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Two healthy Landrace pigs anaesthetized with propofol suffered rapid onset of fatal sepsis. Clinical signs included severe arterial hypotension, loss of peripheral oxygenation, low end-tidal CO2, clinical onset of pulmonary oedema and cardiac dysfunction. Gross and histopathological examination revealed loss of vascular integrity with severe lung oedema and congestion, haemorrhages in several organs and fluid leakage into body cavities. Large numbers of Gram-negative bacteria, primarily Klebsiella sp., were present in the anaesthetic infusion containing propofol and were also cultured from internal organs of both pigs. The propofol was likely contaminated by bacteria after inappropriate handling and storage in the operating room. This report illustrates the potential for severe nosocomial infection when applying propofol in animals and humans and may serve as a reminder of the importance of strict aseptic practice in general, and specifically in the handling of this anaesthetic agent. [ABSTRACT FROM AUTHOR]

Summary: Although respiratory distress is encountered infrequently in equine practice, it can be serious and potentially fatal, requiring immediate and decisive intervention. History and physical examination can often give sufficient clues to identify the cause of respiratory distress and initiate emergency treatment. Ultrasonography can also be invaluable when assessing distress caused by lower respiratory tract issues. Upper respiratory tract obstruction, tension pneumothorax and occasionally pulmonary oedema can be rapidly fatal and require immediate intervention by emergency tracheotomy, thoracocentesis and evacuation of pleural air or administration of furosemide and oxygen, if available. Acute severe asthma and substantial pleural effusion are often not an immediate threat to life but nonetheless require fast intervention including administration of bronchodilators and corticosteroids or pleurocentesis, respectively. [ABSTRACT FROM AUTHOR]

Abstract Aims Remote dielectric sensing (ReDS) represents a contemporary non‐invasive technique reliant on electromagnetic energy to quantify pulmonary congestion. Its prognostic significance within the context of heart failure (HF) patients remains elusive. This study aimed to assess the prognostic implications of residual pulmonary congestion, as gauged by the ReDS system, among patients admitted due to congestive HF. Methods and results We enrolled hospitalized HF patients who underwent ReDS assessments upon admission and discharge in a blinded manner, independent of attending physicians. We evaluated the prognostic impact of the ReDS ratio between admission and discharge on the primary outcome, which encompassed all‐cause mortality and HF‐related re‐hospitalizations. A cohort of 133 patients (median age 78 [72, 84] years, 78 male [59%]) was included. Over a median observation period of 363 days post‐index discharge, an escalated ReDS group (ReDS ratio > 100%), determined through statistical calculation, emerged as an independent predictor of the primary outcome, exhibiting an adjusted hazard ratio of 4.37 (95% confidence interval 1.13–16.81, P = 0.032). The cumulative incidence of the primary outcome was notably higher in the increased ReDS group compared with the decreased ReDS group (50.1% vs. 8.5%, P = 0.034). Conclusions Elevated ReDS ratios detected during the index hospitalization could serve as a promising prognostic indicator in HF patients admitted for treatment. The clinical ramifications of ReDS‐guided HF management warrant validation in subsequent studies.

To our knowledge, no prior study has analysed a possible association between acetazolamide and pulmonary oedema. The aim of this study was to use data from the EudraVigilance to detect a safety signal for acetazolamide‐induced pulmonary oedema. We performed a disproportionality analysis (case–noncase method), calculating reporting odds ratios (RORs) up to 22 February 2024. Among 11 684 208 spontaneous cases of adverse reactions registered in EudraVigilance, 38 275 were pulmonary oedemas. Acetazolamide was involved in 31 cases. In more than half of those cases, the patients received a single dose of acetazolamide after undergoing cataract surgery: latency was 10–90 min. Remarkably, there were five cases of positive rechallenge and six cases resulted in death. The ROR for acetazolamide was 3.63 (95% CI 2.55–5.17). Disproportionality was also observed in VigiBase®: ROR 4.44 (95% CI 3.34–5.90). Our study confirms a signal that suggests a risk of serious pulmonary oedema associated with acetazolamide. [ABSTRACT FROM AUTHOR]

Background: Femoral fractures often lead to complications such as altered pulmonary hemodynamics. Right ventricular global longitudinal strain (RV GLS), which correlates with pulmonary hemodynamics, indicates the subclinical function of the right ventricle (RV). This study aimed to investigate the predictive value of RV GLS for the risk of adverse clinical composite outcomes in patients with femoral fractures. Methods: Data were obtained from a prospective single-center cohort of patients hospitalized for femoral fractures and followed up for at least 1 year between March 2021 and October 2022. The primary outcome was the development of an adverse composite clinical event, which included pneumonia, pulmonary oedema or effusion, pulmonary thromboembolism, and all-cause mortality within the 1-year period following surgery. Results: Among the 163 patients, 36 (22.09%) experienced adverse composite clinical events during 1-year follow-up. The adverse outcome group demonstrated poorer RV GLS and RV free wall strain values than the non-adverse outcome group. The optimal cut-off value of RV GLS for predicting composite adverse clinical events was −12.55%. The cumulative composite event-free survival rate was significantly lower in the RV GLS ≥ −12.55% group (log-rank p-value = 0.003). After adjusting for confounding factors, multivariate Cox proportional hazards regression analyses showed that RV GLS ≥ −12.55% independently increased the risk of composite adverse clinical events by 2.65-fold. Conclusions: Poor RV GLS is a significant predictor of adverse clinical outcomes in patients with femoral fractures. Specifically, an RV GLS value of ≥ −12.55% indicated a substantially increased risk of adverse events. [ABSTRACT FROM AUTHOR]

Aims: Remote dielectric sensing (ReDS) represents a contemporary non‐invasive technique reliant on electromagnetic energy to quantify pulmonary congestion. Its prognostic significance within the context of heart failure (HF) patients remains elusive. This study aimed to assess the prognostic implications of residual pulmonary congestion, as gauged by the ReDS system, among patients admitted due to congestive HF. Methods and results: We enrolled hospitalized HF patients who underwent ReDS assessments upon admission and discharge in a blinded manner, independent of attending physicians. We evaluated the prognostic impact of the ReDS ratio between admission and discharge on the primary outcome, which encompassed all‐cause mortality and HF‐related re‐hospitalizations. A cohort of 133 patients (median age 78 [72, 84] years, 78 male [59%]) was included. Over a median observation period of 363 days post‐index discharge, an escalated ReDS group (ReDS ratio > 100%), determined through statistical calculation, emerged as an independent predictor of the primary outcome, exhibiting an adjusted hazard ratio of 4.37 (95% confidence interval 1.13–16.81, P = 0.032). The cumulative incidence of the primary outcome was notably higher in the increased ReDS group compared with the decreased ReDS group (50.1% vs. 8.5%, P = 0.034). Conclusions: Elevated ReDS ratios detected during the index hospitalization could serve as a promising prognostic indicator in HF patients admitted for treatment. The clinical ramifications of ReDS‐guided HF management warrant validation in subsequent studies. [ABSTRACT FROM AUTHOR]

