Induced hypothermia is a technique that has gained popularity as an adjuvant therapy for patients with traumatic brain injuries, refractory arrhythmias, cardiac arrest and myocardial infarction. Induced hypothermia in patients with cardiogenic shock could improve the recovery of a stunned myocardium by decreasing its metabolic demands. We report a patient who presented with cardiogenic shock after surgical replacement of both aortic and mitral valves. The patient was placed in induced hypothermia for 34 hours. The clinical course was followed using measurements of arterial blood gas concentrations, serum lactate levels and transthoracic echocardiograms. During mechanical ventilation, the patient was monitored using a bedside bispectral index state of consciousness and temperature was measured using a Swan-Ganz catheter. The requirements for vasoactive drugs declined considerably during the hypothermic and rewarming periods. Echocardiography showed improvements in the left ventricle ejection fraction from 30% to 60% in the rewarming period with improvement in the mobility of both the anterior and septal walls. Induced hypothermia could be considered as part of the management strategy for patients with cardiac surgery, extracorporeal circulation and cardiogenic shock.

The clinical diagnosis of acute diaphragmatic injury can be challenging since signs and symptoms may be nonspecific. We present a 67 y/o male patient admitted to the Puerto Rico Trauma Center Intensive Care Unit with blunt abdominal trauma. He was diagnosed with post-traumatic diaphragm eventration after evaluation with a follow up chest x ray. Diaphragm plication and pleurolysis were performed without complications.

Psychomotor disturbance in Intensive Care Unit (ICU) continues to be a challenging issue in view of its various ranges of predisposing factors and this includes withdrawal from chronic substance abuse. A combination of opioids, benzodiazepines and antipsychotics are often used to treat such neurochemical disturbances. We report a case of 43 year-old man with 10 years history of substance abuse who presented with acute opioids intoxication. He required mechanical ventilation but exhibited significant agitation in the ICU. The conventional combination of midazolam and morphine, and later propofol infusion failed to control his agitations following admission. However, his symptoms improved and he was extubated within the first 24 hours of stay after dexmedetomidine infusion.

Objectives: To determine the effects of therapeutic hypothermia performed in a Philippine tertiary hospital on hospital survival and favorable neurological outcomes at discharge.
Design: Retrospective cohort study.
Setting: General ICU in a private, tertiary hospital in the Philippines.
Patients: Medical records of all adult (>18 yrs) patients admitted following resuscitation from cardiac arrest from 9/2007 to 12/2008 were reviewed. Inclusion criteria were: Glasgow Motor Score <6 and treatment at the ICU. Exclusion criteria were: patients with arrest times >60 minutes, pre-arrest CPC score >2, severe hemorrhage, or with imposed limitations to intensive care. Patients whose families or attending physicians did not agree to hypothermia induction were classified as controls.
Interventions: Therapeutic hypothermia, targeting a core temperature of 32-34 ?C, was initiated within 6 hours of return of spontaneous circulation, and maintained for 12-24 hours. Hypothermia induction methods included combinations of ice packs, ice-water gastric lavage, and cold intravenous fluid boluses.
Measurements and Results: Of 49 patients that met final inclusion criteria, 29 were in the intention-to-treat therapeutic hypothermia group. Age, gender, APACHE II scores and initial arrest rhythms were similar between groups. Good neurological outcomes (CPC 1 or 2) were found in 0/20 patients in the control group vs. 9/29 (31%) in patients who received hypothermia therapy (p=0.006). However, the difference in hospital survival only approached statistical significance (15% in controls, 41.4% in hypothermia group, p=0.06). Exact logistic regression showed that initial pulseless ventricular tachycardia or ventricular fibrillation, and therapeutic hypothermia were independently associated with neurologically favorable survival.
Conclusion: Therapeutic hypothermia was associated with favorable neurologic outcomes at hospital discharge.

Optimal sedation strategy in the critically ill should achieve effective analgesia, targeted sedation and reduced risk of delirium and agitation. Whilst there is no single agent that can achieve these goals for all patients, a multimodal approach may optimise the use of different agents through multiple modes of action and reduce possible adverse events. This practice review provides an evidence based and expert opinion on the practical aspects of dexmedetomidine use as part of multimodal ICU sedation.
Dexmedetomidine, when compared to conventional sedatives and opiates, has been demonstrated to be associated with both sedative and analgesic sparing effects, reduced delirium and agitation, minimal respiratory depression and predictable and desirable cardiovascular effects.
In the intensive care setting, dexmedetomidine usage has been effectively used in post operative analgesia and sedation of high risk and complex surgical patients, and during transition from other conventional sedatives. Critically ill patients requiring ventilation for more than 24 hours and patients who experienced emergent agitation and or delirium has also been successfully managed with a dexmedetomidine regimen.
Supplementary sedation and analgesia in addition to dexmedetomidine may be required to optimise comfort and safety in critically ill patients. Dexmedetomidine cannot be used to achieve deep sedation or to control acutely agitated or combative patients; therefore additional and rescue conventional sedatives may be required in some patients.
A loading dose is unnecessary in most patients and if given, may increase the risk of hypotension and bradycardia. Although the current licensed dose is 1 µg/kg/hr, the maximum dose of dexmedetomidine used in ICU sedation clinical trials is 1.5 µg/kg/hr. Dexmedetomidine must not be given as a bolus at any time to avoid exaggerated cardiac depression.
Dexmedetomidine infusion has dose dependent central nervous system and cardiovascular system effects with bradycardia and hypotension as the commonest side effects. It produces a state of sympatholysis, central sedation with significant synergy with other sedatives and analgesics. A starting dose in most patients is 0.4 µg/kg/hr with hourly titration to achieve desired sedation. Withdrawal or addition of conventional sedatives and analgesics can be used to fine tune the desired sedation target and achieve optimal analgesia. There is no need to stop dexmedetomidine infusion prior to extubation. Withdrawal of dexmedetomidine was not associated with any nervous or cardiac manifestations of withdrawal.
Dexmedetomidine is relatively contraindicated in patients with recent free microvascular flap surgical procedures, cerebrovascular surgery or with a risk of vasospasm or severe liver dysfunction and its safety has not been established in pregnancy.

We report a case of post-operative, severe, unilateral pneumonia in a tetraplegic in whom there was difficulty in ventilating and recruiting the affected lung. Airway pressure release ventilation (APRV) was applied to create a pan-inspiratory recruitment effort and the patient was positioned with the affected lung non-dependent to facilitate drainage of secretions. This resulted in a dramatic improvement in recruitment and gas exchange, allowing ventilatory requirements to be weaned rapidly. We highlight the difficulties in lung recruitment for unilateral lung disease and discuss how APRV may be the ideal technique in such situations.

Systemic lupus erythematosus is an autoimmune disease that usually develops neurological manifestations in a high percentage of the cases. Acute transverse myelitis is a rare neurological complication with significant possibility of damage, sequelae and poor prognosis. We present the case of a patient with systemic lupus erythematosus and acute transverse myelitis who responded adequately to treatment with intravenous steroids and cyclophosphamide. Having in mind acute transverse myelitis as a possibility in any patient with systemic lupus erythematosus, allows us to be ready and able to diagnose and treat this complication early, avoiding sequels and poor prognosis.

A 41 year-old woman case with nonproductive cough, dyspnea, weight loss and fever is described. Laboratories were remarkable for hypoxemia, leukocytosis, anemia and elevated hepatic enzymes. Chest X-ray demonstrated bilateral interstitial opacities. She was hospitalized with diagnosis of suspected pneumonia. Patient’s condition progressed to multiple organ failure and unfortunately, death. The diagnostic of gastric adenocarcinoma with lymphangitic spread was established at autopsy. Lymphangitic carcinomatosis can be easily confused with other interstitial lung diseases especially when primary malignancy is unknown. Physicians must be aware of nonspecific findings of this disease in order to obtain a diagnosis and institute adequate therapy.

