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New Crucial Literature: The Science You Need to Know

Are COVID-19 Patients Vulnerable to the Cytokine Storm? Our Understanding Is Limited

Sinha P, Matthay MA, Calfee CS. Is a “Cytokine Storm” Relevant to COVID-19? JAMA Intern Med. 2020.

The authors raise interesting and relevant questions regarding the cautions necessary when applying a “scientific” term to a challenging clinical entity. Coronavirus disease (COVID-19) infection can cause severe pulmonary damage leading to relentless hypoxemia and death in up to 40 percent of affected patients. Because of perceived clinical similarities between this syndrome and other disorders encountered in critically ill patients, such as systemic inflammatory response syndrome (SIRS) and acute respiratory distress syndrome (ARDS) and because the pathophysiology of SIRS and ARDS has been related to increased levels of circulating cytokines, the term “cytokine storm” is used increasingly in scientific and lay publications dealing with pulmonary failure in COVID patients.

In this opinion piece, the authors emphasize that circulating levels of cytokines, such as interleukin-6 and tumor necrosis factor as much as tenfold above baseline, have been documented in SIRS and ARDS patients, but elevated cytokine levels have not been consistently observed in COVID-related pulmonary failure. Furthermore, these studies show that using anti-cytokine drugs for treatment in the absence of clear evidence of tissue injury resulting from increased cytokine activity may expose patients to immunosuppression and an increased risk for secondary bacterial and/or fungal infection. The authors urge caution and additional research before anti-inflammatory or anti-cytokine agents are adopted for widespread use in patients with this disorder.

Clinical Guidelines Address Common Complication: Bile Duct Injuries during Cholecystectomy

Brunt LM, Deziel DJ, Telem DA, et al. Safe Cholecystectomy Multi-society Practice Guideline and State of the Art Consensus Conference on Prevention of Bile Duct Injury During Cholecystectomy. Ann Surg. 2020;272(1):3-23.

Clinical guidelines presented in this report represent the consensus recommendations from a panel of representatives of several professional societies, including SAGES (Society of American Gastrointestinal Endoscopic Surgeons), the Americas Hepato-Pancreato-Biliary Association, the International Hepato-Pancreato-Biliary Association, the Society for Surgery of the Alimentary Tract, and the European Association for Endoscopic Surgery. The authors note that laparoscopic cholecystectomy is one of the most common procedures general surgeons perform. In the 30 years since laparoscopic cholecystectomy was introduced, bile duct injuries have decreased but still occur more frequently than the rate of 0.1 percent documented for open cholecystectomy; current rates of up to 0.36 percent have been reported, justifying the need for practice guidelines.

Although the guidelines document acknowledges that high-grade evidence cannot be cited to support most of the recommendations, the panel agreed on 17 of the 18 questions addressed in the guidelines. One important recommendation was that the critical view of safety be used to identify the anatomic relationships of the cystic duct, common bile duct, and cystic artery. The guidelines recommend use of severity scores such as the Tokyo Guidelines 2018 or the American Association for the Surgery of Trauma severity score to quantify risk of bile duct injury and facilitate preoperative counseling of patients.

Another recommendation was that the fundus-first or top-down approach be abandoned for laparoscopic cholecystectomy done for acute cholecystitis with significant inflammation of the gallbladder and adjacent tissue. Guidance on the use of subtotal cholecystectomy also was provided. Intraoperative cholangiography was encouraged to assist surgical decision making when anatomy is unclear or when bile duct injury is suspected. Additional recommendations addressed the use of alternative imaging approaches (near infrared imaging) and appropriate use of cholecystostomy. Finally, referral of patients with bile duct injuries to experienced biliary surgeons was encouraged. Overall, the recommendations were clear, and useful discussions of the supporting evidence were supplied.

Additional Readings

The Journal of Trauma and Acute Care Surgery, Early Outcomes with Utilization of Tissue Plasminogen Activator in COVID-19 Associated Respiratory Distress: A Series of Five Cases

The Journal of Trauma and Acute Care Surgery, Rescue Therapy for Severe COVID-19 Associated Acute Respiratory Distress Syndrome (ARDS) with Tissue Plasminogen Activator (tPA): A Case Series

New England Journal of Medicine, Effect on Patient Safety of a Resident Physician Schedule without 24-Hour Shifts

JAMA, Cognitive Bias and Public Health Policy During the COVID-19 Pandemic