Friday

When the PLT get LOW

A 72 y/o male with PMH type 2 diabetes, CAD, HFrEF, HTN, and HLD is admitted to the MICU for frequent neurologic monitoring after an endovascular thrombectomy for an acute ischemic stroke caused by thrombosis of the M2 branch of the left MCA. While reviewing his chart, you notice that the patient was recently admitted for 1 week about 10 days ago for dyspnea secondary to acute decompensated heart failure. You also note on his admission labs that he is newly thrombocytopenic, with a platelet count of 80,000. His last platelet count on discharge was 250,000, and he has never been thrombocytopenic before. What is causing his thrombocytopenia?

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ECMO: What is the Intensivist’s Role?

 

A 52-year-old man with a history significant for hypertension presented to the emergency department with cough, dyspnea and fever. He progressed to severe acute respiratory distress syndrome (ARDS) secondary to COVID-19 pneumonia. He developed refractory hypoxemia with P/F < 60 mm Hg despite low tidal volume ventilation, paralysis, inhaled epoprostenol and prone positioning. Is this patient a candidate for venovenous ECMO and, if so, who should guide initiation and management of ECMO? The Society of Critical Care Medicine (SCCM) and Extracorporeal Life Support Organization (ELSO) recently published a position paper on the role of the intensivist in the initiation and management of ECMO. 

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Angiotensin II and COVID-19

As we learn more about the pathophysiology of COVID-19, alternative treatments are being explored for the severe sequelae of this disease. SARS-CoV-2 enters human cells via the ACE2 receptor, located in many organs, including the heart, vascular endothelium, and alveolar epithelium causing an inflammatory cascade that can lead to ARDS, vasodilatory shock, myocarditis, acute kidney injury and capillary leak. Given the relationship between SARS-CoV-2 and the RAAS, is there a role for angiotensin II in vasodilatory shock caused by COVID-19?

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ECMO in pregnancy

 

A 36-year-old woman presented to urgent care with cough, dyspnea and hypoxemia. She was transported to the ED where she rapidly progressed to severe ARDS despite lung protective ventilation, paralysis and inhaled epoprostenol. Post-intubation, it was determined that she was pregnant with ultrasound revealing a fetus at 23 weeks, 6 days gestational age. She underwent cannulation for venovenous ECMO. What is the role of ECMO in the pregnant patient? A recently published analysis of the ELSO registry for peripartum patients supported with ECMO demonstrates a 70 percent survival rate. 

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To art line or not to art line?

You are working in a busy ED when a patient who is 54 arrives with an acute onset headache associated with syncope but no focal neurologic deficits.  His physical exam is unremarkable but his BP is mildly elevated at 175/80. The patient’s head CT is consistent with an aneurysmal subarachnoid hemorrhage.  You begin anti-hypertensive treatment, but wonder how reliable non-invasive blood pressure measurement is in this patient.

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