Importance: Recent reports identify that among hospitalized coronavirus disease 2019 patients, 30% require ICU care. Understanding ICU resource needs remains an essential component of meeting current and projected needs of critically ill coronavirus disease 2019 patients. Objectives: This study queried U.S. ICU clinician perspectives on challenging aspects of care in managing coronavirus disease 2019 patients, current and anticipated resource demands, and personal stress. Design, Setting, and Participants: Using a descriptive survey methodology, an anonymous web-based survey was administered from April 7, 2020, to April 22, 2020 (email and newsletter) to query members of U.S. national critical care organizations. Measurements and Main Results: Through a 16-item descriptive questionnaire, ICU clinician perceptions were assessed regarding current and emerging critical ICU needs in managing the severe acute respiratory syndrome coronavirus 2 infected patients, resource levels, concerns about being exposed to severe acute respiratory syndrome coronavirus 2, and perceived level of personal stress. A total of 9,120 ICU clinicians responded to the survey, representing all 50 U.S. states, with 4,106 (56.9%) working in states with 20,000 or more coronavirus disease 2019 cases. The 7,317 respondents who indicated their profession included ICU nurses (n = 6,731, 91.3%), advanced practice providers (nurse practitioners and physician assistants; n = 334, 4.5%), physicians (n = 212, 2.9%), respiratory therapists (n = 31, 0.4%), and pharmacists (n = 30, 0.4%). A majority (n = 6,510, 88%) reported having cared for a patient with presumed or confirmed coronavirus disease 2019. The most critical ICU needs identified were personal protective equipment, specifically N95 respirator availability, and ICU staffing. Minimizing healthcare worker virus exposure during care was believed to be the most challenging aspect of coronavirus disease 2019 patient care (n = 2,323, 30.9%). Nurses report a high level of concern about exposing family members to severe acute respiratory syndrome coronavirus 2 (median score of 10 on 0-10 scale). Similarly, the level of concern reached the maximum score of 10 in ICU clinicians who had provided care to coronavirus disease 2019 patients. Conclusions: This national ICU clinician survey identifies continued concerns regarding personal protective equipment supplies with the chief issue being N95 respirator availability. As the pandemic continues, ICU clinicians anticipate a number of limited resources that may impact ICU care including personnel, capacity, and surge potential, as well as staff and subsequent family members exposure to severe acute respiratory syndrome coronavirus 2. These persistent concerns greatly magnify personal stress, offering a therapeutic target for professional organization and facility intervention efforts.

Importance: Global cases of coronavirus disease 2019 infection continue to increase, and significant numbers of patients are critically ill, placing an immense burden on ICU resources. Understanding baseline resource needs and surge capacity in the ICU will be essential to meet current and projected healthcare needs. Continued appraisal of the state of readiness for healthcare systems at individual, regional and national levels will be paramount to ensure we are poised to continue the fight against coronavirus disease 2019. Objectives: This study queried U.S. ICU clinician perspectives on ICU preparedness and concerns regarding delivering coronavirus disease 2019 patient care. Design, Setting, and Participants: An anonymous web-based survey administered from March 18, 2020, to March 25, 2020 (email and newsletter) used survey methodology to query members of U.S. national critical care organizations. Main Outcomes and Measures: Through a 12-item descriptive questionnaire, ICU clinicians were assessed regarding preparedness, techniques employed to augment critical care capacity, and concerns related to caring for coronavirus disease 2019 patients. Results: A total of 4,875 ICU clinicians responded to the survey. Respondents included ICU nurses ( n = 3,470, 71.3%), physicians ( n = 664, 13.6%), advanced practice providers (nurse practitioners and physician assistants; n = 334, 6.9%), respiratory therapists ( n = 236, 4.9%), and pharmacists ( n = 79, 1.6%). Over half ( n = 2,552, 52.5%) reported having cared for a presumed or confirmed coronavirus disease 2019 patient. The majority ( n = 4,010, 82.9%) identified that their hospital was employing techniques to augment critical care capacity. However, 64.5% ( n = 3,125) believed that their ICU facility and team were inadequately prepared to treat coronavirus disease 2019 patients. The majority ( n = 4,547, 93.9%) anticipated ICU personal protective equipment shortages based upon their current use profile. The chief reported concerns include ICU resource shortages such as supplies, medications, beds, ICU staffing shortages, and patient surge leading to overcrowding. Conclusions and Relevance: This national ICU clinician survey indicates that hospitals are expanding ICU bed capacity to prepare for coronavirus disease 2019 patient surge. Importantly, amid this preparation, ICU clinicians harbor concerns regarding preparedness, staffing, and common use resources that merit specific education as well as resource allocation and utilization planning.