Drowning is considered to be the leading cause of death in water and the third most common cause of accidental death worldwide, with the highest drowning rates in developing countries. The WHO defines drowning as the process of experiencing respiratory impairment from submersion/immersion in liquid. For forensic experts, death in water is a multifaceted issue presenting a challenge to them. Since all the circumstances from natural death to homicide are possible in the water, critical examination and interpretation of all abnormal findings found during autopsy are of great importance. Drowning is a diagnosis of exclusion, based on ruling out all other causes of death via complete autopsy and toxicology. Drowning causes hypoxemia, loss of consciousness, apnea and ultimately cardiac arrest. Fluid aspiration results in lung injury and acute respiratory distress syndrome. Acute Respiratory Failure is the main component of drowning pathophysiology. Near drowning results in multiple complications including aspiration pneumonia which is often life-threatening. Hence the histopathological changes in the lungs provide good corroborative evidence of death due to drowning. Nevertheless, for the examined drowning signs, no high diagnostic certainty could be observed. However, these findings can increase their diagnostic value if forensic doctors take influencing factors into consideration. From the central record section of the Department of Forensic Medicine, Siddhartha Medical College, Vijayawada, Andhra Pradesh, about 80 medicolegal postmortem reports of death due to drowning in undecomposed bodies were selected in which one whole lung was sent for histopathological examination during the past two years i.e, 2020 - 2022. Parameters like Age, Sex and Marital Status were also studied. Histopathological examination of drowned lungs showed that congestion was seen in 92% of cases, oedema in 96% cases, dilatation of alveoli in 86% of cases, thinning of septa was seen in 84% of cases rupture of alveoli seen in 64% of cases and hemorrhageis seen in 46% of cases. Mostly males are affected and drowning deaths are seen more in 26 - 40 years age group. The histopathological investigations must be performed on all the organs of non-putrefied bodies with the aim of making the difference between death by drowning and other causes of death. The lung examinations can show over-distension of the alveoli, thinning of the alveolar septa and compression with narrowing of the capillary network. [ABSTRACT FROM AUTHOR]

The human body is made up principally of water, two-thirds of which is intracellular and one-third extracellular. Dissolved in body water are a variety of mineral and organic salts and proteins. These components are quantified in millimoles and are electrochemically balanced in each compartment. The relative quantities of each cation and anion are different in each compartment. Fluid motion through the body is determined by hydrostatic, osmotic and oncotic forces. The rate of extravasation is determined by the Starling equation. In perioperative medicine and critical care, temporal fluid shifts occur based on the stress response. Fluid management, in terms of volume and tonicity, should follow this response. Tissue oedema, particularly in the lungs, results from excess intravascular fluid or high venous pressures (hydrostatic pulmonary oedema) or damage to the capillary endothelium (capillary leak). [ABSTRACT FROM AUTHOR]

Lightning strike injury is a rare but a devastating lifethreatening condition affecting virtually all tissues and solid organs of the body. This can be attributed to the various energy transmission mechanisms from lightning strikes. This include ground strike, contact voltage, side flash, wire-mediated lightning, direct strike and weak upper streamer. Acute lung injury following lightning strike is an uncommon presentation which can manifest as pulmonary oedema, alveolar haemorrhage, pulmonary contusion and acute respiratory distress syndrome. This is a case report of a 15-year-old female, who presented to the Emergency CC –BY 4.0 unit following a lightning strike injury. She presented in coma from the referral centre, markedly dyspnoeic, and eventually admitted into the intensive care unit on account of respiratory failure. Chest radiograph findings showed features in-keeping with non- cardiogenic pulmonary oedema. She was mechanically ventilated, placed on steroids, hydrated, and given antibiotics. Following treatment, respiratory distress resolved and she regained full consciousness. She was discharged home after 11 days of admission.

Aims: Few studies have reported data on the optimal timing of left ventricular (LV) unloading during venoarterial extracorporeal membrane oxygenation (VA‐ECMO) for cardiac arrest or shock. This study evaluated the feasibility of an early LV unloading strategy compared with a conventional strategy in VA‐ECMO. Methods and results: Between December 2018 and August 2022, 60 patients at two institutions were randomized in a 1:1 ratio to receive early (n = 30) or conventional (n = 30) LV unloading strategies. The early LV unloading strategy was defined as LV unloading performed at the time of VA‐ECMO insertion. LV unloading was performed using a percutaneous transseptal left atrial cannulation via the femoral vein incorporated into the ECMO venous circuit. The early and conventional LV unloading groups included 29 (96.7%) and 23 (76.7%) patients, respectively (median time from VA‐ECMO insertion to LV unloading: 48.4 h, interquartile range 47.8–96.5 h). The groups showed no significant differences in the rate of VA‐ECMO weaning as the primary endpoint (70.0% vs. 76.7%; relative risk 0.91; 95% confidence interval 0.67–1.24; p = 0.386) and survival to discharge (53.3% vs. 50.0%, p = 0.796). However, the pulmonary congestion score index at 48 h after LV unloading was significantly improved only in the early LV unloading group (2.0 ± 0.7 vs. 1.7 ± 0.6 at baseline vs. at 48 h; p = 0.008). Conclusions: Compared with the conventional approach, early LV unloading did not improve the VA‐ECMO weaning rate, despite the rapid improvement in pulmonary congestion. Therefore, the results of this study do not support the application of this strategy after VA‐ECMO insertion. [ABSTRACT FROM AUTHOR]

Introduction: Myxoma of the left atrium is a less typical cause of mitral obstruction. If this develops, a flash pulmonary oedema can be the first manifestation. Case description: We present a case report of a 50-year-old woman who was admitted to our internal department because of dyspnoea. The patient overcame a stroke three years before the index hospitalisation with a negative transthoracic echocardiography. By anamnesis and physical examination, an exacerbation of COPD was assumed, and the patient was treated accordingly. As the patient showed numerous risk factors for heart failure with preserved ejection fraction, transthoracic echocardiography was performed. A large polypoid mass was found in the left atrium, which caused severe mitral obstruction. Subsequent transoesophageal echocardiography confirmed this finding. The patient underwent urgent cardiac surgery, and the tumour was successfully resected. A histological examination revealed a cardiac myxoma. After the cardiac surgery the patient felt well, and no recurrence of the tumour occurred. Conclusions: We provide a case report of a fast-growing myxoma that was incidentally found in a patient with dyspnoea. We highlight the fast growth rate of the tumour and the potential for misdiagnosed signs of pulmonary oedema caused by mitral obstruction.

A 16‐year‐old, 550 kg Connemara gelding was anaesthetised for resection of multiple small intestine strangulating lipomas via ventral midline celiotomy. Severe hypoxaemia, detected throughout the anaesthetic period (lowest PaO2 58 mmHg [7.6 kPa]), was unresponsive to the ventilatory strategies implemented. Flared nostrils and increased respiratory rate were present at recovery from anaesthesia. When the horse was returned to the yard, bilateral foamy nasal discharge and increased respiratory effort and rate were noticed, consistent with pulmonary oedema. The horse received oxygen supplementation and furosemide, which led to complete resolution within 24 hours. [ABSTRACT FROM AUTHOR]

Objectives: To describe the incidence and outcomes of pulmonary oedema in women with severe maternal outcome during childbirth and identify possible modifiable factors through audit. Methods: All women with severe maternal outcome (maternal deaths or near misses) who were referred to Tygerberg referral hospital from health facilities in Metro East district, South Africa, during 2014–2015 were included. Women with severe maternal outcome and pulmonary oedema during pregnancy or childbirth were evaluated using three types of critical incident audit: criterion‐based case review by one consultant gynaecologist, monodisciplinary critical incident audit by a team of gynaecologists, multidisciplinary audit with expert review from anaesthesiologists and cardiologists. Results: Of 32,161 pregnant women who gave birth in the study period, 399 (1.2%) women had severe maternal outcome and 72/399 (18.1%) had pulmonary oedema with a case fatality rate of 5.6% (4/72). Critical incident audit demonstrated that pre‐eclampsia/HELLP‐syndrome and chronic hypertension were the main conditions underlying pulmonary oedema (44/72, 61.1%). Administration of volumes of intravenous fluids in already sick women, undiagnosed underlying cardiac illness, administration of magnesium sulphate as part of pre‐eclampsia management and oxytocin for augmentation of labour were identified as possible contributors to the pathophysiology of pulmonary oedema. Women‐related factors (improved antenatal care attendance) and health care‐related factors (earlier diagnosis and management) would potentially have improved maternal outcome. Conclusions: Although pulmonary oedema in pregnancy is rare, among women with severe maternal outcome a considerable proportion had pulmonary oedema (18.1%). Audit identified options for prevention of pulmonary oedema and improved outcome. These included early detection and management of preeclampsia with close monitoring of fluid intake and cardiac evaluation in case of suspected pulmonary oedema. Therefore, a multidisciplinary clinical approach is recommended. [ABSTRACT FROM AUTHOR]

