Internal and emergency medicine
-
Comparative Study
Comparison of Troponin I levels versus myocardial dysfunction on prognosis in sepsis.
In the context of sepsis, we tested the relationship between echocardiographic findings and Troponin, and their impact on prognosis. In this prospective study, we enrolled 325 septic patients (41% with shock), not mechanically ventilated, between October, 2012 and June, 2019 among those admitted to our High-Dependency Unit. By echocardiography within 24 h from the admission, sepsis-induced myocardial dysfunction (SIMD) was defined as left ventricular (LV) systolic dysfunction (speckle-tracking-based global longitudinal peak systolic strain, GLS, > - 14%) and/or right ventricular (RV) systolic dysfunction (Tricuspid Annular Plane Systolic Excursion, TAPSE < 16 mm). ⋯ Compared to G1, patients in G3 had worse LV and RV systolic function (GLS - 11.6 ± 3.4% vs - 14.0 ± 3.5%, p < 0.001; TAPSE 18 ± 0.5 vs 19 ± 0.5 mm, p = 0.047) and greater day-28 (34% vs 20%, p = 0.015) mortality. In a Cox survival analysis including age, Troponin and SOFA score, mortality was predicted by the presence of SIMD (RR 3.24, 95% CI 1.72-6.11, p < 0.001) with no contribution of abnormal Troponin level. While abnormal Troponin levels were associated with SIMD diagnosed by echocardiography, only the presence of SIMD predicted the short- and medium-term mortality rate, without an independent contribution of increased Troponin levels.
-
Multicenter Study Observational Study
Prevalence of and factors associated with physical restraint use in the intensive care unit: a multicenter prospective observational study in Japan.
Physical restraint is widely used in the intensive care unit (ICU) to ensure patient safety despite its ethical implications. We performed a prospective observational study in six ICUs in Japan to determine the prevalence of and factors associated with physical restraint use in the ICU, a phenomenon that has not yet been reported on in Japan. Data were collected on 10 random days between November 2018 and February 2019. ⋯ Approximately one-third of the ICU patients required physical restraint in Japan. In addition, physical restraint use was influenced by disease severity, mental condition, and the medical apparatus used. Based on these findings, further investigations are imperative to develop strategies to reduce physical restraint use.
-
Review
From advanced disease to transplantation: an overview of the liver at the time of COVID-19 pandemic.
In 2020, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) also known as coronavirus disease 2019 (COVID-19) disrupted global health, causing hundreds of thousands of deaths worldwide. The liver injury appears to be one of the possible systemic manifestations of COVID-19 disease although the mechanisms causing such injury are not entirely clear. ⋯ Furthermore, liver transplant patients are potentially more vulnerable to SARS-CoV-2 infection due to immune suppression, ageing, and metabolic or cardiovascular comorbidities. This review analyses the increasing amounts of data collected in recent months concerning liver cirrhosis and liver transplants to understand if this finding is still relevant with respect to COVID-19 manifestations.
-
The periprocedural management of patients who are receiving vitamin K antagonists, direct oral anticoagulants and antiplatelet therapy is a common and challenging clinical scenario as the decision to interrupt or continue these medications is anchored on patient and procedure-related risks for bleeding and thrombosis. Adding to the complexity of clinical management is the fact that anticoagulants have varied pharmacokinetic and pharmacodynamic properties and indications for clinical use. ⋯ The objective of this case-based narrative review is to provide a practical evidence-based approach to the perioperative management of patients on anticoagulation and antiplatelet therapy. Four clinical scenarios will be provided: (1) managing patients in whom anticoagulants can be continued; (2) perioperative management of direct oral anticoagulants; (3) management of patients on dual antiplatelet therapy; and (4) anticoagulant management for emergency or urgent surgery.
-
Optimal management of venous thromboembolism (VTE) in cancer patients with thrombocytopenia is uncertain. We described current management and clinical outcomes of these patients. We retrospectively included a cohort of cancer patients with acute VTE and concomitant mild (platelet count 100,000-150,000/mm3), moderate (50,000-99,000/mm3), or severe thrombocytopenia (< 50,000/mm3). ⋯ Three-month incidence of VTE was 3.9% (95% CI 1.3-10.1), 8.5% (95% CI 2.8-21.3), 0% (95% CI 0.0-20.0) in patients with mild, moderate, and severe thrombocytopenia, respectively. The corresponding values for major bleeding and mortality were 1.9% (95% CI 0.3-7.4), 6.4% (95% CI 1.7-18.6), 0% (95% CI 0.0-20.0) and 9.6% (95% CI 5.0-17.4), 48.2% (95% CI 16.1-42.9), 20% (95% CI 6.6-44.3). In the absence of sound evidence, anticoagulation strategy of VTE in cancer patients with thrombocytopenia was tailored on an individual basis, taking into account not only the platelet count but also VTE presentation and the presence of cerebral metastasis.