Objective: Serum cystatin C has been reported as a specific predictor of renal function and renal outcome in cardiac disease patients. In this study, serum cystatin C was measured in non-cardiac critically ill patients. We found that serum cystatin C was a predictive marker of renal dysfunction (RD) in these patients.
Methods: The study design was a retrospective, single-medical-center analysis conducted in the intensive care unit of a university hospital. Two hundred fifty-nine critically ill patients were included in this study. RD was defined as a two-fold increase in the serum creatinine level or a requirement for renal replacement therapy (RRT) on the last ICU day. Serum cystatin C, estimated glomerular filtration rate (eGFR), APACHE II score, sequential organ failure assessment (SOFA) score, and vital signs on admission were analyzed using a logistic regression model and receiver operating characteristic (ROC) analysis.
Results: APACHE II score (p=0.007) and serum cystatin C (p=0.020) were significant risk factors for RD. The ROC analysis showed that a serum level of cystatin C greater than 1.50 mg/L had specificity for RD above 90%.
Conclusions: Serum cystatin C is a predictive marker of RD in non-cardiac critically ill patients.

Health care costs represent a large percentage of the gross domestic product all over the world. According to the National Health Statistics Group, health care expenditure in the United States accounted for as much as 14% of the gross national product in 1992 and it is projected to reach 30% by 2030.
The intensive care unit (ICU) represents the hallmark of highly competent modern hospitals, offering highly trained staff and life-saving technology and it is also one of the most expensive units in the hospital.
Expenses related to running the ICU have been estimated at approximately 20% of total hospital costs, despite only representing 10% of all hospital beds.
Assisted mechanical ventilation particularly affects the high costs in the ICU. Actually, a mere of 1 million persons per year receive mechanical ventilation during their stay in the ICU. A variety of different approaches to stabilize or reduce costs in the ICU have been suggested. Reducing the length of ICU stay, improving the patient’s condition to prevent co-morbid events, and introducing specialized teams to round in the ICU are some of the recent actions taken in the search for cost-effective therapies.
The aim of this article is to provide some of the basic principles of economic assessment in critically ill patients and present an overall review of the strategies followed to reduce costs and resource usage in the ICUs around the world.

One of the most difficult organs to procure for donation is the lung. A detailed understanding of the physiology of mechanical ventilation and its effect on donor lungs is needed to impact on the outcome of lung transplantation. An organized protocol for mechanical ventilation management of the organ donor using the Open Lung Model may positively affect the number of organs that can be procured, and the function of these organs post transplant.
Based on physiologic principles, the use of new modes of ventilation may affect the modulation of cytokines, decrease the transmigration of organisms into the donor lung, and preserve surfactant function in that lung. Therefore, we have developed a protocol guided by physiologic-based parameters and airway pressure release ventilation (APRV), with ongoing feedback from an advanced respiratory care team to manage donor patients closely.
Setting: 650 bed university hospital and transplant center.
Conclusion: We have developed a physiologic-based protocol, using APRV to achieve lung procurement that can decrease peak pressures and recruit the lungs using less and simultaneously increasing the PaO2 while using lower FIO2. This protocol may preserve surfactant function and assist during postoperative management.
Additionally, this management mode may protect the donor organs from physiologic decay and even improve the outcomes. Further studies to measure long-term outcome need to be developed to validate physiologically based mechanical ventilation.

Background: Surgical repair of fractured neck of femur in the elderly is frequently performed under spinal anaesthesia. Elderly patients are particularly susceptible to developing hypotension with this technique. The use of single shot, low-dose bupivacaine/
fentanyl spinal anaesthesia has been shown to significantly reduce the incidence of hypotension. This clinical audit compares the haemodynamic stability and the adequacy of the sensory block duration in elderly patients receiving low-dose bupivacaine spinal anaesthesia with patients receiving standard dose spinal anaesthesia.
Method: Data from 60 elderly patients who had undergone surgical repair of fractured neck of femur within the same time period was collected using theatre coding records and systematic review of clinical notes. Thirty patients received a low-dose (4mg) bupivacaine plus 20 ?g fentanyl spinal anaesthetic (LDSA), 30 received a standard dose (10-14 mg) bupivacaine plus fentanyl (10-20 ?g) spinal anaesthetic (SDSA). Significant hypotension was defined as a systolic pressure decrease equal to or more than 25% of base line value or absolute value ?90 mmHg.
Results: 76% of the SDSA group compared to 10% of the LDSA group experienced significant hypotension. Decreases in mean systolic pressures from baseline over time were significantly greater in the SDSA group (p<0.001). The incidence of inadequate surgical blocks was higher in the LDSA group at 26% (n=8) compared to 3% (n=1) in the SDSA group. Six of the 8 LDSA patients with inadequate blocks reported pain/discomfort around wound closure.
Conclusion: In our elderly patients low-dose bupivacaine/fentanyl spinal anaesthesia provides greater haemodynamic stability compared to standard dose spinal anaesthesia during surgical repair of hip fractures. In a small percentage of patients in the LDSA group the surgical time outlasted the sensory block duration however, local anaesthetic applied to the operation site allowed uneventful completion of surgery.

Fasting has been the standard of many medical procedures such as upper endoscopic procedure, surgery, bronchoscopy and abdominal ultrasound imaging. Generally, the fasting recommendations follow The Canadian Anesthetist’s Society (CAS) and American Society of Anesthesiologists (ASA) guidelines. In that recommendation, patients only received clear liquid which contains simple carbohydrate or water two to six hours prior to surgery. After three hours of meal body has to provide nutritions for itself by gluconeogenesis.
In addition to nutritional issues, gastric irritation and dehydration occur as well. All these conditions can have adverse effects on the patients pre and post-surgical outcomes.
Oral nutritional supplements (ONS) contain complete nutrient is a standard formula which could be given as an option to the patients undergoing surgery or endoscopic procedures. In a preoperative period, besides providing adequate nutrients, ONS also improves patient satisfaction.
We present a case of gastric emptying of 200 ml ONS assessed by ultrasound. The ONS when tracked by the ultrasound resulted in passing through the stomach within two hours. We suggest that 200 ml ONS can be given to patients two hours prior to medical and surgical procedures.

Introduction: Scoring systems were developed to assess the severity of organ failures and to predict mortality. The sequential organ failure assessment (SOFA) score and its modification (MSOFA) are gaining popularity through their proven simplicity, validity, and reliability in previous studies.
Objective: To determine and compare the validity of the SOFA and MSOFA scores with the Acute Physiology and Chronic Health Evaluation II (APACHE II) score for predicting mortality in surgical patients treated in ICU in Dr. Hasan Sadikin General Hospital in Bandung, West Java, Indonesia.
Patients and Methods: This was a prospective observational cohort study involving consecutively 144 surgical patients (from January 2008 to December 2008). APACHE II, SOFA, and MSOFA scores were determined on admission. SOFA and MSOFA scores were also repeated every 48-72 hours until ICU discharge or death for determining mean and maximum values of SOFA and MSOFA. Scores validation were determined using Hosmer-Lemeshow goodness-of-fit test and receiver operating characteristic (ROC) curve analyses to determine the area under the curve (AUC).
Results: Mortality rate was 39.8%. The mean APACHE II score (11.63±5.55, 14.95±4.27; p?0.001), SOFA(3.7±2.23, 5.86±2.88, p?0.001), and MSOFA(3.98±1.95, 5.79±1.98, p?0.001) were all higher in non-survivors than in survivors. Discrimination was less satisfactory for APACHE II (AuROC=0.69; p?0.001) and acceptable for both initial SOFA (AuROC=0.73; p?0.001) and initial MSOFA (AuROC=0.75; p?0.001). Mean and maximum values of SOFA and MSOFA showed even better discrimination values with AuROC=0.92;
p?0.001, and AuROC=0.91; p?0.001 for meanSOFA and maksSOFA respectively, and AuROC=0.90; p?0.001, AuROC=0.90; p?0.001 for meanMSOFA and maksMSOFA respectively.
Conclusion: SOFA and MSOFA scoring systems are better than APACHE II system in predicting mortality in ICU surgical patients. Serial measurements of SOFA and MSOFA score significantly improve their predictive accuracy.

