This paper reports on an investigation into the complexities of student attrition in a distance education course. Deep-seated factors involved in the attrition process are disclosed as the particular qualitative research process that was employed mapped student responses through the course of interviews. These tabulations reveal interesting patterns of change as students volunteer explanations for their decisions.

Sacred pause brings closure, prevents cumulative grief and distress, builds resilience, promotes team effort, and improves professional satisfaction of ICU team. It may lower burnout syndrome in ICU, but further studies are warranted.

AIMTo study the management, complications and outcomes of adult patients admitted with hemophagocytic lymphohistiocytosis (HLH) in the intensive care unit (ICU).METHODSWe performed a retrospective observational study of adult patients with the diagnosis of “HLH” admitted to the two academic medical ICUs of Baylor College of Medicine between 01/01/2013 to 06/30/2017. HLH was diagnosed using the HLH-2004 criteria proposed by the Histiocyte Society.RESULTSSixteen adult cases of HLH were admitted to the medical ICUs over 4 years. Median age of presentation was 49 years and 10 (63%) were males. Median Sequential Organ Failure Assessment (SOFA) score at the time of ICU admission was 10. Median ICU length of stay (LOS) was 11.5 d and median hospital LOS was 29 d. Septic shock and acute respiratory failure accounted for majority of diagnoses necessitating ICU admission. Septic shock was the most common ICU complication seen in (88%) patients, followed by acute kidney injury (81%) and acute respiratory failure requiring mechanical ventilation (75%). Nine patients (56%) developed disseminated intravascular coagulation and eight (50%) had acute liver failure. 10 episodes of clinically significant bleeding were observed. Multi system organ failure was the most common cause of death seen in 12 (75%) patients. The 30 d mortality was 37% (6 cases) and 90 d mortality was 81% (13 cases). There was no difference in mortality based on age (above or less than 50 years), SOFA score on ICU admission (more than or less than 10), immunosuppression, time to diagnose HLH or direct ICU admission versus floor transfer.CONCLUSIONHLH is a devastating disease associated with poor outcomes in ICU. Intensivists need to have a high degree of clinical suspicion for HLH in patients with septic shock/multi system organ failure and progressive bi/pancytopenia who are not responding to standard management in ICU.

Deep sedation is sometimes needed in acute respiratory distress syndrome. Ketamine is a sedative that has been shown to have analgesic and sedating properties without having a detrimental impact on hemodynamics. This pharmacological profile makes ketamine an attractive sedative, potentially reducing the necessity for other sedatives and vasopressors, but there are no studies evaluating its effect on these medications in patients requiring deep sedation for acute respiratory distress syndrome. Materials and methods: This is a retrospective, observational study in a single center, quaternary care hospital in southeast Texas. We looked at adults with COVID-19 requiring mechanical ventilation from March 2020 to September 2020. Results: We found that patients had less propofol requirements at 72 h after ketamine initiation when compared to 24 h (median 34.2 vs 54.7 mg/kg, p = 0.003). Norepinephrine equivalents were also significantly lower at 48 h than 24 h after ketamine initiation (median 38 vs 62.8 mcg/kg, p = 0.028). There was an increase in hydromorphone infusion rates at all three time points after ketamine was introduced. Conclusions: In this cohort of patients with COVID-19 ARDS who required mechanical ventilation receiving ketamine we found propofol sparing effects and vasopressor requirements were reduced, while opioid infusions were not.

Introduction: Noninvasive positive pressure ventilation (NIPPV) plays an important role in the management of respiratory failure. However, since the emergence of the COVID-19 pandemic, utilization of traditional face mask NIPPV has been curtailed in part due to risk of aerosolization of respiratory particles and subsequent health care worker exposure. A randomized clinical trial in 2016 reported that an alternative interface, helmet NIPPV, may be more effective than traditional NIPPV at preventing intubation and improving mortality. The helmet NIPPV interface provides positive airway pressure, while also theoretically minimizing aerosolization, making it a feasible modality in management of respiratory failure in COVID-19 patients. Case and outcomes: This report describes a single-center experience of a series of three COVID-19 patients with hypoxemic respiratory failure managed with helmet NIPPV. One patient was able to avoid intubation while a second patient was successfully extubated to NIPPV. Ultimately, the third patient was unable to avoid intubation with helmet NIPPV, although the application of the device was late in the progression of the disease. Discussion: NIPPV is an important modality in the management of respiratory failure and has been shown to reduce the need for immediate endotracheal intubation in select populations. For patients unable to tolerate facemask NIPPV, the helmet provides an alternate interface. In COVID-19 patients, the helmet interface may reduce the risk of virus exposure to health care workers from aerosolization. Based on this experience, we recommend that helmet NIPPV can be considered as a feasible option for the management of patients with COVID-19, whether the goal is to prevent immediate intubation or avoid post-extubation respiratory failure. Randomized studies are needed to definitively validate the use of helmet NIPPV in this population. Conclusion: Helmet NIPPV is a feasible therapy to manage COVID-19 patients.