Investigating the impact of vascular blockage on blood biochemical parameters, particularly in the context of acute heart failure, is crucial for understanding the underlying mechanisms of arterial thromboembolism in animals. The purpose of the study is to investigate the effect of vascular occlusion on the biochemical parameters of blood in cats with cardiogenic arterial thromboembolism. The study involved 12 cats and formed two groups: the first – animals with acute heart failure and the second – animals with arterial thromboembolism. Anamnesis data were collected for experimental animals, clinical examination, echocardiography, and biochemical examination of blood samples were performed. The activity of alanine aminotransferase, aspartate aminotransferase and gamma-glutamyl transpeptidase, the concentration of glucose, creatinine, urea, potassium, calcium, total and inorganic phosphorus were determined spectrophotometrically in blood serum. It was found that in cats with acute heart failure, the average value of serum aspartate aminotransferase activity increased by 2.8 times, and the creatinine concentration by 1.9 times compared to the upper limit of reference values. This indicates functional changes in the myocardium and kidneys in this pathology. In cats affected by arterial thromboembolism, the blood serum shows a significant elevation in various biochemical parameters compared to the upper limit of the corresponding reference intervals. Specifically, there is a 4.4-fold increase in alanine aminotransferase activity, a 4.3-fold increase in aspartate aminotransferase activity, a 1.4- fold increase in glucose concentration, a 1.8-fold increase in creatinine levels, a 2.0-fold increase in urea levels, and a 1.3-fold increase in inorganic phosphorus levels. The changes in biochemical parameters for feline thromboembolism may be a consequence of functional renal failure, ischemia, and muscle necrosis. Moreover, it was established that in most cats with acute heart failure, the urinary system is primarily affected, and with arterial thromboembolism, changes in muscle tissue also occur. The results obtained are of practical value for veterinary doctors when choosing a therapeutic strategy and prescribing additional diagnostic examinations

Abstract Background Fluid therapy is a common intervention in critically ill patients. It is increasingly recognised that deresuscitation is an essential part of fluid therapy and delayed deresuscitation is associated with longer invasive ventilation and length of intensive care unit (ICU) stay. However, optimal timing and rate of deresuscitation remain unclear. Lung ultrasound (LUS) may be used to identify fluid overload. We hypothesise that daily LUS-guided deresuscitation is superior to deresuscitation without LUS in critically ill patients expected to undergo invasive ventilation for more than 24 h in terms of ventilator free-days and being alive at day 28. Methods The “effect of lung ultrasound-guided fluid deresuscitation on duration of ventilation in intensive care unit patients” (CONFIDENCE) is a national, multicentre, open-label, randomised controlled trial (RCT) in adult critically ill patients that are expected to be invasively ventilated for at least 24 h. Patients with conditions that preclude a negative fluid balance or LUS examination are excluded. CONFIDENCE will operate in 10 ICUs in the Netherlands and enrol 1000 patients. After hemodynamic stabilisation, patients assigned to the intervention will receive daily LUS with fluid balance recommendations. Subjects in the control arm are deresuscitated at the physician’s discretion without the use of LUS. The primary endpoint is the number of ventilator-free days and being alive at day 28. Secondary endpoints include the duration of invasive ventilation; 28-day mortality; 90-day mortality; ICU, in hospital and total length of stay; cumulative fluid balance on days 1–7 after randomisation and on days 1–7 after start of LUS examination; mean serum lactate on days 1–7; the incidence of reintubations, chest drain placement, atrial fibrillation, kidney injury (KDIGO stadium ≥ 2) and hypernatremia; the use of invasive hemodynamic monitoring, and chest-X-ray; and quality of life at day 28. Discussion The CONFIDENCE trial is the first RCT comparing the effect of LUS-guided deresuscitation to routine care in invasively ventilated ICU patients. If proven effective, LUS-guided deresuscitation could improve outcomes in some of the most vulnerable and resource-intensive patients in a manner that is non-invasive, easy to perform, and well-implementable. Trial registration ClinicalTrials.gov NCT05188092. Registered since January 12, 2022

Operative hysteroscopy intravascular absorption (OHIA) syndrome is a rare and potentially life-threatening complication related to irrigation fluid systemic absorption during hysteroscopy. It can lead to severe electrolyte disturbances, cerebral and pulmonary oedema, dysrhythmias and coagulopathy. We present the case of a 30-year-old woman who underwent a hysteroscopic myomectomy. After absorbing 2.5 l of normal saline, she experienced haemodynamic instability, respiratory distress and severe metabolic acidosis, initially mistaken for an anaphylactic or haemorrhagic shock. Insufficient monitoring of fluid deficit and irrigation fluid pressures contributed to the condition. This case underscores the importance of recognising OHIA and its risk factors to enable timely intervention and prevent adverse outcomes. Close fluid balance monitoring is vital in hysteroscopic surgeries to mitigate OHIA development.

Background and Aims: Administering liberal fluid raises concerns about pulmonary congestion postoperatively. Bedside ultrasonography is a valuable tool for the early detection of pulmonary congestion. In this study, we have used it to ascertain the impact of the duration of surgery and intraoperative fluid volume on the causation of pulmonary congestion. Our objective was to determine the incidence of pulmonary congestion as diagnosed by lung ultrasound in patients undergoing general anaesthesia with varied fluid administration. Methods: Seventy participants of American Society of Anesthesiologists physical status I and II, aged between 18 and 60 years, undergoing elective extrathoracic surgeries of over 3 h under general anaesthesia were included. Preoperative lung ultrasound was carried out in all patients, and a postoperative lung ultrasound was carried out at 1 h after extubation. The appearance of three or more "B"-lines was considered positive for lung congestion. Results: Significant differences (P < 0.001) were found in the duration of surgery and the appearance of B-lines in the postoperative period. Participants who developed B lines received, on average, 150% more fluid (1148.16 ± 291.79 ml) than those who did not (591.29 ± 398.42 ml) (P = 0.0240). Net fluid balance was also significantly different in patients who developed B lines (P = 0.0014). None of the patients developed symptoms of lung congestion postoperatively. Conclusion: Long duration of surgery under general anaesthesia (>3 h) with the administration of large volumes of intraoperative fluid and a large net fluid balance are associated with lung congestion as diagnosed by lung ultrasound. [ABSTRACT FROM AUTHOR]

Background: Vaccination has emerged as an effective tool to prevent severe acute respiratory syndrome coronavirus 2 disease (COVID-19). Concerns regarding adverse effects of vaccine are one of the reasons for vaccine hesitancy. One way of addressing the concerns is by studying post-vaccination deaths. This article presents the autopsy findings of the six individuals who died within 6 weeks post-COVID-19 vaccinations. Methods: This was a retrospective study of autopsies done between January and June 2021 in recipients of COVID-19 vaccination. All the organs were preserved. After adequate fixation, the organs were grossed and sections were taken. Results: A total of 6 patients who died after receiving COVID-19 vaccine were autopsied during the study period. All six cases had received Covishield® vaccine. All the individuals were aged between 40 and 60 years, with four males and two females. The duration between vaccination and death ranged from 24 h to 11 days. Three cases had pathology in the kidney, two cases showed pathology in the heart and one case showed pulmonary oedema in both lungs. Conclusions: This article throws light on post-mortem findings of deaths associated with COVID-19 vaccination.