Community-associated methicillin (meticillin)-resistant Staphylococcus aureus (CA-MRSA) continues to emerge as a cause of serious infections, chiefly of the skin and soft tissues. We present the first documented case of CA-MRSA mediastinitis in an adult. Blood and mediastinal isolates were characterized as CA-MRSA by pulsed-field gel electrophoresis and susceptibility testing. CASE REPORTA 47-year-old female presented to the Emergency Department with progressive, severe chest pain and dyspnea. She had been evaluated for fever and a productive cough on an outpatient basis 3 days prior and was prescribed levofloxacin when a chest X-ray revealed multilobar infiltrates. She denied any recent hospitalization or surgeries and reported no sore throat, oral lesions, dental problems, dysphagia, odynophagia, nausea, or vomiting. Her pertinent medical history included hypertension, hyperlipidemia, fibromyalgia, and well-controlled systemic lupus erythematosus.On examination, the patient was febrile to 102.4°F, hypotensive (blood pressure, 88/60 mmHg), tachycardic to 131 beats/ min, tachypneic (respiratory rate of 40 breaths/min), and hypoxic (90% oxygen saturation on 4 liters/min oxygen by nasal cannula). Physical examination revealed normal conjunctivae, an absence of oral or dental lesions, no crepitus or induration of the neck, no evidence of cardiac murmurs or rubs, and decreased breath sounds on auscultation. A neurological examination was normal. Within a few hours, the patient displayed evidence of respiratory distress, which required intubation. Nasogastric tube placement following intubation resulted in some epistaxis. A repeat chest X-ray was unchanged from that performed on admission, revealing multilobar infiltrates without pleural effusion or focal abscess or a widened mediastinum. Hematological testing revealed a white cell count of 33,400/l. Evidence of elevated cardiac biomarkers and ST segment elevations on electrocardiography prompted immediate cardiac catheterization, which did not reveal any evidence of thrombosis or infarction. Since the patient was febrile and relatively hypotensive with leukocytosis and evidence of multilobar pneumonia, broad-spectrum antibiotics were initiated for possible sepsis, including vancomycin at 1 g given intravenously every 12 h. Within 24 h of admission, multiple blood and sputum cultures were positive for methicillin (meticillin)-resistant Staphylococcus aureus (MRSA) and her antibiotic regimen was narrowed to vancomycin only. The initial vancomycin trough concentration was noted to be 12.4 g/ml, and her vancomycin dose was increased to 1.5 g given intravenously every 12 h, resulting in a vancomycin trough concentration of 18.6 g/ml on hospital day 4. Vancomycin trough concentrations were maintained between 14 and 22 g/ml during her inpatient stay. A chest computed tomography (CT) was performed on hospital day 2, revealing a moderate pericardial effusion with no evidence of abscess. A transthoracic echocardiogram was performed on hospital day 2 and was negative for absce...

A review of the literature revealed eleven previous cases of concurrent GBS and ITP; however, we report the first case of concurrent AMSAN and ITP. Among these cases, trends were noted to include sex, preceding infections, and cranial nerve involvement.

We report the case of a 23-year-old woman who presented with bloody diarrhoea and multiple syncopal events. While the initial diagnosis clinically appeared to be inflammatory bowel disease, she was found to have a portal vein thrombosis (PVT) on MR cholangiopancreatography and acute intestinal ischaemia on colonic biopsy. The aetiology of this patient's PVT is attributed to her acquired prothrombotic state from an estrogen-containing contraceptive pill in conjunction with regular tobacco use. Extensive mesenteric venous thrombosis from an acute PVT has been shown to cause intestinal ischaemia, likely from venous obstruction and reflexive arterial constriction; however, the diagnosis is often delayed until surgery or autopsy. Our case report highlights this patient's clinical presentation, workup and treatment, as part of a review for the risk factors and guidelines recommendations for management of an acute PVT.