Many newly published articles have focused on the association between COVID-19 and thrombogenicity. Indeed, it has become a frequently observed phenomena. In this study, we report on a 45-year-old man with a COVID-19-positive test. His dramatic progression started 5 days after admission. He developed a right ventricular (RV) thrombus (rare condition) and multiple brain sites infarction. We discuss this phenomena by showing the extent to which the thrombosis can take place, the possible relation between inflammatory, D-dimer and case progression and suggest a treatment approach particularly in cases with multiple thrombogenicity organ involvement.

Introduction: Bloodstream infections are one of the leading causes of mortality and morbidity. Time to positive blood culture may be reflective of the severity of infection. We aim to study the impact of time to positivity (TTP) of blood culture upon clinical outcome. Methods: Data from blood cultures for 17 months duration reviewed. Outcome measures included in-hospital mortality and length of stay in ICU (LOSICU). TTP was determined for each sample. Demographics (age, gender, BMI, and nationality), APACHE-2 score for severity of illness, comorbid conditions, and other confounding factors were recorded. Results: One hundred and one patients with 346 positive blood cultures with mean age of 62 and mean APACHE-2 score of 18.9 + 9.7 (mean +SD) with overall observed mortality of 61%. Median TTP was 20.2 h with quartiles cutoff Q1 = 15.3, Q2 = 20.2, Q3 = 28, and range 8–104 h. Only APACHE-2 scores predict LOSICU. TTP is not a significant predictor for mortality or LOSICU. Discussion: Data on TTP of blood cultures have a complex interaction with clinical outcomes. Conclusion: TTP of blood cultures does not predict mortality or length of stay in ICU.

Introduction: Positive end expiratory pressure (PEEP) exerts variable effects on preload, pulmonary vascular flow, and afterload. Lung recruitment with gradual increase in PEEP improves oxygenation, but it may have variable cardiovascular effects. Method: A patient with respiratory failure from tetanus was recruited after informed consent. The sedated and paralyzed patient was subjected to sequential increase in PEEP with measurement of hemodynamics, ventilator parameters, and echocardiographic parameters (Doppler flow across tricuspid, pulmonic, and mitral valves at end inspiration and end expiration, in addition to blood volume flowing across RVOT and mitral valve). Results: We observed an initial rise in pulmonic and mitral blood flows, followed by a decline back to baseline around PEEP of 20, with an eventual decline associated with a drop in mean MAP <60 torr above PEEP of 29. Similar effects were also observed on blood volume flowing across RVOT and mitral valve. PEEP of 5 was associated with best blood flow parameters. Conclusion: Although systemic pressure was maintained at PEEP of 29, pulmonary blood flow started to be compromised at PEEP of 20. Best pulmonary perfusion parameters were achieved at PEEP of 5.

Bronchopleural fistula (BPF) is a pathological connection between the bronchial tree and pleural space usually formed as a result of local or systemic illness affecting pulmonary or pleural tissue. It is associated with significant morbidity and prolonged stay in the hospital. We present the case of a 33-year-old male with multiple sclerosis with multiple co-morbidities who developed respiratory failure from pneumonia requiring mechanical ventilation (MV) and tracheostomy. He developed pneumothorax which remained persistent despite medical management and chest tube insertion suggesting BPF. A high-resolution CT chest confirmed BPF. The patient was not a suitable candidate for endoscopic or surgical repair. An occlusive microvascular plug was placed under fluoroscopy to close the leak. High-resolution chest CT confirmed resolution of air leak. The patient was subsequently discharged to a long-term ventilator facility for liberation of MV. Follow-up after discharge revealed successful liberation from the ventilator. BPF management is a challenge which requires multidisciplinary approach and careful assessment to choose the best approach for treatment especially in high-risk patients with a compromised pulmonary status. For patients who are not suitable candidates for surgical or endoscopic repair, radiologically guided application of an occluding device or sealants are attractive options.

Background: Low tidal volume ventilation (LTVV) strategy improves outcomes; however, despite recommended by guidelines, adherence to this practice is not high.Methods: Tidal volume for mechanically ventilated patients were recorded for each 12-hour shift, day and night shifts for consecutive 101 patients. Adherence was determined by comparing these tidal volumes to standard low tidal volumes of 6 ml/kg of ideal body weight. Adherence rates were calculated and adherence rates of daytime shifts were compared to those of night time shifts. Adherence rates for weekday shifts were compared with those of weekend shifts. Clinical variables were recorded to analyze predictors of adherence pattern.Results: The sample size was 101 patients with 870 patient-ventilator days with 1734 patient ventilator shifts. Shift adherence was only 47.5%. There was no significant difference between day and night shifts or weekday and weekend shifts. Stepwise multiple regression analysis shows that age, gender, body mass index (BMI), and partial pressure of carbon dioxide (PCO2) have significant correlation with adherence to LTVV practice.Conclusion: The study found that adherence to lung protective low tidal volume mechanical ventilation practice is low. Practice adherence is not different over weekend or night shifts. Age, gender, BMI, and PCO2 have significant correlation with adherence to LTVV practice.