Background: Intravenous fluid administration is an essential part of perioperative care for children receiving a kidney transplant. There is a paucity of evidence to guide optimal perioperative fluid management. This study aimed to identify the volume of perioperative fluids administered across 5 UK paediatric kidney transplant centres and explore associations between fluid volume administered, graft function, and fluid-related adverse events. Methods: Data were collected from five UK paediatric kidney transplant centres on perioperative fluid volumes administered, and incidence of pulmonary oedema, systemic hypertension, and requirement for intensive care support. Children < 18 years of age who received a kidney-only transplant between 1st January 2020 and 31st December 2021 were included. Results: Complete data from 102 children were analysed. The median total volume of fluid administered in 72 h was 377 ml/kg (IQR 149 ml/kg) with a high degree of variability. A negative relationship between total fluid volume administered and day 7 eGFR was noted (p < 0.001). Association between urine volume post-transplant and day 7 eGFR was also negative (p < 0.001). Adverse events were frequent but no significant difference was found in the fluid volume administered to those who developed an adverse event, vs those who did not. Conclusions: This study describes a high degree of variability in perioperative fluid volumes administered to children receiving kidney transplants. Both fluid volume and urine output were negatively associated with short-term graft function. These data contrast traditional interpretation of high urine output as a marker of graft health, and highlight the need for prospective clinical trials to optimise perioperative fluid administration for this group. A higher resolution version of the Graphical abstract is available as Supplementary information [ABSTRACT FROM AUTHOR]

Background: Fluid therapy is a common intervention in critically ill patients. It is increasingly recognised that deresuscitation is an essential part of fluid therapy and delayed deresuscitation is associated with longer invasive ventilation and length of intensive care unit (ICU) stay. However, optimal timing and rate of deresuscitation remain unclear. Lung ultrasound (LUS) may be used to identify fluid overload. We hypothesise that daily LUS-guided deresuscitation is superior to deresuscitation without LUS in critically ill patients expected to undergo invasive ventilation for more than 24 h in terms of ventilator free-days and being alive at day 28. Methods: The "effect of lung ultrasound-guided fluid deresuscitation on duration of ventilation in intensive care unit patients" (CONFIDENCE) is a national, multicentre, open-label, randomised controlled trial (RCT) in adult critically ill patients that are expected to be invasively ventilated for at least 24 h. Patients with conditions that preclude a negative fluid balance or LUS examination are excluded. CONFIDENCE will operate in 10 ICUs in the Netherlands and enrol 1000 patients. After hemodynamic stabilisation, patients assigned to the intervention will receive daily LUS with fluid balance recommendations. Subjects in the control arm are deresuscitated at the physician's discretion without the use of LUS. The primary endpoint is the number of ventilator-free days and being alive at day 28. Secondary endpoints include the duration of invasive ventilation; 28-day mortality; 90-day mortality; ICU, in hospital and total length of stay; cumulative fluid balance on days 1–7 after randomisation and on days 1–7 after start of LUS examination; mean serum lactate on days 1–7; the incidence of reintubations, chest drain placement, atrial fibrillation, kidney injury (KDIGO stadium ≥ 2) and hypernatremia; the use of invasive hemodynamic monitoring, and chest-X-ray; and quality of life at day 28. Discussion: The CONFIDENCE trial is the first RCT comparing the effect of LUS-guided deresuscitation to routine care in invasively ventilated ICU patients. If proven effective, LUS-guided deresuscitation could improve outcomes in some of the most vulnerable and resource-intensive patients in a manner that is non-invasive, easy to perform, and well-implementable. Trial registration: ClinicalTrials.gov NCT05188092. Registered since January 12, 2022 [ABSTRACT FROM AUTHOR]

Background and Objectives: Transfusion‐associated circulatory overload (TACO) is a pulmonary transfusion complication and a leading cause of transfusion‐related morbidity and mortality. Volume overload and rising hydrostatic pressure as a consequence of transfusion are seen as the central pathway leading to TACO. A possible preventative measure for TACO could be the use of low‐volume blood products like volume‐reduced lyophilized plasma. We hypothesize that volume‐reduced lyophilized plasma decreases circulatory overload leading to a reduced pulmonary capillary pressure and can therefore be an effective strategy to prevent TACO. Materials and Methods: A validated two‐hit animal model in rats with heart failure was used. Animals were randomized to receive 4 units of either solvent‐detergent pooled plasma (SDP) as control, standard volume lyophilized plasma (LP‐S) or hyperoncotic volume‐reduced lyophilized plasma (LP‐VR). The primary outcome was the difference between pre‐transfusion and post‐transfusion left ventricular end‐diastolic pressure (ΔLVEDP). Secondary outcomes included markers for acute lung injury. Results: LVEDP increased in all randomization groups following transfusion. The greatest elevation was seen in the group receiving LP‐VR (+11.9 mmHg [5.9–15.6]), but there were no significant differences when compared to groups receiving either LP‐S (+6.3 mmHg [2.9–13.4], p = 0.29) or SDP (+7.7 mmHg [4.5–10.5], p = 0.55). There were no significant differences in markers for acute lung injury, such as pulmonary wet/dry weight ratios, lung histopathology scores or PaO2/FiO2 ratio between the three groups. Conclusion: Transfusion with hyperoncotic volume‐reduced plasma did not attenuate circulatory overload compared to standard volume plasma and was therefore not an effective preventative strategy for TACO in this rat model. [ABSTRACT FROM AUTHOR]

Introduction: The Radiographic Assessment of Lung Edema (RALE) score provides a semi-quantitative measure of pulmonary edema. In patients with acute respiratory distress syndrome (ARDS), the RALE score is associated with mortality. In mechanically ventilated patients in the intensive care unit (ICU) with respiratory failure not due to ARDS, a variable degree of lung edema is observed as well. We aimed to evaluate the prognostic value of RALE in mechanically ventilated ICU patients. Methods: Secondary analysis of patients enrolled in the 'Diagnosis of Acute Respiratory Distress Syndrome' (DARTS) project with an available chest X-ray (CXR) at baseline. Where present, additional CXRs at day 1 were analysed. The primary endpoint was 30-day mortality. Outcomes were also stratified for ARDS subgroups (no ARDS, non-COVID-ARDS and COVID-ARDS). Results: 422 patients were included, of which 84 had an additional CXR the following day. Baseline RALE scores were not associated with 30-day mortality in the entire cohort (OR: 1.01, 95% CI: 0.98–1.03, p = 0.66), nor in subgroups of ARDS patients. Early changes in RALE score (baseline to day 1) were only associated with mortality in a subgroup of ARDS patients (OR: 1.21, 95% CI: 1.02–1.51, p = 0.04), after correcting for other known prognostic factors. Conclusions: The prognostic value of the RALE score cannot be extended to mechanically ventilated ICU patients in general. Only in ARDS patients, early changes in RALE score were associated with mortality. [ABSTRACT FROM AUTHOR]

Background Valve thrombosis is a well-documented cause of bioprosthetic valve failure. Case reports have been published of prosthetic valve thrombosis secondary to COVID-19 infection. This is the first case report of COVID-19 associated valve thrombosis in a patient with transcatheter aortic valve replacement (TAVR). Case summary A 90-year-old female with atrial fibrillation on therapeutic apixaban and status-post TAVR presented with COVID-19 infection and was found to have severe bioprosthetic valvular regurgitation with features suggestive of valve thrombosis. She underwent valve-in-valve TAVR with resolution of valvular dysfunction. Discussion This case report contributes to a growing body of evidence describing the occurrence of thrombotic complications in patients with valve replacement and COVID-19 infection. Increased vigilance and continued investigation are warranted to better characterize thrombotic risk and to inform optimal antithrombotic strategies during COVID-19 infection. [ABSTRACT FROM AUTHOR]

Key message Perinatal cardiomyopathy presents similarly to dilated cardiomyopathy and should be suspected in perinatal women presenting with dyspnoea, even with no previous history of heart disease.

