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Pneumothorax is a rare complication among mechanically ventilated patients since low tidal volumes are used nowadays instead of traditional high tidal volumes, but the incidence is slightly higher in patients with high positive end-expiratory pressure (PEEP). Herein we describe a case series of nine patients who were on mechanical ventilation due to acute respiratory distress syndrome (ARDS) secondary to coronavirus disease 2019 (COVID-19) and developed pneumothorax in due course. A retrospective analysis was done on COVID-19 intubated patients from March 2020 to June 2020 in a community hospital in Central New Jersey, which was one of the early hit states in the United States at the beginning of the pandemic. Outcomes were studied. The demographics of patients like age, gender, and body mass index (BMI); risk factors like smoking, comorbidities especially chronic lung disease, and the treatment they received were compared. We compared the total number of days on the ventilator, the highest PEEP they received, and the ventilator day when pneumothorax developed. All the patients who developed pneumothorax had a chest tube inserted to treat it. The mortality was noted to be 100% indicating that pneumothorax is a life-threatening complication of COVID-19 and COVID-19 by itself is a risk factor for pneumothorax likely due to a change in lung mechanics. There is a need for large-scale studies to confirm that these outcomes are related to COVID-19.

Invasive Klebsiella pneumoniae Liver Abscess. A Worldwide Emerging Disease.

This article is a Letter to the Editor and does not include an Abstract.

This is a case of an elderly woman who presented to our emergency room with an episode of a witnessed fall. The past medical history of the patient was significant for post-stroke epilepsy for which she was on oxcarbazepine. Initial blood work showed a white cell count of 4.5, haemoglobin of 12.4, and platelet count of 15,000. Peripheral blood smear showed normal platelet and red cell morphology without clumping. The patient's history suggested that she was recently started on oxcarbazepine prompting discontinuing of the drug. The platelet count improved from 15,000 cells/mL to 80,000 cells/mL on discharge.Antiepileptic medications have been reported to cause various blood dyscrasias in the literature. There are few studies that report the association of carbamazepine and thrombocytopenia and much fewer written about oxcarbazepine. Thrombocytopenia appears to be an uncommon reported side effect of oxcarbazepine; more commonly reported side effects include dizziness, tiredness, memory problems and headache. The treatment of antiepileptic drug-associated thrombocytopenia is discontinuing the medication and monitoring the platelet counts. In few cases, immunoglobulin infusion is required. Antiepileptic drug-associated thrombocytopenia is difficult to predict and so it is imperative to monitor the platelet level when antiepileptic drugs are started and even after the medication is switched to a different one.

Background:Anesthetics, analgesics, and surgery may profoundly affect sleep architecture and aggravate sleep-related breathing disturbances. The authors hypothesized that patients with preoperative polysomnographic evidence of obstructive sleep apnea (OSA) would experience greater changes in these parameters than patients without OSA.Methods:After obtaining approvals from the Institutional Review Boards, consented patients underwent portable polysomnography preoperatively and on postoperative nights (N) 1, 3, 5, and 7 at home or in hospital. The primary and secondary outcome measurements were polysomnographic parameters of sleep-disordered breathing and sleep architecture.Results:Of the 58 patients completed the study, 38 patients had OSA (apnea hypopnea index [AHI] >5) with median preoperative AHI of 18 events per hour and 20 non-OSA patients had median preoperative AHI of 2. AHI was increased after surgery in both OSA and non-OSA patients (P < 0.05), with peak increase on postoperative N3 (OSA vs. non-OSA, 29 [14, 57] vs. 8 [2, 18], median [25th, 75th percentile], P < 0.05). Hypopnea index accounted for 72% of the postoperative increase in AHI. The central apnea index was low (median = 0) but was significantly increased on postoperative N1 in only non-OSA patients. Sleep efficiency, rapid eye movement sleep, and slow-wave sleep were decreased on N1 in both groups, with gradual recovery.Conclusions:Postoperatively, sleep architecture was disturbed and AHI was increased in both OSA and non-OSA patients. Although the disturbances in sleep architecture were greatest on postoperative N1, breathing disturbances during sleep were greatest on postoperative N3.

A 51-year-old man with end-stage renal disease presented with extensive necrotic ulcers and eschar on both legs.