Posterior reversible encephalopathy syndrome (PRES) is a clinical-neuroradiological entity characterized by headache, vomiting, altered mental status, blurred vision and seizures as well as images suggesting whitegray matter edema involving in most cases posterior regions of the central nervous system, as demonstrated by magnetic resonance image. The development of PRES is most commonly associated with hypertensive encephalopathy, preeclampsia-eclampsia and hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome, and immunosuppressive/cytotoxic drugs. While usually reversible, the early recognition and treatment of this syndrome is important to prevent permanent neurological sequelae. The treatment is based in the management or withdrawal of the triggering factor. In this manuscript we will briefly review the pathogenesis, clinical scenario, diagnostic studies and management of PRES.

Exposure to hydrogen fluoride, whether in its gaseous or liquid form, can cause severe metabolic disturbances and even death. We present a case of an adult gentleman who was successfully treated after exposure to a large vapor cloud of hydrogen fluoride while working at a refinery. The patient exhibited various symptoms and signs including dermal, ophthalmic, and pulmonary irritation. He was successfully treated using various forms and routes of calcium gluconate administration. The prompt reaction and attention of the patient and his co-workers to this life-threatening exposure, and the recognition and awareness of the emergency department personnel limited the systemic absorption and toxicity. A comprehensive review of the literature is presented.

Introduction: Plesiomonas shigelloides gastroenteritis is rare in humans and occurs following the consumption of raw seafood, contaminated water and oysters containing the microorganism.
Clinical Picture: We describe a case of a young healthy lady, who had severe gastroenteritis after eating undercooked fish at Hawker Centre. The stool culture grew positive for Plesiomonas shigelloides.
Treatment and Outcome: She was treated with intravenous ceftriaxone and later changed to oral ciprofloxacin. She was discharged well.
Conclusion: Plesiomonas shigelloides should be diagnosed and treated early as can cause severe gastroenteritis even in young healthy individuals. Untreated infections can be severe and fatal especially in immunocompromised hosts. Prevention of infection is the key and can be done by avoiding the consumption of raw seafood, contaminated water and oysters containing the microorganism.

Objective and Setting: Ventilator associated pneumonia (VAP) is the leading cause of mortality of hospital-acquired infections. One strategy for addressing this issue has been the ventilator bundle. This intervention was implemented in the University District Hospital (UDH) as part of an initiative to improve health care in the neurosurgical intensive care unit (NSICU) of an academic centre.
Design and Interventions: From July 2007 to December 2007 educational strategies consisting of monthly lectures, bed pamphlets and card reminders were used to educate the health care team. Ventilator bundle intervention compliance was evaluated daily in random shifts during a 14-day period during July-August 2007 and December 2007.
Measurements and Results: Pre-educational compliance was recorded at 6%. Individual component compliance was (1) Head of bed (HOB)>30° - 14%, (2) Withdrawal of sedation - 67%, (3) Peptic ulcer (PUD) prophylaxis - 93%, (4) Deep venous thrombosis (DVT) prophylaxis - 87%. Post-educational compliance was 59% with individual compliances of 74%, 72%, 95%, 92% respectively. A statistically significant increase in compliance was observed in ventilator bundle compliance and HOB elevation (p<0.01).
Conclusions: A simple educational strategy can improve compliance of the ventilator bundle. This in turn and although not demonstrated can subsequently effect the mortality of patients. Collaborative work between team members of the unit is the key to compliance.

We describe a patient with lobar atelectasis who was successfully treated with airway pressure release venti-lation (APRV) after failed attempts at recruitment with endotracheal suctioning, chest therapy, and bronchoscopy. We review the literature on the effectiveness of the various methods to treat lobar atelectasis. Mechanically ventilated patients have an ineffective cough reflex and are unable to adequately deal with their respiratory sections. Atelectasis is therefore a common problem in these patients. The risk of atelectasis may be increased with the widespread use of a lung protective strategy utilizing low tidal volumes (6 ml/kg IBW). Atelectasis may worsen hypoxemia through shunting and may predispose to nosocomial pneumonia. Traditionally the treatment of atelectasis in mechanically ventilated patients has centered on chest therapy (slapping, beating and vibrating) and endotracheal suctioning. When this fails, bronchoscopy and/or recruitment maneuvers are attempted. We describe the successful use of airway pressure release ventilation (APRV) for the treatment of atelectasis in a patient who failed the traditional treatment modalities.

Spinal cord injury (SCI) is a serious condition that produces lifelong disabilities, with only limited therapeutic measures currently available. The incidence of SCI in the United States is estimated to be 30-40 cases per one million inhabitants, with resultant in-hospital mortality of 20 to 52 percent. Traumatic SCI is followed by a progressive injury process that involves various pathophysiological events that lead to tissue destruction. Although the mechanisms are not fully understood, progressive vascular events, such as ischemia/reperfusion-induced endothelial damage, are involved in this process. As in sepsis, studies have demonstrated that activated neutrophils are important in inducing the damage to endothelial cells. A common complication in patients with SCI is sepsis, which is associated with acute organ dysfunction, and results in a generalized inflammatory and procoagulant state. Sepsis is a major cause of death in intensive care units worldwide, with mortality rates that range from 20% for sepsis to 40% for severe sepsis to >60% for septic shock, that if related to SCI may be aggravated with concomitant spinal shock. We describe our experience with recombinant human activated protein C (rhAPC) in patients with SCI and severe sepsis (SS).

Preoperative fasting had been the standard of care for years. In the light of newest recommendations this practice has been changing. In 1999, The Canadian Anesthetist’s Society (CAS) and American Society of Anes-thesiologists (ASA) had published guidelines, which recommends that patients be allowed to drink clear fluid two hours prior to induction of anesthesia. However, still the traditional preoperative approach of fasting for several hours is being carried out in several institutions. We present a case of burn patient who had undergone skin-graft surgically on four occasions. The patient received two different nutritional regimens in the pre-operative period; enteral nutrition and fasting. The preoperative nutrition management of patient with enteral nutrition resulted in more satisfaction, less hunger, thirst and reduced postoperative nausea and vomiting (PONV) as compared to when the patient was receiving no enteral nutrition in preoperative period.

Background: Quantification of left ventricular (LV) dyssynchrony allows for objective measures of resynchronization therapy (CRT) effectiveness. We tested the hypothesis that site of LV pacing, fusion beats and baseline contractility alter contraction synchrony as quantified by regional and global measures of LV performance.
Methods and Results: In 8 open-chested pentobarbital-anesthetized
canine preparations we compared the effects of right atrial (RA), RA-high right ventricular (RV) free wall, as a model of left bundle branch block contraction pattern, RA-LV apex (LVa), RA-LV free wall (LVfw), and RA-RV-apical LV (CRTa) and RA-RV-free wall LV (CRTfw), as CRT. LV pressure-volume loops recorded using high-fidelity pressure and conductance catheters and echocardiographic angle-corrected color-coded strain imaging of mid-LV short axis views analyzed radial strain from six segments. To control for contractile state esmolol-induced beta blockage was studied, and in 5 dogs to control for RA and ventricular pacing fusion beat artifacts, repeat studies were done following AV node ablation. RA-RV pacing reduced stroke work (SW) (57±18 to 33±13* mmHg·mL,*p<0.05 vs RA pacing), decreased LV end-diastolic volume and induced marked radial dyssynchrony (maximal time difference between peak segmental strain) from 31±15 to 234±60* ms. Changes in radial dyssynchrony correlated significantly with changes in SW (r=-0.53, p<0.01). Dyssynchrony improved with both CRTa and CRTfw (69*±31 and 98*±63 ms, respectively) while SW only improved with CRTa (62±22* and 37±13 mmHg·mL, respectively * p<0.05 vs RV pacing). CRTa also tended to increased LV end-diastolic volume over RA-RV. Esmolol slowed HR from 118±10 to 108±10 beats/min* and tended to decrease contractility (end-systolic elastance (Ees) from 12.1±7.9 to 8.9±3.9 mmHg/ml, p=0.167) but did not alter the degree of RV-pacing induced dyssynchrony. AV ablation had no effect on the observed apical and free wall contraction differences seen during baseline conditions.
Conclusion: Although both CRTa and CRTfw reduced contraction dyssynchrony, CRTa tended to improve global LV performance more by increasing end-diastolic volume. Thus, CRT may improve global LV performance differently, depending on the LV pacing site.