Introduction: Scorpion envenomation is a life-threatening paediatric emergency. Prazosin-an alpha-1 blocker is the gold standard therapy for scorpion envenomation. Many children with scorpion envenomation were under-treated at Primary Healthcare (PHC) and Secondary Healthcare (SHC) level because of lack of awareness about prazosin therapy. If Prazosin is started earlier at PHC and SHC level, complications and mortality can be reduced. Aim: To conduct sensitisation programme for PHC and SHC doctors regarding the management of paediatric emergencies including scorpion envenomation, and to evaluate the effectiveness of sensitisation programme on prazosin therapy for scorpion envenomation at PHC and SHC level. Materials and Methods: This non concurrent clinical trial consisted of training PHC and SHC doctors at the Department of Paediatrics, Government Dharmapuri Medical College Hospital, Tamil Nadu, India for a period of two years (January 2018-December 2019). After the training, children aged 1 month-12 years with features of scorpion envenomation referred from PHC and SHC to this tertiary care centre, during January 2021-September 2021 were evaluated. The data regarding initiation of prazosin therapy at PHC and SHC level and the clinical profile, complications and outcome at tertiary care level were noted. The present study parameters were compared with previous study on scorpion envenomation, done before the sensitisation programme in the same centre, and the data were compared. Results: Training was given to 120 medical officers of PHC and SHC. Sixty-two children, with scorpion envenomation referred from PHC and SHC, were included in the study. Seven (10%) children were brought to the tertiary care centre directly were excluded. Prazosin therapy was initiated in 43 (69.3%) children at PHC and SHC level before referral. Initiation of prazosin within four hours of scorpion sting was done in 45 (72.6%). Common symptoms were pain {42 (68%)}, diaphoresis {26 (42%)} and salivation {25 (40%)}. Cold peripheries, myocarditis and pulmonary oedema were noted in 24 (39%), 4 (6%) and 6 (10%) children, respectively. Dobutamine and Non Invasive Ventilation (NIV) were needed in 13 (21%) and 11 (18%) cases, respectively. When compared to the observations pre-training, peripheral circulatory failure (76% to 39%) (p=0.019), pulmonary oedema (27% to 10%) (p=0.010), myocarditis (17% to 6%) (p=0.039), ionotrope support (41% to 21%) (p=0.024), and NIV (39% to 18%) (p

Lung transplantation is the definitive end-stage treatment for many lung diseases, and postoperative pulmonary oedema severely affects survival after lung transplantation. Optimizing perioperative fluid management can reduce the incidence of postoperative pulmonary oedema and improve the prognosis of lung transplant patients by removing the influence of patient, donor’s lung and ECMO factors. Therefore, this article reviews seven aspects of lung transplant patients' pathophysiological characteristics, physiological characteristics of fluids, the influence of the donor lung on pulmonary oedema as well as current fluid rehydration concepts, advantages or disadvantages of intraoperative monitoring tools or types of fluids on postoperative pulmonary oedema, while showing the existing challenges in section 7. The aim is to show the specificity of perioperative fluid management in lung transplant patients and to provide new ideas for individualised fluid management in lung transplantation.

Background: Vaccination has emerged as an effective tool to prevent severe acute respiratory syndrome coronavirus 2 disease (COVID-19). Concerns regarding adverse effects of vaccine are one of the reasons for vaccine hesitancy. One way of addressing the concerns is by studying post-vaccination deaths. This article presents the autopsy findings of the six individuals who died within 6 weeks post-COVID-19 vaccinations. Methods: This was a retrospective study of autopsies done between January and June 2021 in recipients of COVID-19 vaccination. All the organs were preserved. After adequate fixation, the organs were grossed and sections were taken. Results: A total of 6 patients who died after receiving COVID-19 vaccine were autopsied during the study period. All six cases had received Covishield® vaccine. All the individuals were aged between 40 and 60 years, with four males and two females. The duration between vaccination and death ranged from 24 h to 11 days. Three cases had pathology in the kidney, two cases showed pathology in the heart and one case showed pulmonary oedema in both lungs. Conclusions: This article throws light on post-mortem findings of deaths associated with COVID-19 vaccination. [ABSTRACT FROM AUTHOR]

Investigating the impact of vascular blockage on blood biochemical parameters, particularly in the context of acute heart failure, is crucial for understanding the underlying mechanisms of arterial thromboembolism in animals. The purpose of the study is to investigate the effect of vascular occlusion on the biochemical parameters of blood in cats with cardiogenic arterial thromboembolism. The study involved 12 cats and formed two groups: the first -- animals with acute heart failure and the second -- animals with arterial thromboembolism. Anamnesis data were collected for experimental animals, clinical examination, echocardiography, and biochemical examination of blood samples were performed. The activity of alanine aminotransferase, aspartate aminotransferase and gamma-glutamyl transpeptidase, the concentration of glucose, creatinine, urea, potassium, calcium, total and inorganic phosphorus were determined spectrophotometrically in blood serum. It was found that in cats with acute heart failure, the average value of serum aspartate aminotransferase activity increased by 2.8 times, and the creatinine concentration by 1.9 times compared to the upper limit of reference values. This indicates functional changes in the myocardium and kidneys in this pathology. In cats affected by arterial thromboembolism, the blood serum shows a significant elevation in various biochemical parameters compared to the upper limit of the corresponding reference intervals. Specifically, there is a 4.4-fold increase in alanine aminotransferase activity, a 4.3-fold increase in aspartate aminotransferase activity, a 1.4- fold increase in glucose concentration, a 1.8-fold increase in creatinine levels, a 2.0-fold increase in urea levels, and a 1.3-fold increase in inorganic phosphorus levels. The changes in biochemical parameters for feline thromboembolism may be a consequence of functional renal failure, ischemia, and muscle necrosis. Moreover, it was established that in most cats with acute heart failure, the urinary system is primarily affected, and with arterial thromboembolism, changes in muscle tissue also occur. The results obtained are of practical value for veterinary doctors when choosing a therapeutic strategy and prescribing additional diagnostic examinations [ABSTRACT FROM AUTHOR]

Background: Fluid assessment is challenging, and fluid overload poses a significant problem among dialysis patients, with pulmonary oedema being the most serious consequence. Our study aims to develop a simple objective fluid assessment strategy using lung ultrasound (LUS) and artificial intelligence (AI) to assess the fluid status of dialysis patients. Methods: This was a single-centre study of 76 hemodialysis and peritoneal dialysis patients carried out between July 2020 to May 2022. The fluid status of dialysis patients was assessed via a simplified 8-point LUS method using a portable handheld ultrasound device (HHUSD), clinical examination and bioimpedance analysis (BIA). The primary outcome was the performance of 8-point LUS using a portable HHUSD in diagnosing fluid overload compared to physical examination and BIA. The secondary outcome was to develop and validate a novel AI software program to quantify B-line count and assess the fluid status of dialysis patients. Results: Our study showed a moderate correlation between LUS B-line count and fluid overload assessed by clinical examination (r = 0.475, p < 0.001) and BIA (r = 0.356. p < 0.001). The use of AI to detect B-lines on LUS in our study for dialysis patients was shown to have good agreement with LUS B lines observed by physicians; (r = 0.825, p < 0.001) for the training dataset and (r = 0.844, p < 0.001) for the validation dataset. Conclusion: Our study confirms that 8-point LUS using HHUSD, with AI-based detection of B lines, can provide clinically useful information on the assessment of hydration status and diagnosis of fluid overload for dialysis patients in a user-friendly and time-efficient way. [ABSTRACT FROM AUTHOR]

This case demonstrates the value of perioperative point-of-care ultrasound for rapid bedside evaluation and treatment of pulmonary oedema in an infant. A nine-week-old male infant undergoing cleft lip repair received significant intravenous fluid resuscitation for intraoperative hypotension. After uneventful extubation, he developed increased work of breathing and a gradual decline in oxygen saturation despite supplemental oxygen by way of a facemask. Lung point-of-care ultrasound revealed confluent B-lines in multiple lung fields, consistent with pulmonary oedema, likely from fluid overload. He was treated with furosemide resulting in clinical improvement within 30 minutes. [ABSTRACT FROM AUTHOR]