Obstructive sleep apnea (OSA) is presumed to be a risk factor for postoperative morbidity and mortality, but the current evidence is incomplete. This retrospective matched cohort study tested the hypothesis that OSA is a risk factor for the development of postoperative complications.Hospital ethics approval was obtained for the conduct of this study. The patients who were selected for the study were18 yr of age, diagnosed preoperatively with OSA, and scheduled to undergo elective surgery. A cohort of surgical patients without OSA was used as a comparator group based on a one-to-one match. Matching criteria included gender, age difference5 yr, type of surgery, and a5 yr difference between two surgery dates. Summary data are presented and conditional logistic regression was used to identify risk factors for postoperative complications.The 240 pairs of study subjects aged 57 +/- 13 yr included 184 (77%) males and 56 (23%) females. The OSA patients had a higher mean body mass index relative to their non-OSA counterparts (35 +/- 9 vs 28 +/- 6 kg . m-2, respectively) and a higher frequency of co-morbidities, including hypertension (48% vs 36%, respectively) and obesity (61% vs 23%, respectively). Also, the incidence of postoperative complications in the OSA patients was significantly greater (44% OSA group vs 28% non-OSA group; P0.05). The most commonly observed between-group difference was oxygen desaturation90% (17% OSA group vs 8% non-OSA group). The OSA patients who did not use home continuous positive airway pressure (CPAP) devices prior to surgery but required the use of a CPAP device after surgery had the highest rate of complications. Conditional logistic regression was used to diagnose OSA and pre-existing stroke as significant risk factors for developing postoperative complications. The hazard ratio for OSA was 2.0 (1.25-3.19).Patients with diagnosed OSA have an increased incidence of postoperative complications, the most frequent being oxygen desaturation.

PURPOSE: Upper airway abnormalities carry the risk of obstructive sleep apnea (OSA) and difficult tracheal intubations. Both conditions contribute to significant clinical problems and have increased perioperative morbidity and mortality. We hypothesized that patients who presented with difficult intubation would have a very high prevalence of OSA and that those with unexpected difficult intubation may require referral to sleep clinics for polysomnography (PSG). METHODS: Patients classified as a grade 4 Cormack and Lehane on direct laryngoscopic view, and who required more than two attempts for successful endotracheal intubation, were referred to the study by consultant anesthesiologists at four hospitals. Apnea-hypopnea index (AHI) data and postoperative events were collected. Patients with AHI 5/h were considered positive for OSA. Clinical and PSG variables were compared using t-tests and 2 test. RESULTS: Over a 20-mo period, 84 patients with a difficult intubation were referred into the study. Thirty-three patients agreed to participate. Sixty-six percent (22 of 33) had OSA (AHI 5/h). Of the 22 OSA patients, 10 patients (64%) had mild OSA (AHI 5–15), 6 (18%) had moderate OSA (AHI 15/h), and 6 (18%) had severe OSA (AHI 30/h). Of the 33 patients, 11 patients (33%) were recommended for continuous positive airway pressure treatment. Between the OSA group and the non-OSA group, there were significant differences in gender, neck size, and the quality of sleep, but there were no significant differences in age and body mass index. CONCLUSIONS: Sixty-six percent of patients with unexpected difficult intubation who consented to undergo a sleep study were diagnosed with OSA by PSG. Patients with difficult intubation are at high risk for OSA and should be screened for signs and symptoms of sleep apnea. Screening for OSA should be considered by referral to a sleep clinic for PSG. (Anesth Analg 2008;107:915‐20)

Background Obstructive sleep apnea (OSA) is a major risk factor for perioperative adverse events. However, no screening tool for OSA has been validated in surgical patients. This study was conducted to develop and validate a concise and easy-to-use questionnaire for OSA screening in surgical patients. Methods After hospital ethics approval, preoperative patients aged 18 yr or older and without previously diagnosed OSA were recruited. After a factor analysis, reliability check, and pilot study; four yes/no questions were used to develop this screening tool. The four questions were respectively related to snoring, tiredness during daytime, observed apnea, and high blood pressure (STOP). For validation, the score from the STOP questionnaire was evaluated versus the apnea-hypopnea index from monitored polysomnography. Results The STOP questionnaire was given to 2,467 patients, 27.5% classified as being at high risk of OSA. Two hundred eleven patients underwent polysomnography, 34 for the pilot test and 177 for validation. In the validation group, the apnea-hypopnea index was 20 +/- 6. The sensitivities of the STOP questionnaire with apnea-hypopnea index greater than 5, greater than 15, and greater than 30 as cutoffs were 65.6, 74.3, and 79.5%, respectively. When incorporating body mass index, age, neck circumference, and gender into the STOP questionnaire, sensitivities were increased to 83.6, 92.9, and 100% with the same apnea-hypopnea index cutoffs. Conclusions The STOP questionnaire is a concise and easy-to-use screening tool for OSA. It has been developed and validated in surgical patients at preoperative clinics. Combined with body mass index, age, neck size, and gender, it had a high sensitivity, especially for patients with moderate to severe OSA.