Background: Purpura fulminans is an acute illness commonly associated with meningococcemia or invasive streptococcal disease. It is characterized by disseminated intravascular coagulation and purpuric skin lesions. In this article we reported a case of purpura fulminans associated with Staphylococcus aureus.
Methods: The case was identified in the General Hospital of Mazatlán, Sinaloa, México during 2007. Staphylococcus aureus infection was diagnosed on the basis of culture result. Susceptibility to methicillin was determined. The ability of the isolated organism to produce super antigens was not possible to determine.
Results: The isolated strain of Staphylococcus aureus in the present case was isolated from secretion of an intact phlyctena; the organism was not obtained from blood cultures. The isolated strain was methicillin resistant. We used immunomodulator drugs as alfa-2a interferon and thalidomide, antibiotics and support measures. The patient survived with intact extremities.
Conclusions: Purpura fulminans due to Staphylococcus aureus is a newly and emerging disease commonly associated with superantigen production. It is a very aggressive and even fatal illness that deserves special attention.

A 59-year-old Hispanic lady with history of rheumatic fever and chronic atrial fi brillation presented to the emergency department with severe dyspnea. Seventeen years prior to this presentation, she had undergone re-do mitral valve replacement, and tricuspid annuloplasty. The patient’s chest radiograph revealed massively dilated right chambers of the heart (Figure 1). An electrocardiogram showed right axis deviation, atrial fi brillation with a controlled heart rate of 70 beats per minute. A chest computed tomography (CT) scan revealed a gigantic right atrium measuring approximately 12 cm in its largest diameter (Figure 2).
These images are relevant because this reveals one of the few cases of massively dilated right atrium, despite previous mitral valve replacement and tricuspid annuloplasty. Other etiologies of a dilated right atrium in patient with dyspnea in the ED and intensive care unit (ICU) include: chronic obstructive pulmonary disease, tricuspid valvular stenosis, severe mitral valvular pathology with pulmonary hypertension, chronic pulmonary emboli, and untreated congenital heart disease.

A 30-year-old Hispanic gentleman with past medical history of hypertension and dyslipidemia, presented to the emergency department with complaints of a blunt, constant, epigastric pain radiating to his back for 24 hours. Physical examination revealed a man in severe distress, tachypneic and tachycardic. Laboratory data, as well as the physical exam, were consistent with acute severe pancreatitis. The patient was admitted to the intensive care unit (ICU) and a computed tomography (CT) of his abdomen was obtained revealing a large thrombus in the portal vein (Figure 1).
The patient’s condition deteriorated requiring assisted ventilation and vasopressor support. Two weeks following his admission to the ICU, a repeat CT of the abdomen revealed persistence of the portal vein thrombus and a new splenic vein thrombosis (Figure 2). The patient was managed conservatively with anticoagulation and eventually weaned off assisted ventilation. The patient was discharged home several weeks after his initial admission.

An 85-year-old man with history of severe dementia lay down for a nap and was witnessed by his family to immediately lose consciousness, with agonal breathing. He was ventilated by facemask by the paramedics when they attended. His vital signs were stable. On admission to hospital he grimaced to painful stimulus only (Glasgow Coma Score=6/15). His arterial blood gas revealed - pH 7.21, pCO2 70 mmHg and bicarbonate 27 mmol/L. He was intubated.
The patient had a fall 1 week before. He had complained of intermittent headache and neck pain since then. He also developed new symptoms of breathlessness upon lying fl at. Computed tomography (CT) of cranium and neck was done. Figure 1 and 2 showed a fracture through the base of the odontoid (type II). Figure 3 showed prevertebral soft tissue swelling associated with the fracture. After discussion with the family, he was treated conservatively with a cervical collar in view of his advanced age and dementia.

Venomous snakebites, although uncommon, are potentially fatal. Venomous snakes can be grouped as having hemotoxic and neurotoxic venom. Children with venomous snakebites present with signs and symptoms ranging from fang bite marks, with or without swelling and local pain, to severe condition such as coagulopathy, renal failure and shock. We reported two pediatric cases of snakebites admitted at the same day to Pediatric Emergency Department Dr. Hasan Sadikin Hospital from two different areas in Bandung. Both patients had similar clinical signs and symptoms consisted of fang bite marks, local pain, tingling, swelling beyond the area adjacent to proximal lesion. Both patients were bitten by venomous snakes and thus were treated with antivenin sera immediately. Identifi cation of the snake from the first case could be done straight away because the victim could recognize the snake from the pictures that were shown to him that we assumed came from subfamily of Elapidae. Patient from the second case could not identify the type of snake. Hospitalization for at least 24-48 hours is required to monitor victims of venomous snakebites for signs and symptoms of neurologic or hematologic disorder. Both patients were discharged from the hospital in good condition after 48 hours of monitoring.

Background: Airway pressure release ventilation (APRV) is an alternative approach to the “open-lung” ventilation strategy and has recently emerged as an alternative ventilatory strategy in patients with severe ARDS.
Aims: Our objective was to assess the effect of APRV+low level pressure support (PS) on indices of oxygenation and ventilation in patients with severe ARDS.
Methods: During the study period we recorded oxygenation and ventilation data (for up to 96 hours) as well as the use of sedative and vasopressor agents in patients in our MICU with severe ARDS (PaO2/FiO2<150) who we switched to APRV+PS from low tidal volume assist-controlled (AC) ventilation. Vd/Vt was measured by volumetric capnography. Patients were followed until hospital discharge or death.
Results: Twenty-two patients with severe ARDS secondary to sepsis were studied. The patients were on AC for 4±3.5 days prior to conversion to APRV. The PaO2/FiO2 increased (134±48 to 210±87 mmHg; p=0.03) while the Vd/Vt fell signifi cantly (66±10 to 54±10%; p=0.01) by 24 hours. These changes were maintained throughout the study period. The total daily dose of sedative and vasopressor agents decreased by 46% and 55% respectively by 24 hours. While these patients were critically ill with a high anticipated mortality, 12 (54%) survived to hospital discharge.
Conclusions: APRV+PS improves oxygenation and V/Q mismatching in patients with severe ARDS allowing a decrease in the use of sedative agents. While the survival benefit of APRV could not be assessed in this study, APRV should be considered in the ventilatory strategy of patients with severe ARDS.

Background: Water irrigation during transurethral resection of prostate (TURP) often caused hyponatremia, hypoosmolality, and decreasing of pH called TURP syndrome. Current standard fluid therapy in TURP still could not prevent or correct TURP syndrome. This study was aimed to assess the efficacy and safety of preoperative hypertonic sodium lactate (HSL) infusion in maintaining plasma sodium level, osmolality, arterial pH and hemodynamic parameters during TURP compared to normal saline (NS).
Methods: In this prospective randomized controlled double blind study, 22 patients underwent TURP surgery under spinal anesthesia were assigned into 2 groups with 11 patients in each group. HSL or NS were administered before spinal anesthesia with loading dose 4 mL/kgBW within 20 minutes. During procedure NS with 2-4 mL/kgBW/hr were infused as maintenance in both groups.
Result: Postoperative mean of sodium level and osmolality in HSL group was significantly different compared to NS group (142.2±2.0 mEq/L vs 138.9±2.1 mEq/L, p<0.05, and 294.6±3.5 mOsm/kg vs 290.6±3.2 mOsm/kg, p<0.05) respectively. Postoperative pH in HSL group was 7.433±0.04, whereas in NS group was 7.356±0.05 (p<0.05). Evolution of hemodynamic parameters was better in HSL group. Five of 11 patients in NS group need ephedrine injection due to decreased of blood pressure >30% after spinal anesthesia, whereas none of patients in HSL group need ephedrine.
Conclusion: Preoperative administration of hypertonic sodium lactate in TURP was better in maintaining plasma sodium level, osmolality, arterial pH and also hemodynamic parameters than normal saline.