Abstract Background An abrupt lung deflation in rodents results in lung injury through vascular mechanisms. Ventilator disconnections during endo-tracheal suctioning in humans often cause cardio-respiratory instability. Whether repeated disconnections or lung deflations cause lung injury or oedema is not known and was tested here in a porcine large animal model. Methods Yorkshire pigs (~ 12 weeks) were studied in three series. First, we compared PEEP abruptly deflated from 26 cmH2O or from PEEP 5 cmH2O to zero. Second, pigs were randomly crossed over to receive rapid versus gradual PEEP removal from 20 cmH2O. Third, pigs with relative volume overload, were ventilated with PEEP 15 cmH2O and randomized to repeated ETT disconnections (15 s every 15 min) or no disconnection for 3 h. Hemodynamics, pulmonary variables were monitored, and lung histology and bronchoalveolar lavage studied. Results As compared to PEEP 5 cmH2O, abrupt deflation from PEEP 26 cmH2O increased PVR, lowered oxygenation, and increased lung wet-to-dry ratio. From PEEP 20 cmH2O, gradual versus abrupt deflation mitigated the changes in oxygenation and vascular resistance. From PEEP 15, repeated disconnections in presence of fluid loading led to reduced compliance, lower oxygenation, higher pulmonary artery pressure, higher lung wet-to-dry ratio, higher lung injury score and increased oedema on morphometry, compared to no disconnects. Conclusion Single abrupt deflation from high PEEP, and repeated short deflations from moderate PEEP cause pulmonary oedema, impaired oxygenation, and increased PVR, in this large animal model, thus replicating our previous finding from rodents. Rapid deflation may thus be a clinically relevant cause of impaired lung function, which may be attenuated by gradual pressure release.

The objective of this study was to evaluate critically the nature and prevalence of histological pulmonary lesions in dogs and cats that had died or were euthanized because of tick paralysis. A retrospective and prospective case study of 11 cats and 23 dogs was carried out. Retrospective cases were gathered from the Veterinary Laboratory Services database at The University of Queensland (UQ). Prospective cases were provided by Veterinary Specialist Services and UQ VETs Small Animal Hospital. Lung and other tissue samples were collected for histopathological analysis. All tick intoxicated animals demonstrated evidence of pulmonary parenchymal changes: alveolar oedema, interstitial and alveolar congestion and alveolar fibrin exudation. Eleven of 23 (48%) dogs exhibited mild to severe bronchopneumonia. A lower rate (18%) of bronchopneumonia was found in cats, with one case of aspiration pneumonia. A novel pulmonary histological grading scheme was developed to evaluate the correlation between clinical presentation and histopathological changes. Novel extrapulmonary lesions in cats included hepatic necrosis and acute renal tubular necrosis attributed to hypoxia. We concluded that both dogs and cats with high clinical grade tick paralysis are extremely likely to have pulmonary pathology. High-protein oedema and fibrin exudation are predicted to be present in most cases of canine and feline tick paralysis. [ABSTRACT FROM AUTHOR]

This case report describes the anaesthesia of a ram undergoing an exploratory laparotomy, which suffered from respiratory distress during the perioperative period. On the morning of surgery, the animal presented with oedematous ears, most likely caused by a tight‐fitting muzzle that had been used for preoperative fasting. After sedation, a mild stridor was heard. During endotracheal intubation, a swollen larynx was observed, and a frothy discharge emerged through the endotracheal tube after placement. Most likely, the tight muzzle caused a partial obstruction of the nostrils, increasing the respiratory effort and causing an increase in the pressure gradient, which provoked laryngeal and pulmonary oedema. Treatment consisted of repeated suctioning of fluid from the endotracheal tube, furosemide, dexamethasone, mechanical ventilation with 100% oxygen during anaesthesia and oxygen supplementation during recovery. Despite moderately low arterial oxygen tension during anaesthesia, the animal recovered uneventfully and did not show further signs of respiratory distress. [ABSTRACT FROM AUTHOR]

Background: Pulmonary oedema is a feared and difficult to predict complication of severe malaria that can emerge after start of antimalarial treatment. Proinflammatory mediators are thought to play a central role in its pathogenesis., Methods: An exploratory study was conducted to evaluate the predictive capacity of biomarkers for development of clinical pulmonary oedema in patients with severe falciparum malaria at two hospitals in Bangladesh. Plasma concentrations of interleukin-6 (IL-6), IL-8, tumour necrosis factor (TNF), soluble Receptor of Advanced Glycation End-products (sRAGE), surfactant protein-D (SP-D), club cell secretory protein (CC16), and Krebs von den Lungen-6 (KL-6) on admission were compared with healthy controls. Correlations between these biomarker and plasma lactate and Plasmodium falciparum histidine-rich protein 2 (PfHRP2) levels were evaluated. Receiver Operating Characteristic (ROC) curves were constructed to assess the predictive capacity for clinical pulmonary oedema of the biomarkers of interest., Results: Of 106 screened patients with falciparum malaria, 56 were classified as having severe malaria with a mortality rate of 29%. Nine (16%) patients developed clinical pulmonary oedema after admission. Plasma levels of the biomarkers of interest were higher in patients compared to healthy controls. IL-6, IL-8, TNF, sRAGE, and CC16 levels correlated well with plasma PfHRP2 levels (r s = 0.39; P = 0.004, r s = 0.43; P = 0.001, r s = 0.54; P < 0.001, r s = 0.44; P < 0.001, r s = 0.43; P = 0.001, respectively). Furthermore, IL-6 and IL-8 levels correlated well with plasma lactate levels (r s = 0.37; P = 0.005, r s = 0.47; P < 0.001, respectively). None of the biomarkers of interest had predictive capacity for development of clinical pulmonary oedema., Conclusions: IL-6, IL-8, TNF, sRAGE, SP-D, CC16 and KL-6 cannot be used in predicting clinical pulmonary oedema in severe malaria patients., (© 2024. The Author(s).)

Abstract Complicated eclampsia resulting in cardiac arrest and subsequent fetal and maternal survival is rare. A 25-year-old primigravida was referred after initial resuscitation for cardiac arrest following a maternal collapse during pregnancy due to eclampsia at 36 weeks of pregnancy. The diagnosis at referral was antepartum eclampsia, pulmonary oedema and intrauterine fetal death. Re-evaluation revealed presence of fetal cardiac activity on ultrasound and an immediate emergency Caesarean Section was carried out and a live baby with APGAR of 3/10 was delivered and cared for in neonatal intensive care unit after intubation and positive pressure ventilation. Mother was managed in obstetric intensive care unit and was on ventilator for 72 h. She was treated for pulmonary oedema and persistent hypertensive crisis requiring multiple antihypertensives including nitroglycerine. Her echocardiogram showed global hypokinesia and left ventricular ejection fraction of 45% on day 1 which later improved to normal by day 15. MRI brain showed features of posterior reversible encephalopathy syndrome. She was given levitricetam for seizure prophylaxis. In addition, she required treatment for aspiration pneumonia. She was discharged after 16 days on two antihypertensive drugs along with her baby in good health. Timely resuscitation following cardiac arrest and transport to a tertiary care centre and control of hypertensive crisis with multidisciplinary care were the life-saving factors in this case.

Abstract Background Cardiogenic pulmonary oedema (CPE) may contribute to ventilator-associated lung injury (VALI) in patients with cardiogenic shock. The appropriate ventilatory strategy remains unclear. We aimed to evaluate the impact of ultra-low tidal volume ventilation with tidal volume of 3 ml/kg predicted body weight (PBW) in patients with CPE and veno–arterial extracorporeal membrane oxygenation (V–A ECMO) on lung inflammation compared to conventional ventilation. Methods A single-centre randomized crossover trial was performed in the Cardiac Intensive Care Unit (ICU) at a tertiary university hospital. Seventeen adults requiring V–A ECMO and mechanical ventilation due to cardiogenic shock were included from February 2017 to December 2018. Patients were ventilated for two consecutive periods of 24 h with tidal volumes of 6 and 3 ml/kg of PBW, respectively, applied in random order. Primary outcome was the change in proinflammatory mediators in bronchoalveolar lavage fluid (BALF) between both ventilatory strategies. Results Ventilation with 3 ml/kg PBW yielded lower driving pressures and end-expiratory lung volumes. Overall, there were no differences in BALF cytokines. Post hoc analyses revealed that patients with high baseline levels of IL-6 showed statistically significant lower levels of IL-6 and IL-8 during ultra-low tidal volume ventilation. This reduction was significantly proportional to the decrease in driving pressure. In contrast, those with lower IL-6 baseline levels showed a significant increase in these biomarkers. Conclusions Ultra-low tidal volume ventilation in patients with CPE and V–A ECMO may attenuate inflammation in selected cases. VALI may be driven by an interaction between the individual proinflammatory profile and the mechanical load overimposed by the ventilator. Trial registration The trial was registered in ClinicalTrials.gov (identifier NCT03041428, Registration date: 2nd February 2017).

