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Objective Multiple factors have been identified as causes of intracranial compliance impairment (ICCI) among patients with obesity. On the other hand, obesity has been linked with worst outcomes in COVID‐19. Thus, the hypothesis of severe acute respiratory syndrome (SARS) conducing to cerebral hemodynamic disorders (CHD) able to worsen ICCI and play an additional role on prognosis determination for COVID‐19 among obese patients becomes suitable. Methods 50 cases of SARS by COVID‐19 were evaluated, for the presence of ICCI and cerebrovascular circulatory disturbances in correspondence with whether unfavorable outcomes (death or impossibility for mechanical ventilation weaning [MVW]) within 7 days after evaluation. The objective was to observe whether obese patients (BMI ≥ 30) disclosed worse outcomes and tests results compared with lean subjects with same clinical background. Results 23 (46%) patients among 50 had obesity. ICCI was verified in 18 (78%) obese, whereas in 13 (48%) of 27 non‐obese (p = 0,029). CHD were not significantly different between groups, despite being high prevalent in both. 69% unfavorable outcomes were observed among obese and 44% for lean subjects (p = 0,075). Conclusion In the present study, intracranial compliance impairment was significantly more observed among obese subjects and may have contributed for SARS COVID‐19 worsen prognosis.

Intracranial hypertension (IH) is a common and significant secondary insult in patients with acute neurologic injury. Clinical signs in patients with altered level of consciousness poorly predict IH, except in advanced stages. Head computed tomography (CT) scans are the initial examination in these patients since it can detect structural causes for IH and provides surgery indication. Optic nerve sheath ultrasound has good accuracy for detecting IH and can be useful as a triage tool in some settings.

There is no consensual definition of refractory shock. The use of more than 0.5 mcg/kg/min of norepinephrine or epinephrine to maintain target blood pressure is often used in clinical trials as a threshold. Nearly 6% of critically ill patients will develop refractory shock, which accounts for 18% of deaths in intensive care unit. Mortality rates are usually greater than 50%. The assessment of fluid responsiveness and cardiac function can help to guide therapy, and inotropes may be used if hypoperfusion signs persist after initial resuscitation. Arginine vasopressin is frequently used in refractory shock, although definite evidence to support this practice is still missing. Its associations with corticosteroids improved outcome in observational studies and are therefore promising alternatives. Other rescue therapies such as terlipressin, methylene blue, and high-volume isovolemic hemofiltration await more evidence before use in routine practice.

There are few reports in the literature regarding the use of venoarterial extracorporeal membrane oxygenation (ECMO) for double-dysfunction from both heart and lung contusions in polytrauma patients. This article reports a 48-year-old patient admitted after a traffic accident. He rapidly progressed to shock with low cardiac output due to myocardial contusion and refractory hypoxemia due to pulmonary contusion, an unstable chest wall and bilateral pneumothorax. ECMO was an effective rescue procedure in this dramatic situation and was successfully discontinued on the fourth day after the trauma. The patient also developed an extensive brain infarction and eventually died on the seventh day after admission.

To the Editor:A healthy 31-year-old man who was the victim of a motorvehicle accident developed multiple-organ failure secondary tocomplications of polytrauma, including acute kidney injuryrequiring continuous renal replacement therapy.Despite regional anticoagulation using citrate (mean postfiltercalcium concentration, 0.43 mmol/L), there was recurrent clottingwithin the circuit. A markedly greasy aspect of coagulated bloodin the dialyzer and bubble trap was noted (Fig 1). Triglycerideconcentration in the dialysis circuit blood was 1,667 mg/dL,which was similar to the serum level (1,772 mg/dL). Propofolwas the presumed cause of hypertriglyceridemia because ithad been used to control intracranial hypertension for the last10 days.Microscopic analysis of the dialyzer membrane revealed clotand fibrin without signs of fat deposition, as demonstrated byhistopathologic analysis with Sudan Black stain. Five days afterceasing propofol therapy, the patient’s blood triglyceride con-centration decreased to 534 mg/dL andfilter patency was bettermaintained. The patient had complete kidney recovery onfollow-up.A similar problem was described by Kazory et al