Purpose: To measure the degree of compliance of national guidelines for admission to the Intensive Care Unit (ICU) at San Juan City Hospital (SJCH).
Design: This was a prospective observational cohort study at an urban academic hospital. We revised prospectively for three consecutive months all the patients admitted to ICU and then compare the admission criteria used with the national guidelines for ICU admission.
Patients and participants: We included all patients who were admitted to ICU from September 1st to November 30th, 2006, for a total of 125 patients.
Interventions: Data collection from the medical record at the time of admission to ICU.
Measurements and results: A total of 125 patients were admitted to ICU during the three months period of the study. Of these 58% were in compliance with national guidelines. The pulmonary system criteria was the most numerous admission criteria with 41.9% followed by the cardiac system criteria with 25.7% and gastrointestinal system criteria with 13.5%. Regarding the objective parameters model criteria the vital signs and laboratory values was the most frequent with 35.7% followed by electrocardiogram parameters criteria with 21.4% and physical findings criteria with 7.1%.
Conclusions: Our findings revealed that, in general, admissions at SJCH are done accordingly to national guidelines. But a 42% of admissions without criteria is a very high number of admissions which signified a wrong utilization of expensive resources. This finding correlates with the deficiencies in admission criteria knowledge among medical admission officers.

Heparin has been available as a clinical treatment and prevention for thromboembolic disease for half a century. Known complications of heparin therapy include bleeding, allergic reactions, osteoporosis, and thrombocytopenia. Heparin-induced thrombocytopenia (HIT) is a common and potentially grave adverse effect of heparin treatment. HIT is unusual among drug-induced thrombocytopenias in that it is more apt to cause thrombosis than bleeding. HIT-associated thrombosis can result in arterial and venous thrombosis leading to stroke, myocardial infarction, limb gangrene, amputation and even death. HIT pathogenesis is thought to involve antibody binding to an epitope on the platelet factor 4 (PF4)-heparin complex. The antibody bound complex then binds Fc?RII receptors on the platelet surface, which activates blood-coagulation pathways and concomitantly produces extensive platelet activation and aggregation. HIT diagnosis is based on the presence of thrombosis and diagnostic laboratory tests including immunoassays for HIT antibodies and functional tests, such as the 14C-serotonin release assay. Heparin treatment should be withdrawn immediately upon diagnosis of HIT, and the patient should be subjected to an alternative treatment for at least 5 days unless the HIT diagnosis is disproven. Once the patient has been stabilized, warfarin treatment should commence while the patient is still receiving the alternative anticoagulant therapy.

Objective: To determine the incidence of ventilator associated pneumonia (VAP) in the intensive care unit, and to characterize most common causative pathogens and resistance pattern. To evaluate compliance to VAP prevention strategies and their documentation in order to identify areas for quality improvement.
Design: A retrospective single center study was performed in which medical records were reviewed from all patients on mechanical ventilator admitted to intensive care unit from January to December 2007. The Clinical Pulmonary Infection Score (CPIS) and problem list were used to identify VAP cases. Data on microbial isolates and antimicrobial resistance were collected as well as documentation of measures to prevent VAP.
Setting: A multidisciplinary, eight-bed Intensive Care Unit (ICU) at a metropolitan municipal hospital in Puerto Rico.
Patients and participants: A total of 60 patients that required mechanical ventilation for more than 48 hours.
Measurements and results: The overall estimated VAP rate was 37.15. There was an extremely low compliance to head of bed elevation, daily sedation interruption and oral care. The most common pathogens identified in early and late onset VAP were Klebsiella species, Acinetobacter baumanii, and Pseudomonas aeruginosa, all being multidrug resistant pathogens.
Conclusions: The lack of compliance to VAP preventive measures as part of the routine management of patients in mechanical ventilation may explain the high VAP rate. Multidisciplinary teams are needed to establish standardized protocols as well as periodic quality improvement reviews to prevent this complication.

Rhinocerebral mucormycosis is recognized as a potentially aggressive and commonly fatal fungal infection. Mucormycosis is a rare opportunistic necrotizing infection within the class Zygomycetes and the order mucorales. Mucormycosis is commonly seen in patients with diabetes, hemochromatosis, burns, leukemia, lymphoma, HIV and other immunocompromised status. Clinical course of the infection typically begins with the symptoms of sinusitis or rhinitis with mucosal ulceration or necrosis. The infection disseminates to the orbit and cerebrum by direct extension as in our patient, or it may spread by vessels such as those of cavernous sinus. Imaging and early surgical debribement is essential in management of these patients.

Airway pressure release ventilation (APRV) is a novel mode of positive pressure ventilation that has a number of advantages over low-tidal volume, assist-control ventilation in patients with the acute respiratory distress syndrome (ARDS). APRV may have particular utility in morbidly obese patients with respiratory failure. We report a case of a morbidly obese patient who developed aspiration pneumonitis and severe life threatening ARDS who was successfully managed with APRV.

Objective: The primary objective of this study was to characterize how vasopressor and inotropic agents are prescribed and administered in the hemodynamic management of sepsis. Secondary objectives were 1) to evaluate adherence with published guidelines to identify areas of deviation and 2) to describe pharmacists’ perceived incidence of adverse drug reactions (ADRs) of vasopressors and inotropes.
Design and setting: Web-based survey.
Patients and participants: Critical care pharmacists.
Interventions: An email invitation was sent to critical care pharmacists asking them to complete a web-based survey. The survey opened September 29, 2004 and closed March 4, 2005.
Measurements and results: Of 1065 pharmacists, 235 (22.1%) responded to the survey. Median hospital and ICU size were 451 and 20 beds, respectively. Primary types of ICUs included general (42.1%), medical (28.5%), surgical/trauma (18.3%), cardiac (9.8%), and other (1.3%). Independent of pulmonary artery catheter (PAC) use, the most common initial vasopressor choice in surgical/trauma ICUs was norepinephrine. In the other ICUs, the most common first-line agent was norepinephrine if a PAC was present and dopamine if a PAC was not present. The most common dosage regimen of vasopressin was a continuous infusion of 0.04 units/min (49.8%). The most commonly used inotrope was dobutamine. Respondents reported using inotropes either sometimes (48.1%) or rarely (34.0%), with therapy continuing 24–48 (54.5%) or 48–72 (26.0%) hours. Commonly associated agents with specifi c adverse effects included dopamine with tachycardia and norepinephrine with digital ischemia. Much variability was shown in drug concentrations and various dosages of vasopressors and inotropes between institutions.
Conclusions: Despite published guidelines, vasopressor and inotrope use in hemodynamic management of patients with sepsis and septic shock displayed much variability. Perceived incidence of ADRs for these agents also demonstrated inconsistency among respondents. National organizations need to develop recommendations for standardization of concentrations of continuous infusion medications in the ICU.

Objective: Despite advances in medicine, adverse clinical events, especially cardio-respiratory arrests, still occur in hospitalized patients. Unplanned Intensive Care Unit (ICU) admissions are frequently a result of this failure to recognize or appropriately treat the ‘pre-arrest’ period, when signs of physiologic deterioration are often evident. Although survival rates to hospital discharge for cardiac arrests are universally poor, the patterns of clinical deterioration and outcome of unplanned medical ICU admissions is not well studied. We aim to evaluate whether unplanned medical ICU admissions are associated with higher inhospital mortality.
Design: Prospective observational, 3-month data collection and analysis of case records and charts. In particular, intubation rates and reasons for unplanned admissions were analyzed.
Setting: 18-bed medical Intensive Care Unit in Changi General Hospital, a regional 790-bed hospital in Singapore.
Patients and participants: All medical and cardiac admissions to the Medical ICU from the general wards from October 2007 to January 2008. Direct admissions from the emergency department were excluded.
Measurements and results: A total of 423 admissions of which 37 (8.7%) were unplanned and 386 (91.3%) were planned. Data was analyzed using SPSS 12.0.1, and Pearson Chi-square for comparison. P value <0.05 considered to be statistically signifi cant. There was a statistically signifi cant difference in hospital mortality between planned (54 deaths, 14%) and unplanned admissions (25 deaths, 67.6%), (p <0.001). All but 1 patient in the unplanned group required intubation. Desaturation was the commonest reason for unplanned admissions, followed closely by sudden cardiorespiratory collapse and hypotension.
Conclusions: The high mortality rate among unplanned medical ICU admissions is a cause for concern. Implementing a system of early critical illness detection and specialist intervention may help reduce such mortality as well as provide more defi nitive planned palliative decisions.