B-lines in lung ultrasound (LU) are non-specific but highly informative sign of interstitial pulmonary oedema (iPE). Sustained exposure to a high-volume left-to-right patent ductus arteriosus (PDA) shunt is associated with iPE. Cardiorespiratory deterioration, named post-ligation cardiac syndrome (PLCS), may follow surgical ligation between 6 and 12 h post-operatively. We conducted a pilot longitudinal evaluation of peri-procedural LU score change. Infants < 32-week gestational age or < 1500-g birthweight undergoing PDA ligation, where pre-, 1 h and 6–12 h LU were performed, were included. Two independent raters evaluated LU score (LUS). Neonatologist performed echocardiography (NPE) was performed concurrently to appraise changes in left ventricular output (LVO). Milrinone was initiated if LVO was < 200 mL/kg/min 1 h after surgery, to prevent PLCS. The primary outcome was peri-procedural LUS change. Secondary outcomes included PLCS. Five infants were included (birthweight 787(88) g; gestational age 25.6(0.7) weeks). Postnatal age and weight at the intervention were 41(14) days and 1175(295) g. All infants, but one, received milrinone prophylaxis. None of the patients developed PLCS or required rescue HFOV. Post-interventional LUS were lower compared to pre-operative LUS (p = 0.041 vs 1 h, p = 0.042 vs 6–12 h). A concurrent fall post-operative LVO was noted (p < 0.05 vs pre-operative). Conclusion: A sustained fall in LUS after PDA ligation was identified, which most likely reflects reduction in pulmonary blood flow and interstitial edema. Changes in LUS paralleled changes in LVO, suggesting physiologic linkage. These data suggest that LU may be a useful tool to guide monitoring the biologic nature of pulmonary disease after PDA ligation. What is Known: • Sustained exposure to a high-volume left-to-right patent ductus arteriosus (PDA) shunt is associated with interstitial pulmonary oedema. • In the most immature patients, cardiorespiratory deterioration, named post-ligation cardiac syndrome, presents 6–12 h post-operatively. What is New: • An early and sustained fall in lung ultrasound score (LUS) after PDA ligation most likely reflects reduction in pulmonary blood flow and interstitial oedema. LUS changes parallel changes in left ventricular output, suggesting linkage. • LU is a promising adjunctive tool in the post-operative management of PDA ligation. [ABSTRACT FROM AUTHOR]

Lungs are the primary interface between the atmosphere and working tissues and act as the primary metabolic machinery of the body. The gas exchange that occurs inside the lungs through alveoli ensures adequate supply of oxygen to the tissues and determines the physical and physiological well beingness of the individuals. Barometric pressure decreases as altitude increases and individuals performing physically taxing activities in hypobaric hypoxic conditions need oxygen supplement due to reduced partial pressure of oxygen unless fully acclimatized. The physical activities at high altitude need more oxygen (partial pressure) to compensate for reduced barometric pressure. High Altitude Pulmonary Oedema (HAPO) is a deadly and fatal condition that can manifest in sojourners, mountaineers, scientific expedition teams or military personnel at high altitude. This paper while providing an insight into HAPO conditions, describes the principles behind design and safety of military customised fabric chamber developed by authors for field treatment. [ABSTRACT FROM AUTHOR]

The purpose of the study was to investigate post-mortem changes in dogs infected with Babesia canis and to establish the probable cause of death of the affected animals.

Abstract Background Diaphragm dysfunction and weaning-induced pulmonary oedema are commonly involved during weaning failure, but their physiological interactions have been poorly reported. Our hypothesis was that diaphragm dysfunction is not particularly associated with weaning-induced pulmonary oedema. Methods It was a single-centre and physiological study conducted in patients who had failed a first spontaneous breathing trial and who underwent a second trial. The diaphragm function was evaluated by measuring the tracheal pressure generated in response to a bilateral magnetic phrenic nerves stimulations. Weaning-induced pulmonary oedema was diagnosed in case of failure of the spontaneous breathing trial if patients exhibited signs of plasma concentration or echocardiographic diagnosis of pulmonary artery occlusion pressure elevation. Results Fifty-three patients were included and 31/53 (58%) failed the spontaneous breathing trial, including 24/31 (77%) patients with weaning-induced pulmonary oedema. Diaphragm dysfunction was present in 33/53 (62%) patients. Diaphragm dysfunction or weaning-induced pulmonary oedema were present in 26/31 (84%) of the patients who failed the spontaneous breathing trial. Weaning-induced pulmonary oedema occurred in 20/33 (61%) patients with a diaphragm dysfunction and in 4/20 (20%) patients without (p = 0.005). Conclusion Weaning-induced pulmonary oedema was three times more frequent in case of diaphragm dysfunction. Even in case of diaphragm dysfunction, physicians might be encouraged to investigate the presence of weaning-induced pulmonary oedema during weaning failure.

ObjectivesPositive pressure ventilation exposes the lung to mechanical stresses that can exacerbate injury. The exact mechanism of this pathologic process remains elusive. The goal of this study was to describe recruitment/derecruitment at acinar length scales over short-time frames and test the hypothesis that mechanical interdependence between neighboring lung units determines the spatial and temporal distributions of recruitment/derecruitment, using a computational model.DesignExperimental animal study.SettingInternational synchrotron radiation laboratory.SubjectsFour anesthetized rabbits, ventilated in pressure controlled mode.InterventionsThe lung was consecutively imaged at ~ 1.5-minute intervals using phase-contrast synchrotron imaging, at positive end-expiratory pressures of 12, 9, 6, 3, and 0 cm H2O before and after lavage and mechanical ventilation induced injury. The extent and spatial distribution of recruitment/derecruitment was analyzed by subtracting subsequent images. In a realistic lung structure, we implemented a mechanistic model in which each unit has individual pressures and speeds of opening and closing. Derecruited and recruited lung fractions (Fderecruited, Frecruited) were computed based on the comparison of the aerated volumes at successive time points.Measurements and main resultsAlternative recruitment/derecruitment occurred in neighboring alveoli over short-time scales in all tested positive end-expiratory pressure levels and despite stable pressure controlled mode. The computational model reproduced this behavior only when parenchymal interdependence between neighboring acini was accounted for. Simulations closely mimicked the experimental magnitude of Fderecruited and Frecruited when mechanical interdependence was included, while its exclusion gave Frecruited values of zero at positive end-expiratory pressure greater than or equal to 3 cm H2O.ConclusionsThese findings give further insight into the microscopic behavior of the injured lung and provide a means of testing protective-ventilation strategies to prevent recruitment/derecruitment and subsequent lung damage.

