in 24% (n = 9) at the time of analysis. The cohort was 68% male, aged 65 ± 12 years, and with an ICU mortality 21% (n = 8). The median spent in ICU was 10 (IQR 7-18) days. The ML analysis demonstrated a heterogeneous output space (Fig 1A) we could define a gradual change in the shape of the pulmonary outflow velocity profile, from a normal  towards pulmonary hypertension (Fig 1A, x axis). Jointly with differences in diastolic function (mitral inflow fusion and A wave accentuation) defined two regions: with signs of pulmonary hypertension (gray); and with normal pulmonary pressures but LV diastolic dysfunction (yellow). Investigation of patient trajectories (Fig 1B) demonstrated the feasibility of tracking changes during ICU hospitalization, showing a shift of a patient that died in the ICU, from initial diastolic dysfunction towards pulmonary hypertension (red), and a patient shifting from a region with normal diastolic function towards pulmonary hypertension, but with a positive outcome (blue). Echo data concurs with observed dynamics (Fig 1C and 1D).

Conclusion

ML can integrate complex, whole-cardiac cycle echo data to group heterogeneous patients based on similarity of cardiac function. Patient trajectories across the output space demonstrate the feasibility of ML for echo data-based follow-up of patients during ICU hospitalization. Further echo and clinical data integration can improve characterisation of the output space regions and better define changes in cardiac function during hospitalization.

Abstract Figure 1

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Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Two cases of acquired methemoglobinemia

Methemoglobinemia is a rare pathology that results from the oxidation of iron in the hemoglobin molecule. Oxidation of iron switches it from the ferrous to the ferric state, and impedes the ability of hemoglobin to carry oxygen. Hence, methemoglobinemia often results in hypoxemia. The disease can be hereditary or acquired, and its diagnosis can be challenging. This rare condition may often be missed by clinicians, since information on oxygen saturation provided by standard pulse oximeters is unreliable. We here present two cases of acquired methemoglobinemia. The first one is a 24-year old woman, who received dapsone as an alternative antibiotic therapy because of known allergies to a series of other antibiotics and who could not get weaned from mechanical ventilation despite minimal ventilator support. The second case describes a 49-year old man who developed respiratory insufficiency following the use of 'poppers' containing alkyl nitrites. Following treatment of both patients using the antidote methylene blue, they could be successfully weaned from mechanical ventilation.

Video-assisted laryngoscopy: a useful adjunct in endotracheal intubation

The difficult airway is the single most important cause of anaesthesia-related morbidity and mortality and most catastrophes are due to unexpected difficulty, which are more likely in emergencies. We report a difficult airway scenario in a patient with a high energetic trauma and used several techniques for the "can't intubate, can't ventilate scenario". Eventually, successful intubation was obtained with the video-assisted laryngoscope.