Background: National practice guidelines do not exist for the treatment of acute hypertension (AH) in the critically ill adult. An initial step towards guideline development is to document current prescribing patterns of intravenous (IV) antihypertensives for AH, which serves as the purpose of this survey.
Methods: An e-mail to participate in this Web-based survey was sent to 5574 critical care physician and pharmacist members of the Society of Critical Care Medicine and the American College of Clinical Pharmacy. The survey, which requested responses concerning antihypertensive management in the respondents’ intensive care unit (ICU), opened March 12, 2007 and closed May 11, 2007.
Results: Three hundred ninety three (7.1%) responses were returned; 25 were excluded. The most common practice setting (44.6%) was a mixed-population ICU. One hundred three (28.3%) respondents reported that a guideline exists in their institution for the treatment of hypertensive emergency (HE) in acute hemorrhagic stroke (AHS), while only 30 (8.2%) had guidelines for the non-stroke (NS) patient. Among physician respondents, mean systolic blood pressures (SBP) used to initiate IV antihypertensives were 180.9 (range 105-220) mmHg and 167.2 (range 100-220) mmHg in NS and AHS patients, respectively. In the NS patient, intermittent IV labetalol was the drug of choice among physicians (21.3%) and pharmacists (26.5%), while nicardipine was the drug of choice for the AHS patient (34.7%, 36.2% respectively). The second line agent of choice for the NS patient was sodium nitroprusside among physicians (19.8%) and continuous infusion labetalol for pharmacists (19.8%). For the AHS patient, the second line agent of choice was nicardipine among physicians (21.8%) and pharmacists (27.6%). One hundred thirty one (36%) respondents reported that they have seen a patient with symptomatic cyanide and/
or thiocyanate toxicity.
Conclusions: Because most institutions do not have HE guidelines, our data described herein provides the rationale for developing a national guideline.

Background: The eye is not an organ immune to insults as a result of impairments to normal function or illnesses. In those patients that are intubated and/or sedated, the protective blink reflex is often not working properly, or not working at all. This paper will review some of the conditions of the eye most often encountered in the intensive care unit (ICU).
Methods: PubMed was searched using the keywords ophthalmological problems, ICU, ophthalmology, eye, keratitis, chemosis, candidemia, infections to locate reports of ophthalmologic problems in the intensive care unit and literature about recommendations for the management of those ophthalmologic conditions.
Results: The present study is a review of the recent literature related to the diagnosis and management of ophthalmological issues in the ICU.
Conclusions: The eye is an important, and often under utilized, diagnostic indicator of disease. In the ICU the eye is vulnerable to the increased potential of insult. It is necessary to prevent eye damage by trying to preserve its protective layers integrity and
regularly examined in ICU patients.

In the year 2008, knowledge and technology develop continually in every field of our lives, and, with no exception, in critical care medicine as well. This continuous growth is implicit in our daily activities. We could not imagine our lives today without it. Nowadays, as health care professionals, we surely do not want a fever to last for one week before we can make a diagnosis of typhoid fever for our patients. We can use some simple tests instead and institute prompt therapy.
We believe that these rapid developments in the acute care medicine fi elds motivated Dr. Iqbal Mustafa 11 years ago to found this Critical Care and Shock Journal; a Journal that despite many other similar journals has persisted and evolved.

Resuscitation from death is not an every day event; however, it is no longer a rarity. Cardiopulmonary resuscitation (CPR) has, therefore, become a common tool in our management of these critically ill patients.
Despite an improved understanding and management of cardiac arrest, and the widespread application of do not resuscitate (DNR) orders in an attempt to prevent the inappropriate use of CPR, the success rate following in-hospital cardiac arrest has remained unchanged
over the last three decades, with return of spontaneous circulation (ROSC) in about 30% with approximately 15% of patients being discharged neurologically intact [1-5].

Weaning from mechanical ventilation is defi ned as the transition from the ventilatory dependence of the patient to a spontaneous breathing status. Recognizing when a patient is ready to be weaned from mechanical ventilation is greatly infl uences the outcome, and may prevent compromising a patient. Weaning indices were developed to help the physician predict the outcome of weaning trials, a common concern in the intensive care unit (ICU) setting. Many physiological mechanisms explain the reason why many patients fail weaning trial, mostly related to a noncompliant respiratory function
and cardiovascular instability. The primary goal is to reduce failed attempts, and to adopt successful weaning protocols, in order to overcome problems that may arise in the critically ill patients. The ratio of respiratory rate to tidal volume (f/Vt), among other indices, and weaning trials like pressure support ventilation (PSV) or spontaneous breathing with the use of T tube are explained.

Objective: Study the survival-to-hospital discharge rate for veterans who underwent Advanced Cardiac Life Support (ACLS) and reach a better understanding of the variables that infl uence their
survival after cardiac arrest. To aid in developing strategies directed towards decreasing the risks related to the event.
Design: A retrospective record review of advanced resuscitative attempts during the period of January 1st to December 31st, 2006.
Setting: VA Caribbean Health Care System, San Juan.
Patients: Veterans admitted during the study period who suffered cardiac arrest.
Measurements: Patient’s age, sex, diagnosis, initial rhythm, location, time of event and duration of the resuscitation efforts (downtime), were collected.
Main results: There were 128 arrests documented during the study period: 122 (95%) were inhospital events and 6 involved patients brought to the emergency department during the course of resuscitation. The mean age was 72 years and 98% were males; most events occurred at general medical/surgical wards (61%). Events were mostly of cardiac origin (82.78%), with asystole (AS) and pulseless electrical activity (PEA) being the most common initial rhythms (61%). The most frequent pre-arrest diagnoses were sepsis, communityacquired pneumonia, renal failure and malignancy.
Survival-to-hospital discharge was 7.38%; most survivors suffered primarily respiratory arrests while at the general wards. Arrest events were evenly distributed throughout the 24-hour day, and the average downtime in survivors was lower than in non-survivors (12 vs. 22.35 mins respectively, p=0.03).
Conclusions: We found a substantially lower survival rate for in-hospital cardiac arrests than has been previously reported. Possible explanations for this phenomenon include the high incidence
of arrhythmias associated with poor outcome (AS, PEA), the frequency of unwitnessed events occurring in general wards, patient’s age and underlying diagnoses. Measures for the timely
identifi cation of admitted patients who are at risk for poor resuscitative outcomes with these characteristics should be instituted.

Purpose: Positioning mechanically ventilated patients in an adequate semi-recumbent position is a low cost and apparently easy applied measure to prevent new VAP. We performed an unannounced
audit to compare the actual backrest angle with the target backrest angle of 30-45 degrees, assess whether compliance was better in patients whose bed had a built-in bedside protractor, and document
diffi culties reported when failing to achieve the target backrest angle.
Methods: From 1/3/2007 to 30/6/2007, unannounced ad hoc inspections were made on patients receiving mechanical ventilation in the intensive care unit. During inspections, the angle of elevation of bed was formally measured by a manual technique using a hand-held protractor. The nurse at bed-side was also asked to estimate the angle of elevation of bed without referring to the built-in protractor and interviewed with a structured questionnaire.
Results: From 1/3/2007 to 30/6/2007, inspections were made on 295 occasions. The median angle of backrest elevation was 25 degrees (interquartile range [IQR]: 20 to 30 degrees). The median angle of elevation estimated by the nurse at the bed-side was 30 (IQR: 20 to 30 degrees), (p <0.001). Semi-recumbent positions meeting the 30 degree minimum target angle were observed on only 120 (41%) occasions. Reasons provided for failing to achieve the target angle included incorrect estimation of the backrest angle and interference of the semi-recumbent position with nursing procedures and nursing inconvenience.
Conclusions: This audit showed that the minimum target semi-recumbent position of 30 degrees was achieved only 40% of the time in an academic intensive care unit. Nurses at bedside consistently
overestimated the angle of elevation of bed, and the presence of a built-in bedside protractor was not associated with a greater compliance with the target backrest elevation angle. Strictly enforced protocols, education programs for nurses and doctors
and regular audit may improve compliance with backrest elevation targets.

