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General Critical Care

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Guess

this is an Xray of a 43 years old female patient admitted yesterday in our ICU, done post intubation & central line insersion.



Do you notice what is of concern?

Alexei Ortiz Milan
Alexei Ortiz Milan
Dec 13, 2024

Also infusion of constract material or other substances during XR exposure can contribute to the increase of the brightness of the CVC

Effect of Four Hemoglobin Transfusion Threshold Strategies in Patients With Acute Myocardial Infarction and Anemia: A Target Trial Emulation Using MINT Trial Data: Annals of Internal Medicine: Vol 0, No 0


This secondary analysis of the MINT trial evaluated four transfusion thresholds (<10 g/dL, <9 g/dL, <8 g/dL, and <7 g/dL) in 3492 patients with acute MI and anemia. The 30-day risk for death or recurrent MI increased progressively as transfusion thresholds decreased, with a 14.8% risk at <10 g/dL, 15.1% at <9 g/dL, 15.9% at <8 g/dL, and 18.3% at <7 g/dL. However, wide confidence intervals preclude definitive conclusions. These findings suggest higher thresholds may reduce risk, but further research is needed due to imprecision in the estimates



Noor Ali Shah
Noor Ali Shah
Sep 20, 2024

Very nice and interesting case.

Excellent debriefing 👍.

Well done my dear. 👌.

Only one thing I am concerned , whether there’s any surgical emphysema after trial of tracheostomy tube insertion ?


Edited

Large vegetation on the posterior leaflet of mitral valve with severe MR!

Noor Ali Shah
Noor Ali Shah
Sep 18, 2024

Bacterial endocarditis is a serious condition that can sometimes lead to death. Bacterial endocarditis can also cause the bacteria to clump with cells and other things in the blood or blood clots.These clumps are often called vegetations.


The posterior leaflet is the section of the mitral valve that is located posterior to the 2 commissural areas. It has a wider attachment to the annulus than the anterior Meaning Large vegetations (>10 mm) may be associated with an increased risk of embolization. Importance Infective endocarditis is a life-threating condition with annual mortality of as much as 40% and is associated with embolic events in as many as 80% of cases.


Symptoms may include aching muscles and joints, chills, fever, headaches, breathlessness, a new or change to an existing heart murmur, nausea, or a swelling to the abdomen, legs or feet.


Signs and symptoms of SBE include the following:

Petechiae

Subungual (splinter) hemorrhages: Dark red, linear lesions in the nail beds

Osler nodes: Tender subcutaneous nodules usually found on the distal pads of the digits

Janeway lesions: Nontender maculae on the palms and soles

Roth spots: Retinal hemorrhages with small, clear centers (rare).


Embolic stroke with focal neurologic deficits (the most common neurologic sign)

Intracerebral hemorrhage

Multiple micro abscesses.



Diagnosis:


• Echocardiography: Key imaging modality for detecting vegetations.

• Transthoracic Echocardiogram (TTE): Initial non-invasive imaging.

• Transesophageal Echocardiogram (TEE): More sensitive, especially for detecting posterior leaflet involvement.

• Blood Cultures: To identify the causative organism.

• Laboratory Tests: Elevated inflammatory markers like CRP and ESR.


The Duke diagnostic criteria were developed by Durack and colleagues as a guide for reaching a valid definitive diagnosis of IE. The criteria combine the clinical, microbiologic, pathologic, and echocardiographic characteristics of a specific case.


Major blood culture criteria for IE include the following:

Two blood cultures positive for organisms typically found in patients with IE

Blood cultures persistently positive for 1 of these organisms, from cultures drawn more than 12 hours apart

Three or more separate blood cultures drawn at least 1 hour apart.


Major echocardiographic criteria include the following:

Echocardiogram positive for IE, documented by an oscillating intracardiac mass on a valve or on supporting structures, in the path of regurgitant jets, or on implanted material, in the absence of an alternative anatomic explanation

Myocardial abscess

Development of partial dehiscence of a prosthetic valve

New-onset valvular regurgitation.


Minor criteria for IE include the following:

Predisposing heart condition or intravenous drug use (IVDA)

Fever of 38°C (100.4°F) or higher

Vascular phenomena, including major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhage, or Janeway lesions

Immunologic phenomena such as glomerulonephritis, Osler nodes, Roth spots, or rheumatoid factor

Positive blood culture results not meeting major criteria or serologic evidence of active infection with an organism consistent with IE

Echocardiogram results consistent with IE but not meeting major echocardiographic criteria

A definitive clinical diagnosis can be made based on the following:

Two major criteria.

One major criterion and 3 minor criteria

Five minor criteria.


Types of infective endocarditis;


Native valve endocarditis (NVE), acute and subacute .

Prosthetic valve endocarditis (PVE), early and late.

Intravenous drug abuse (IVDA) endocarditis.



Treatment depends on the type of fungus or bacteria causing the infection and its severity. When caught in earlier stages, antibiotics can be effective. When there are vegetations, damage to the heart valve or an infected prosthetic valve, surgery is often necessary.


Indications for Surgery

Approximately 15% to 25% of patients with IE eventually require surgery.

Indications for surgical intervention in patients with NVE are as follows:

Congestive heart failure refractory to standard medical therapy

Fungal IE (except that caused by Histoplasma capsulatum)

Persistent sepsis after 72 hours of appropriate antibiotic treatment

Recurrent septic emboli, especially after 2 weeks of antibiotic treatment

Rupture of an aneurysm of the sinus of Valsalva

Conduction disturbances caused by a septal abscess

Kissing infection of the anterior mitral leaflet in patients with IE of the aortic valve.


In the above with huge mitral vegetation, we are usually doing Mitral Value Replacement, keeping in the risks and benefits in our centre.


Good luck and regards to all members.


Edited
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