The most recent National Highway Traffic Safety Administration report suggests that drowsiness should be the next public health awareness frontier beyond driving and seatbelt use. Sleep is as important to the human body as food and water are, but most people in the Western society do not get enough sleep. Insufficient sleep or disruptions to the sleep-wake cycle (e.g., those that occur with shift work or traveling to a different time zone) cause the pathophysiological state known as sleep deprivation. a sleep-deprived individual is accident prone, has impaired judgment, and is more likely to make mistakes. Studies have documented that staying awake for 24 hours leads to reduced hand-to-eye coordination, which is similar to having a blood alcohol concentration (BAC) of 0.08%. As a result, sleep deprivation contributes to road accidents and work injuries. Lack of sleep is known to affect psychomotor performance and has been linked to increased risk for emotional problems such as depression. Efforts should be invested into developing a roadside testing device equivalent to the breathalyzer to measure current sleepiness.

BACKGROUND: Pain clinics tend to see more complex chronic pain patients than primary care settings, but the types of patients seen may differ among practices.OBJECTIVE: The aim of the present observational study was to describe the pain and demographic characteristics of patients attending a university-affiliated tertiary care pain clinic in Toronto, Ontario.METHODS: Data were collected on 1242 consecutive new patients seen over a three-year period at the Comprehensive Pain Program in central Toronto.RESULTS: Musculoskeletal problems affecting large joints and the spine were the predominant cause of pain (more prevalent in women), followed by neuropathic disorders (more prevalent in men) in patients with recognizable physical pathology. The most affected age group was in the 35- to 49-year age range, with a mean pain duration of 7.8 years before the consultation. While 77% of the Comprehensive Pain Program patients had relevant and detectable physical pathology for pain complaints, three-quarters of the overall study population also had significant associated psychological or psychiatric comorbidity. Women, in general, attended the pain clinic in greater numbers and had less apparent physical pathology than men. Finally, less than one in five patients was employed at the time of referral.CONCLUSIONS: The relevance of the data in relation to other pain clinics is discussed, as well as waiting lists and other barriers faced by chronic pain patients, pain practitioners and pain facilities in Ontario and Canada.

BACKGROUND Delirium is a commonly observed problem for adult patients in the intensive care unit (ICU) that is associated with increased mortality, increased hospital length of stay, and long-term disability of ICU survivors. This makes prevention and prompt treatment of delirium imperative goals for critical-care providers. Bedside critical-care nurses are uniquely poised to champion efforts to prevent, detect, and treat delirium but oftentimes are not aware of the most recent evidence-based guidelines or the potential long-term implications for the ICU survivor. Nurses have reported higher levels of confidence in detecting delirium, increased knowledge of delirium, and enhancement of patient care skills after receiving formal didactic educational training. OBJECTIVES The objectives of this quality improvement project were to develop, implement, and evaluate a nursing education program for critical-care nurses that presented a protocol for the prevention and management of delirium in adult ICU patient populations, as well as improve nurses' familiarity, comfort, and compliance with using a standardized evaluation method for delirium and intervention care bundle. DESIGN A didactic training program for bedside critical-care nurses was developed and implemented. Upon completion of the educational sessions, a daily bedside delirium screening and care bundle protocol were implemented for all patients in ICUs throughout the facility. PARTICIPANTS Bedside critical-care nurses were invited to participate in the formal teaching sessions. This included nursing staff from each of the 3 ICUs in this facility, as well as supplemental "float pool" staff. MEASUREMENTS Pre-educational and posteducational nursing attitudes and self-perceived confidence levels regarding delirium care were measured using a 5-point Likert scale. Pre-educational and posteducational nursing knowledge was measured using raw scores obtained from a 15-item multiple choice test. Following the implementation of the delirium screening and care bundle protocol, nursing staff compliance with screening and care bundle items was measured, as well as overall incidence of positive delirium screenings among all screenings completed. RESULTS A sample of 49 nurses participated in the formal educational teaching sessions. All 5 nursing attitude and perceived confidence statements measured before and after the educational sessions showed a significant increase in positive perceptions overall (P < .0001). Overall mean posteducation knowledge test raw scores showed a significant improvement from pre-educational scores (70% ± 12.8% vs 95% ± 6.9%; P < .0001). Once-daily ICU delirium screenings and care bundle interventions were initiated for all ICU patients; overall compliance during the measurement period was 56.3% (598 of 1061 possible delirium screenings and protocols completed). Of all daily patient screenings performed, 20.4% resulted positive for ICU delirium. All patients who received the care bundle interventions received the interventions uniformly, regardless of clinical delirium status. CONCLUSION This quality improvement project demonstrates that a formal didactic training program for ICU nurses can result in increased awareness and knowledge of ICU delirium and adequately prepare them for how to properly screen and treat patients. Although overall compliance with implementing daily ICU delirium screenings and care bundle interventions was relatively low, those patients who did receive screening and interventions demonstrated that the incidence of positive delirium screenings at this facility is low compared with reported figures. In addition, patients who did receive the appropriate care bundle interventions did so in a uniform manner, regardless of the presence or absence of clinical delirium.