Introduction: Aeromonas hydrophila gastroenteritis is rare in humans and common amongst fish, reptiles and amphibians. In humans, infections caused by Aeromonas species usually occur with increased frequency during warmer months. The organism is frequently isolated from meat products and its transmission is by feco-oral route.
Clinical picture: We report 2 cases of Aeromonas hydrophila gastroenteritis in elderly, diabetic patients. Both patients had severe diarrhea and stool cultures grew Aeromonas hydrophila.
Treatment and outcome: Both responded to intravenous ceftriaxone and were discharged well.
Clinical implication: It is self limiting in immunocompetent hosts. In elderly, immunocompromised or pediatric patients, it can cause bacteremia and high mortality if not treated early.

A middle age Caucasian gentleman presented to the Emergency Department with fever, chills and hypotension. Chest X-ray revealed consolidation in right lower lobe consistent with pneumonia. A chest radiograph after central line placement revealed a venous anomaly. CT scan with contrast revealed persistent left superior vena cava and absent right superior vena cava.

Brain natriuretic peptide levels (BNP) have been best studied in the heart failure (HF) literature and has been increasingly used in the critical care population as an estimate of cardiac function. BNP
is secreted by cardiomyocytes in response to an increase in transmural ventricular pressure. The measurement of BNP is well known in the cardiac literature. Studies in the critical care population have looked at measuring BNP in different subsets of patients with sepsis, pulmonary embolism (PE), acute respiratory distress syndrome (ARDS), pulmonary hypertension (PH) and non-cardiogenic pulmonary edema (CPE). BNP has been used to differentiate HF syndrome from other causes of respiratory failure both in the acute and chronic settings. The measurement of BNP in the critical care population is fraught with difficulties only one of which is the significant effect of renal failure on our ability to interpret BNP levels effectively. This review summarizes the current literature on the utility and significance of measuring BNP in the critical care population.

Objective: The main goal of this research is to know
a nurse’s attitude to patients that may suffer delirium
during the hospitalization time. A second goal
is to analyze whether relative’s visit time is a factor
to be considered.
Design: Multicentre prospective and observational
study.
Methodology: This study was performed in several
hospitals that belong to the public sanitary health
system of the Principado de Asturias (SESPA) and
one hospital that belongs to Servicio Andaluz de
Salud (SAS). The target populations are general
hospitalization nurses, nurses specialized in
intensive care, and relatives of patients admitted
in intensive care units (ICU). As a tool we used a
Likert questionnaire for validation of attitudes.
This questionnaire included 20 questions about
different situations that the nurses and relatives
maintain in patients with delirium.
Results: 215 questionnaires were sent to the target
population including 87.91% nurses and 12.09%
patient’s relatives. Cabueñes Hospital (SESPA) returned the highest number of questionnaires
(46.51%). Intensive care nurses returned the
highest number of questionnaires (73.02%). We
considered different assistant levels for ICU, that
in mostly corresponded to levels III and IV. The
analysis of the variables studied using a multiple
regression linear model revealed that the answers
to 9 out of 20 possible items were signifi cantly
different. Finally, the differences were highest in 3
of those 9 items.
Conclusions: Nurses don’t fi nd to the patients with
delirium, of more interest than other types of patients,
although they are highly concerned by their health
before and after the delirium. Nurses are partially
but not completely aware that delirium is a very
serious illness. Nurses are not confi dent regarding
whether the patient’s relatives could calm down
the patient and help him to overcome the disease.
Given the heterogeneity of the answers there are no
defi nitive conclusions regarding whether a change
of the visit hours might be important in the recovery
of patients with delirium.

Objective: The objective of the study is to determine
factors that infl uence the outcome of long stay patients
in a general intensive care unit (ICU) and/
or high-dependency unit (HDU) in a New Zealand
teaching hospital.
Setting: 10-bed general ICU and 4-bed surgical
HDU in a 400-bed hospital.
Study type: Population based retrospective cohort
study.
Methods: All patients with prolonged stay in a high
resource area (>7 days in the ICU or >14 days in either
the ICU or HDU) between 2000 and 2003 were
reviewed. Demographic data, co-morbidities, diagnoses,
clinical events, hospital and 1-year mortality
data were obtained using available databases and
patient records. Multiple logistic regression analysis
was performed to identify which variables are associated
with death among patients with a prolonged stay in a high-resource unit (ICU/HDU).
Results: 207 patients were included in the study.
Twenty eight percent died before hospital discharge
and 40% died within one year of their admission.
Univariate analysis showed that increasing age,
APACHE II score, admission post cardiac arrest,
inpatient cardiac arrest, development of sepsis and
requirement for renal support therapy were all risk
factors for increased mortality. However, when adjusted
for age, gender and APACHE II score the
only risk factor strongly associated with death was
having a cardiac arrest in the ICU.
Conclusions: Prolonged ICU and/or HDU stay is associated
with a high mortality rate particularly in
patients with advancing age and increasing severity
of illness. In this study, only cardiac arrest after a
prolonged stay in the ICU and/or HDU is a strong
predictor of death independent of the age and the
APACHE II score.

Background: This study aimed to collect information
about long-term survival and independence of
patients requiring acute hospital admissions and
care in Intensive Care Unit (ICU) and High Dependency
Unit (HDU) in a non tertiary setting.
Setting: An 11-bed multidisciplinary co-located
ICU and HDU, a JFICM level 2 unit, providing all
intensive care services for a non-tertiary (secondary)
New Zealand District Health Board Hospital.
Method: All acute adult admissions presenting to
ICU/HDU between 1 Jan 2001 and 31 Dec 2001
were studied. Admission demographic and physiological
data was collected. From a review of the
hospital records, NZ death registry, and the ICU
database of published obituary notices, dates of
death were identifi ed. After the fi rst anniversary
of their initial ICU admission, discharged patients
in whom death had not been confi rmed, were contacted.
Patients surviving ICU were surveyed to
determine their independence. The age and gender
adjusted annual survival for the general population
was compared to observed survival following ICU/
HDU admission. Main Results: Adult acute admissions comprised
586 (68.5%) of the total of 855 ICU/HDU admissions
in 2001 (86 paediatric [<15 years] and 169 elective
admissions excluded). Acute adult admissions (M
49.9%; F 50.1%) had a median age of 58 years, an
ICU survival of 86.3%, and a hospital survival of
82.7%. Long-term outcome was established in 94%
of admissions. One year post admission 73.2% were
confi rmed as alive. Increased age decreased survivorship,
with only 35.3% of the >85 years old group
surviving one year. After ICU admission, one year
survival was lower than that of the general population.
Age-group matched survival was from 93% to
32% for males and 60.2% to 90.4% for females of
the general population survival rate. 94.4% of survivors
were independent.
Conclusions: Following acute admission, ICU patients
have a lower level of survivorship than the
general population, but the vast majority of the
73.2% patients that survive one year remain independent.
Generally the quality of life at one year is
acceptable to survivors.

We present the case and images of a 52 yearold Hispanic gentleman with a history of hepatitis C and chronic liver disease that developed Vibrio vulnifi cus sepsis secondary to eating raw oysters.
His course was complicated by necrotizing fasciitis in the upper extremities and renal failure.