Background: An abrupt lung deflation in rodents results in lung injury through vascular mechanisms. Ventilator disconnections during endo-tracheal suctioning in humans often cause cardio-respiratory instability. Whether repeated disconnections or lung deflations cause lung injury or oedema is not known and was tested here in a porcine large animal model.Methods: Yorkshire pigs (~ 12 weeks) were studied in three series. First, we compared PEEP abruptly deflated from 26 cmH2O or from PEEP 5 cmH2O to zero. Second, pigs were randomly crossed over to receive rapid versus gradual PEEP removal from 20 cmH2O. Third, pigs with relative volume overload, were ventilated with PEEP 15 cmH2O and randomized to repeated ETT disconnections (15 s every 15 min) or no disconnection for 3 h. Hemodynamics, pulmonary variables were monitored, and lung histology and bronchoalveolar lavage studied.Results: As compared to PEEP 5 cmH2O, abrupt deflation from PEEP 26 cmH2O increased PVR, lowered oxygenation, and increased lung wet-to-dry ratio. From PEEP 20 cmH2O, gradual versus abrupt deflation mitigated the changes in oxygenation and vascular resistance. From PEEP 15, repeated disconnections in presence of fluid loading led to reduced compliance, lower oxygenation, higher pulmonary artery pressure, higher lung wet-to-dry ratio, higher lung injury score and increased oedema on morphometry, compared to no disconnects.Conclusion: Single abrupt deflation from high PEEP, and repeated short deflations from moderate PEEP cause pulmonary oedema, impaired oxygenation, and increased PVR, in this large animal model, thus replicating our previous finding from rodents. Rapid deflation may thus be a clinically relevant cause of impaired lung function, which may be attenuated by gradual pressure release. [ABSTRACT FROM AUTHOR]

Background Tako-tsubo stress cardiomyopathy is a clinical syndrome marked by transient reduction of left ventricular function in the setting of emotional or physical stress and in the absence of obstructive coronary artery disease. We describe a case of an atypical variant of Tako-tsubo in a male patient following an elective direct current cardioversion (DCCV). Case summary A 78-year-old male whose atrial fibrillation persisted after earlier unsuccessful direct current DCCV and radiofrequency ablations presented to the emergency department for acutely worsening dyspnoea and orthopnoea 12 h following his most recent DCCV. Previously, he was known to have non-obstructive coronary artery disease. Evaluation was notable for troponin I 0.019 ng/mL (negative <0.050 ng/mL), pro-brain natriuretic peptide 2321 pg/mL (reference range 0.0–900 pg/mL). There were no acute electrocardiogram abnormalities. He required bilevel positive airway pressure but was weaned off eventually to room air. Transthoracic echocardiogram revealed newly reduced left ventricular ejection fraction of 45–50%, associated with hypokinesis of the basal anteroseptal segment, as well as akinesis of mid-inferoseptal and mid-anteroseptal segments. Apical contractility was preserved. On Day 5 of hospitalization, diagnostic left heart catheterization again revealed benign coronary anatomy, and he was discharged home the following day. Discussion Only five other cases of cardioversion mediated Tako-tsubo cardiomyopathy have been reported in the literature. To our knowledge, this is the first case of DCCV-induced atypical Tako-tsubo cardiomyopathy. Although overall prognosis is favourable, some have been observed to require advanced support therapy. Given risk for life-threatening complications, patients undergoing cardioversion should be educated on symptoms of congestive cardiomyopathy. [ABSTRACT FROM AUTHOR]

Background and Aims: Rising extravascular lung-water index (ELWI) following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC), if not timely intervened, can progress to pulmonary oedema. Transpulmonary thermodilution (TPTDL) is a standard technique to estimate ELWI (T-ELWI score), and track ongoing changes. Lung ultrasound (LUS) is another technique for ELWI (L-ELWI score) estimation. However, reproducibility and reliability of LUS for tracking serial L-ELWI changes during CRS + HIPEC remains to be validated. Methods: This prospective observational study included 360 L-ELWI and T-ELWI measurements at 12 peri-operative time-points. Cohen's Kappa test was used to assess reproducibility, Inter-rater agreement (between the anaesthetist and radiologist), and agreement between LUS and TPTDL for classifying the severity of pulmonary oedema. Reliability of LUS for 'tracking serial changes' in ELWI over time in individual patients was assessed by determining the repeated measures correlation (z-rrm) between weighted L-ELWI and T-ELWI scores. The ability of both techniques to discriminate pulmonary oedema was compared by analysing the area under ROC curves. Results: Excellent inter-rater agreement for assigned L-ELWI scores was observed (linear weighted κ = 0.95 for both). Both techniques had a good agreement in classifying the severity of pulmonary oedema (linear weighted κ = 0.63, 95% CI 0.51–0.79). T-ELWI and weighted L-ELWI scores correlated strongly (z-rrm = 0.88, 95% CI 0.80–0.92, P < 0.0001). Both techniques had comparable ability to discriminate pulmonary oedema (difference in area under ROC curve = 0.0014, 95%CI –0.0027 to 0.0055, P = 0.5043). Conclusion: We found the utility of LUS as a reliable and reproducible technique for ELWI estimation and tracking its changes over time in CRS + HIPEC.

Background and Aims: Appropriate volume assessment and fluid management can prevent maternal deaths in the severely pre-eclamptic (SPE) parturients. We planned a systematic review and meta-analysis (MA) to evaluate the role and ability of point-of-care ultrasound (POCUS) in the assessment of volume status and early detection of lung oedema in an SPE parturient. Methods: An e-literature search was done from several databases. Data were extracted under five domains including POCUS-derived parameters like echo comet score (ECS), lung ultrasound (LUS) scores, B-patterns, optic nerve sheath diameter (ONSD), E/e' ratio, presence of pleural effusion, pulmonary interstitial syndrome and pulmonary congestion. The risk of bias was assessed. Extracted data were analysed using MetaXL and Revman 5.3. Heterogeneity in the studies was evaluated using the Cochrane Q test and I2 statistics. Funnel plots were used for the assessment of publication bias. Results: Seven prospective studies including 574 parturients (including 396 pre-eclamptics) were selected. POCUS included lung, optic nerve, cardiac and thoracic US. In two studies, the ECS and LUS scores pre-delivery were higher in pre-eclamptics. Two studies found a mean ONSD of 5–5.84 mm before delivery. MA revealed a significantly lower mean ECS score at post-delivery than pre-delivery, and the summary prevalence of B-pattern and pleural effusion among SPE parturients was found to be 0.28 (0.03–0.84) and 0.1 (0–0.2), respectively. A good correlation was observed between B-line patterns and diastolic dysfunction (increased E/e' ratio), LUS score and thoracic fluid content, ONSD and ECS in individual studies. Conclusion: POCUS parameters can be useful as early markers of fluid status and serve as useful tools in the precise clinical management of pre-eclampsia.

Background/Aim. High-altitude pulmonary oedema (HAPE), which normally occurs at altitudes higher than 3,000 m, is a potentially fatal disease due to hypoxia. The role of mitochondrial genomes in determining an individual's susceptibility to HAPE has not been determined yet. However, a number of genetic polymorphisms have recently been found to be overrepresented in HAPE patients. The majority of published genome-wide association studies have investigated only a small number of top-ranking single-nucleotide polymorphisms (SNPs)/genes by the overview of nuclear DNA and considered each of the identified SNPs/genes in-dependently. Little research has been conducted on mitochondrial genomes in relapsing HAPE patients by genome-wide association studies. Methods. To identify biological pathways important to HAPE occurrence, we examined approximately 500,000 SNPs genome-wide from 10 unrelated cases of relapsing HAPE and we compared the SNPs in these cases with those in the Chinese in Beijing, China population (45 controls) to discover the association between genotypes and HAPE susceptibility among the mitochondrial function-related genes. We used the FUMA platform to expand those SNPs to selected candidate SNPs. Results. A total of 369 candidate SNPs, 4 lead SNPs, 4 genomic risk loci and 5 mapped genes were obtained. The 7 mapped genes were ADAMTS9-AS2, NEK1, CLCN3, C4orf27(HPF1), RP11-219J21.2, ANKRD26 and YME1L1. Conclusion. This study confirms the association of ADAMTS9-AS2, NEK1, CLCN3, C4orf27(HPF1), RP11- 219J21.2, ANKRD26 and YME1L1 with HAPE, which may provide future targets for the treatment of this disease.