Objectives The nationwide prevalence of cannabis use/abuse has more than doubled from 2002 to 2011. Whether the outpatient trend is reflected in the inpatient setting is unknown. We examined the prevalence and incidence of cannabis abuse/dependence as determined by discharge coding in a 10-year (2002-2011) National Inpatient Sample, as well as various trends among demographics, comorbidities, and hospitalization outcomes. Methods Cannabis abuse/dependence was identified on the basis of International Classification of Diseases, 9th Revision, Clinical Modification codes 304.3* and 305.2* in adults aged 18 years or more. We excluded cases coded "in remission." National estimates of trends and matched-regression analyses were conducted. Results Overall, 2,833,567 (0.91%) admissions with documented cannabis abuse/dependence were identified, patients had a mean age of 35.12 ± 0.06 years, 62% were male, and there was an increasing trend in prevalence from 0.52% to 1.34% ( P P P = .002). Among acute pancreatitis admissions, cannabis abusers had a shorter length of stay (−11%) and lower hospitalization costs (−7%) than nonabusers. Conclusion Cannabis abuse/dependence is on the rise in the inpatient population, with an increasing trend toward older and sicker patients with increasing rates of moderate to severe disability. Psychiatric disorders and alcoholism are the main associated primary conditions. Cannabis abuse is associated with increased asthma incidence in nontobacco smokers and decreased hospital resource use in acute pancreatitis admissions.

Hyperglycemia and hypoglycemia have been linked to worse outcomes in critically ill patients. While there is controversy as to the optimal tightness of glucose control in critically ill patients, there is agreement that an upper limit to safe glucose levels exists and that avoiding hypoglycemic episodes should be prioritized. Our algorithm can assist clinicians in maintaining blood glucose ([Gbl]) within a desired target range while avoiding hypoglycemia.

The objective of the study was to determine the association between average glucose level (AVG) and hospital outcomes in critically ill patients.

Introduction: The effect of opioids on driving performance has been much debated. Driving is a complex task requiring integration of psychomotor, cognitive, motor and decision-making skills, visualspatial abilities, divided attention, and behavioral and emotional control. The objective of this systematic review was to assess the quality of studies and to revisit the concept that patients on stable opioids are safe to drive as it applies to everyday practice. Methods: We searched MEDLINE, EMBASE, PSYCinfo, CENTRAL, TRANSPORT, CINAHL, reference lists of retrieved articles and narrative reviews, for studies on chronic cancer and noncancer pain patients on opioids, tested by driving, driving simulator, or cognitive/ psychomotor tests. Methodological quality was assessed with Methodological Index for Nonrandomized Studies, cognitive/psychomotor tests were appraised regarding their sensitivity and validation, and whether confounding variables potentially affecting the study conclusions were recorded. The results were analyzed both quantitatively and qualitatively. Results: We included 35 studies (2044 patients, 1994 controls), 9% of the studies were of poor, 54% of fair, and 37% of high quality; 3 quarters of the studies used high sensitivity cognitive tests. Amount and dose of opioids varied largely in many studies. Mean number of possible but unreported confounders was 2.2 (range, 0 to 4), relating to failure of the studies to mention coprescriptions with psychotropic effects, pain severity, sleep disorder or daytime somnolence, and/or significant depressive or anxiety-related problems. Interpretation: The commonly held concept that “chronic pain patients on stable opioids are safe to drive” cannot be generalized to all such patients in everyday practice, but may be applicable only to a subset who meet certain criteria.

In patients undergoing mechanical ventilation for Acute Respiratory Distress Syndrome (ARDS), neuromuscular blocking agents (NMBAs) may improve oxygenation and decrease ventilator-induced lung injury but may also cause muscle weakness.

Acute pancreatitis (AP) is a rare event in pregnancy, occurring in approximately 3 in 10 000 pregnancies. The spectrum of AP in pregnancy ranges from mild pancreatitis to serious pancreatitis associated with necrosis, abscesses, pseudocysts and multiple organ dysfunction syndromes. Pregnancy related hematological and biochemical alterations influence the interpretation of diagnostic tests and assessment of severity of AP. As in any other disease associated with pregnancy, AP is associated with greater concerns as it deals with two lives rather than just one as in the non-pregnant population. The recent advances in clinical gastroenterology have improved the early diagnosis and effective management of biliary pancreatitis. Diagnostic studies such as endoscopic ultrasound, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography and therapeutic modalities that include endoscopic sphincterotomy, biliary stenting, common bile duct stone extraction and laparoscopic cholecystectomy are major milestones in gastroenterology. When properly managed AP in pregnancy does not carry a dismal prognosis as in the past.