Objective: To describe the natural history and risk factors of the cholestatic post-cardiac surgery syndrome.
Methods: We reviewed all cases of patients with hyperbilirubinemia after cardiac surgery admitted to a large metropolitan referral hospital during January 2005 to December 2005 (n=317).
Results: Fourteen patients (11 male, 3 female) developed postoperative hyperbilirubinemia after excluding hyperbilirubinemia secondary to acute cholecystitis, acute pancreatitis, and shock. Sixty four percent of patients have mild and subclinical hepatobiliary disease preoperatively. Preoperative echocardiography showed right ventricular enlargement and/or hypokinesis in most patients. The mean serum total bilirubin peaked at postoperative day 9 and return to normal by postoperative day 18. The highest recorded serum total bilirubin was 13 mg/dL (221 umol/L). The mean serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), and alkaline phosphatase (ALP) levels were mildly elevated and showed no distinct peak during postoperative period.
Conclusion: In this series, 4.4% of patients undergoing cardiac surgery developed idiopathic post-operative jaundice. Preexisting liver disease and increased right heart pressures were associated with this syndrome. After excluding other causes of hyperbilirubinemia, serum total bilirubin can be expected to normalize in first 18 days after surgery.

Purpose: To measure the degree of physician’s knowledge of the SSC management guidelines in Puerto Rico.
Materials and methods: A questionnaire was administered personally to 231 physicians. It included therapeutic interventions and important elements of the guidelines. Physicians including internal medicine and general surgery from public and private hospitals around the entire island answered the questionnaire.
Results: In general, the sample population performed quite poorly, with a mean of less than 50% correct answers, including the internal medicine attendings. PGY-3 residents had a higher percentage of correct answers than attending (52.5% vs. 47.4%, p =0.21). Correlating directly with the level of training, a trend toward more knowledge was noted (PGY-3 52.5% vs. PGY-1 42.2%, p =0.08). PGY2 and PGY-3 residents in internal medicine demonstrated a significant knowledge of the SIRS criteria compared with the first year residents (p =0.01 for PGY-1 vs. PGY-2, and p =0.02 for PGY-1 vs. PGY-3). Of the questions concerning bundle components, the worst scores were on those focused on use of steroids (21.3%), glucose control (42.6%) and ventilation (40.1%).
Conclusions: Regardless of their levels of training, internists and surgeons fared quite poorly in those questions that specifically address most therapeutic interventions known to reduce sepsis mortality. Our findings revealed no difference in knowledge between physicians in-training and their counterparts in private practice. This is quite unexpected, as one would anticipate improved and updated knowledge in those in the academia.
Considering the morbidity and mortality associated with sepsis, these findings warrant an initiative to correct them.

The care of the critically ill patient in the pediatric intensive care unit (PICU) has remained an important topic for those health care providers dealing with children. The purpose of this article is to introduce to the reader a summary of selected papers which we consider relevant to the care of the pediatric critically ill patient and that were published in the year 2006. These articles were selected on the basis of application to the PICU, overall importance and are not to be solely considered authoritative in their field. There are many other useful articles. We have attempted to choose those articles with scientific merit and rigorous methodology that we believe present interesting data in the field.

Aim: To describe the endotracheal cuff pressure (Pcuff) measurements of patients receiving ventilation via endotracheal tubes in an Intensive Care Unit (ICU).
Method: Pcuff were measured daily using a cuff tonometer and the pressure then adjusted to <30 cmH2O in patients ventilated in the ICU, over fifteen months. Data collected were demographics, the location where intubation occurred, and airway pressures when available (PEEP, peak, and plateau). Data was analysed using Kruskal-Wallis and Dunn’s Multiple Comparison Test.
Results: 1073 data sets were collected from 199 intubated ventilated adults. Of all Pcuff measured 15.7% (169) exceeded 30 cmH2O. The first Pcuff measurements made during ICU stay had median pressure 30 cmH2O (IQR 23.5-40) and 34.5% (68) exceeded 30 cmH2O. Median Pcuff of patients admitted following intubation in the Operating Theatre (OT) were 26 cmH2O (IQR 20-37), those via Emergency Department (ED) were 32 cmH2O (IQR 28-57), and those intubated in ICU were 28 cmH2O (IQR 22-34.25). Pcuff of patients intubated in OT differed significantly from ED patients, as did ICU patients compared to ED (p <0.005). ICU and OT patients did not differ.
Conclusion: Pcuff measurement is not routine at intubation. Described complications of elevated Pcuff include cuff herniation, vocal cord damage, tracheal mucosal ischaemia, and airway obstruction.
Unrecognised elevated Pcuff is common, with a higher incidence in ED than ICU or OT. Skilled intubation assistance from anaesthetic technicians is routine in OT, common in ICU, but less frequent in ED, and may influence the initial Pcuff.

Introduction: Escherichia coli meningitis was rarely reported in adult patients. Moreover it is very rare in an adult patient without diabetes mellitus or neurosurgical shunts. In adult patients, it carries a high mortality ranging from 27% to 90% with
treatment, and 100% without treatment.
Case report: We describe a 78 year old lady who presented with altered mental state and neck stiffness. Her cerebrospinal fluid analysis was consistent with bacterial meningitis and she had E.
coli bacteraemia. She was treated with ceftrioxone 2 gm twice a day for 2 weeks. She also developed non-ST elevation myocardial infarction on day 3 of admission. She was treated with aspirin, low molecular weight heparin and monitored on telemetry for 3 days. She remained in hospital for 2 weeks and was discharged well.
Conclusion: E. coli meningitis carries high mortality. E. coli may cause meningitis in adult patients without diabetes mellitus or neurosurgical shunts. Early diagnosis and treatment is key to good outcome as mortality without treatment is 100%.

Clinical presentation of miliary tuberculosis is highly variable. Patients that present with central nervous system disease such as meningitis or tuberculoma is seen in up to 20% of the cases. Meningeal involvement is usually seen in up to 54% of the cases of miliary tuberculosis, and in just a few minority of patients the AFB smears are positive.

BNP may be raised in patient with DF without heart failure. The exact pathogenesis of raised BNP in DF is unclear.

Mechanical ventilation has always been a cornerstone of respiratory support for patients with respiratory muscle paralysis. In selected patients, diaphragm pacing (DP) through electrical stimulation of the phrenic nerves provides an alternative to mechanical ventilation with signifi cant advantages in life quality. We report an interesting case of unilateral diaphragmatic paralysis in which unilateral diaphragmatic pacing produced signifi cant improvement in quality of life.

In the condition of electrolyte unbalance and hypoalbuminemia the Stewart approach is better than the traditional approach. Nevertheless, the calculation of SIG is more timeconsuming, therefore the corrected anion gap (AGcorr) was suggested to use in clinical practice as a combination with SBE.

More than a century after the description of sarcoidosis, the disease remains not well understood. Sarcoidosis is an infl ammatory disease of unknown etiology characterized by noncaseating granulomas with multiple organs affected. The epidemiology reveals lung involvement in 90- 95% of the patients and just 5-13% incidence of neurological involvement. We present an unusual case of a patient with medulla oblongata and retroperitoneal sarcoidosis with no other organ involvement. In addition to the case presentation and extensive up-to-date literature review on extrapulmonary sarcoidosis, we describe the diffi culties in making the diagnosis and the challenge in differentiating sarcoidosis from other illnesses such as tuberculosis.

The roles of lipopolysaccharide (LPS), monocyte chemoattractant protein-1 (MCP-1) and tumor necrosis factor (TNF) in the genesis of endothelial cell injury are being defi ned. Therapy for IPS includes supportive care and immunosuppressive agents. The role of TNF antagonists is being studied in ongoing clinical trials.

Plasmatic biomarkers measurement during the initial phase of sepsis may help to individualize therapy. An evaluation at 24 h based on IL-6/IL-10 ratio may anticipate a more aggressive infl ammatory profi le. These patients would specially benefi t from immunomodulating therapies to improve survival.

TH appears underutilized in our sample of practitioners from two developing countries. Clinicians in these countries are not
familiar with ILCOR TH guidelines. Therapeutic hypothermia is certainly practical in most clinical settings and programs aimed
at educating practitioners about TH are needed in developing countries to improve neurological outcome in comatose victims of
cardiac arrest.