Avoiding harm: central venous access in Kartagener syndrome and other vascular anomalies

Placement of internal jugular catheters is more likely to be complicated if a left-sided approach is used, assuming normal anatomy. Kartagener syndrome is the sine qua non of sidedness confusion and results in cognitive challenges that increase the risk of adverse patient outcomes. The altered anatomy can cause profound disorientation from our usual processes. In normal circumstances the right-sided approach is used for placement of internal jugular catheters, but in Kartagener syndrome the left-sided approach should be preferred. Surgical volume and use of ultrasound guided techniques are positively correlated with better outcomes. Clinical experience may be a detriment to performance. Knowledge of these issues will help clinicians maintain vigilance and avoid error. Keywords: Kartagener syndrome, central venous access, superior vena cava, landmark technique, internal jugular vein catheterization cognitive bias

Accuracy of reporting estimated blood loss in open repair of pelvic and acetabular fractures

Background: Pelvic injuries after blunt trauma are often repaired with open reduction-internal fixation (ORIF), often resulting in high blood loss. We compare calculations of estimated perioperative blood loss (EPBL) against reported intraoperative blood loss (RIBL) by visual estimation to evaluate their accuracy during ORIF for pelvic fractures. Materials and Methods: A retrospective observational study was conducted at a Level 1 trauma center. 142 patients requiring ORIF of acetabular and/or pelvic ring fracture between ages 18 to 89 years from 3/1/2017 to 2/28/2019 were included. EPBL was calculated by Gross Method. Statistical analyses were conducted using R statistical software. Medians and inter-quartile ranges were used to summarize variables. A two-sample Wilcoxon signed rank test was performed. The agreement and reproducibility of RIBL and EPBL were examined with concordance correlation coefficients (CCC) and Bland-Altman plots. Results: Median RIBL was 450 mL [250, 800], while median EPBL was 2142 mL [1213, 3607]. The median difference was -1692 mL (p<0.001). The Bland-Altman plot showed consistent under-reporting in RIBL versus EPBL. A proportional bias (p<0.001), indicated that the level of bias was not constant between levels of blood loss. The CCC between RIBL and EPBL was 0.076 [-0.016, 0.167]. Pearson’s Correlation Coefficient was 0.213 (p=0.011). RIBL and EPBL had a weak positive correlation. Discussion: Blood loss during ORIF calculated by EPBL was significantly higher than RIBL. Our results suggest that blood loss reporting may be inaccurate in ORIF of pelvic fractures. These findings necessitate formulation of an accurate method permitting proper blood loss reporting. Keywords: postoperative blood loss; surgical blood loss; orthopedic surgery; estimation techniques

Dasatinib-induced diffuse alveolar hemorrhage

The BCR-ABL tyrosine kinase inhibitor dasatinib is a potent treatment for chronic myeloid leukemia (CML). However, it is associated with pulmonary toxicities. Commonly reported dasatinib related pulmonary toxicities include pleural effusion, lung parenchymal abnormalities, and pulmonary hypertension. Diffuse alveolar hemorrhage (DAH) during treatment with dasatinib is very rare. To the best of our knowledge there are only two cases reported. Here we report a 57-year-old Caucasian woman who developed acute hypoxic respiratory failure while on dasatinib for treatment of CML. She was diagnosed with DAH suspected to be secondary to dasatinib, after other common etiologies were ruled out. There was full recovery after stopping dasatinib and treatment with corticosteroids. Keywords: Dasatinib, pulmonary toxicity, diffuse alveolar hemorrhage, chronic myeloid leukemia

De novo inflammatory bowel disease is a potential post-acute sequela of SARS-CoV-2 infection

Background: Even though patients with inflammatory bowel disease (IBD) are not at increased risk of COVID-19 infection, patients with post-acute COVID-19 have been reported to have de novo IBD or a new diagnosis of IBD. Objective: This article reviews the presentation, diagnosis, and clinical course of patients described in the literature to have new-onset IBD after the diagnosis of COVID-19 infection as well as discusses the possible pathophysiological mechanism. Methodology: Extensive literature review by compiling information from case reports and original studies identified by a Pubmed and EMBASE search from inception to May 2021. Results: We identified 4 cases of de novo IBD that were reported in the literature, 2 weeks – 5 months after acute COVID-19 infection. Patients presented with persistent bloody diarrhea, abdominal pain, and anemia. Three patients were diagnosed with ulcerative colitis and one patient was diagnosed with Crohn's disease. Available evidence indicates that COVID-19 infection can instigate an intestinal inflammation and trigger de novo IBD, potentially through intestinal barrier leakage, alterations in gene expression, gut microbiota dysbiosis, and exaggerated immune response. Conclusion: The presence of the SARS-CoV-2 virus in the gut can cause de novo IBD through complex multiple factors. Further studies need to be done to confirm a causal link and the underlying mechanism. Clinicians should be vigilant about the possibility of IBD in patients present with anemia, abdominal pain, or chronic bloody diarrhea after a short interval of COVID-19 infection that warrant a referral to a gastroenterologist.

Pontine demyelination as a late complication of resolved mild COVID-19 infection

Previous case reports have demonstrated COVID-19 related neurotropism. Neural infection may result from trans-lamina cribrosa invasion that allows COVID-19 to reach the brain through the olfactory tract. A wide range of symptoms from headaches, anosmia, dysgeusia to neuropathy, encephalitis, cerebrovascular stroke, and rarely demyelination has been reported. Here, we report a case of pontine demyelination causing generalized weakness as a rare neurological complication in a COVID-19 survivor. Our case highlights that even mild and moderate COVID-19 infection can have late neurological sequelae. Keywords: COVID-19, demyelination, neurological complications, corticosteroids

Exploring and managing psychiatric symptoms in ICU healthcare professionals during the ongoing COVID-19 pandemic: a focused review and guideline

Introduction: The COVID-19 pandemic has ravaged the healthcare system and stretched resources thin. The impact on healthcare staff working in the intensive care unit setting has been especially devastating. Objective: To conduct a review of the impact of the pandemic on healthcare personnel in the intensive care unit setting in the hope of utilizing information gathered to inform various stakeholders. Design: Focused literature and abstract review Conclusion: This article seeks to highlight the association between critical care as it relates to trauma and COVID-19 and point stakeholders toward opportunities for anticipating and managing secondary effects in effort to promote psychological adaptation.

Upper extremity deep venous thrombosis secondary to thyrotoxic periodic paralysis with accompanying hyperphosphatemia and severe hypomagnesemia

Thyrotoxic periodic paralysis is a rare but life-threatening complication of hyperthyroidism. Characteristic features involve thyrotoxicosis, acute paralysis, and hypokalemia. Mild hypomagnesemia and hypophosphatemia are also present in most cases due to the resulting transcellular shift of electrolytes. Complications of thyrotoxic periodic paralysis reported in the literature have included cerebral venous thrombosis as well as lower extremity deep venous thrombosis. We present a patient with an unusual presentation of thyrotoxic periodic paralysis as reflected by hyperphosphatemia, upper extremity deep venous thrombosis and severe hypomagnesemia. This is the first reported case of upper extremity deep vein thrombosis in association with a peripherally inserted central catheter line secondary to thyrotoxicosis.