Critical Care and Shock

Volume 10

November 2007, Volume 10, No. 4

• Natural History and Risk Factors of the “Cholestatic Post-cardiac Surgery Syndrome”:

  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.

• Sepsis: A Study of Physician’s Knowledge about the Surviving Sepsis Campaign in Puerto Rico:

  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.

• Year in Review 2006: The Critically Ill Patient in the Pediatric ICU:

  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.

• Endotracheal Cuff Pressures in Ventilated Patients in Intensive Care:

  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.

• Spontaneous Escherichia Coli Meningitis in an Adult:

  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%.

• Acute Confusion: An Unusual Presentation of Miliary Tuberculosis:

  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.

August 2007, Volume 10, No. 3

20070612220220

• Significantly Raised Brain Natriuretic Peptide in a Young Patient with Dengue Fever without Heart and Renal Failure:

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

• Unilateral Diaphragmatic Pacing: An Innovative Solution for Unilateral Diaphragmatic Paralysis:

  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.

• Acid-Base Disturbance Analysis: Comparison of the Traditional and Stewart Approaches:

  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.

• Extra-Pulmonary Sarcoidosis: Neurosarcoidosis - Case Presentation and Literature Review:

  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.

• Non Infectious Pulmonary Complications after Bone Marrow Transplant with a Special Focus on Idiopathic Pneumonia Syndrome:

  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.

• Pro- and Anti-Infl ammatory Balance of Septic Patients is Associated with Severity and Outcome:

  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.

• Use and Understanding of Therapeutic Hypothermia in Developing Countries:

  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.

May 2007, Volume 10, No. 2

20070302010555

• Mineral Oil: The Occult Cause of Critical Illness
• Effectiveness Study of rHuEPO in the ICU:

  In this real-world retrospective analysis, critically ill patients treated with rHuEPO did not experience clinical benefi ts; however, patients were sicker and received rHuEPO late in their ICU stay. Monitoring prescribing patterns and patient selection of rHuEPO treatment in critically ill patients in clinical practice is recommended to optimize rHuEPO use and outcomes.

• Gastric Strongyloides with Ulceration and Klebsiella pneumonia Bacteraemia:

  Strongyloides infection is usually confi ned to small intestine in gastrointestinal tract. Gastric mucosal Strongyloides with ulceration is extremely uncommon. We describe a patient who presented with gastrointestinal bleeding with gastric Strongyloides diagnosed by biopsy from the base of the gastric ulcer. Patient was treated with ivermectin 9 mg once a day for 2 days. The hospital stay was complicated by severe Klebsiella pneumoniae bacteraemia which needed treatment with meropenem for 2 weeks. Patient was discharged after 40 days of hospital stay.

• Critical Care of the Liver Transplant ICU Patients: A Pittsburgh “Point of View”:

  The purpose of this review is to summarize the advances in critical care management of the liver transplant ICU patients (patients with end stage liver disease, before and after orthotopic liver transplant). The review is based on search of Medline literature, with a focus on liver failure patients and critical care issues around liver transplantation. Starzl Transplantation Institute at the University of Pittsburgh Medical Center is one of the global leaders in the treatment of end stage liver disease (ESLD). This review is in part based on our work in the 28-bed liver transplant ICU at Montefi ore Hospital, University of Pittsburgh Medical Center, in Pittsburgh, PA. Over the past few years, our understanding of the several important pathophysiologic markers of end stage liver disease has been signifi cantly improved. For example, we do now much better understand hyperdynamic circulation of liver failure, hepatorenal syndrome and its consequences, the role of TIPSS (transjugular intrahepatic portosystemic shunt) and adrenal insuffi ciency in liver failure patients. The management and prophylaxis of variceal bleeding and subacute bacterial peritonitis (SBP), has been successfully standardized. These and other advances in understanding of ESLD pathophysiology and its clinical results, have certainly contributed to more promising outcomes in the ICU management of these complex patients.

• Abdominal Sarcoidosis:

  Abdominal sarcoidosis is an uncommon form of sarcoidosis. The clinical presentation of esophageal, gastric, small bowel, colon, appendicular, spleen, pancreas, and abdominal aortic sarcoidosis are discussed in this review. The differential diagnosis of abdominal sarcoidosis is extensive. Other granulomatous diseases including tuberculosis, fungal infections, parasitic diseases, infl ammatory bowel disease, and Whipple’s disease should be excluded before making the diagnosis of gastrointestinal sarcoidosis. Corticosteroid therapy is the mainstay of medical therapy in abdominal sarcoidosis. Second line agents such as methotrexate are also discussed. Surgical intervention may be necessary in patients with bowel obstruction, perforation, or massive hemorrhage. The authors also provide their experience regarding preoperative pulmonary evaluation of patients with pulmonary sarcoidosis undergoing surgery.

February 2007, Volume 10, No. 1

20061203224403

• Abdominal Compartment Syndrome: Case Report:

  Abdominal compartment syndrome (ACS) was originally described in trauma patients but is now known to occur in critically ill patients with a myriad of acute illnesses.

• Perforated Pre-pyloric Ulcer Presenting with ST elevation on EKG:

  A 66 year-old female with long-standing history of rheumatoid arthritis on chronic steroid therapy, presented for routine kyphoplasty for a compression fracture of L1 and L2. Pre-operative electrocardiogram (EKG) revealed a normal sinus rhythm and no abnormalities. Her intra-operative course was complicated by severe hypotension. A post operative EKG revealed ST elevation in inferior and lateral leads with ST changes. She underwent a left heart catheterization that revealed normal coronary arteries and an ejection fraction of 70%. Because of concomitant abdominal discomfort, a computed tomography of abdomen was obtained and revealed a perforated viscus.

• Changing Medical ICU Environment and the Impact on Nosocomial Infection:

  Nosocomial infections (NIs) are one of the most common complications that occur in ICU patients and confer an increased relative risk of 3.5 for mortality. These types of infections may affect from 5 to 35% of patients who are admitted to ICU’s. Guidelines for Environmental Infection Control in Health-Care Facilities by the CDC, and the Healthcare Infection Control Practices Advisory Committee [HICPAC] guidelines have become standard. These recommendations have been tested in clinical trials of routine infection control surveillance. Also, a revised policy for antimicrobial therapy has proved a reduction in ICU acquired infections and mortality. An extensive review of the principles of infection control in the ICU has been published elsewhere.

• Massive Pericardial Effusion as a Presentation of Hypothyroidism:

  A 46 year-old Hispanic female with no past medical history, and no history of trauma presented to the hospital with complaints of shortness of breath worsening gradually over past two months. The patient’s physical examination was remarkable for diminished heart sounds at auscultation. A complete blood count chemistry was within normal limit. Collagen vascular profi le was negative. A chest x-ray revealed enlarged cardiac shilloute suggestive of pericardial effusion. A computed tomography (CT) scan of chest showed massive pericardial effusion. A 2D-echocardiogram confi rmed the massive pericardial effusion without any evidence of right ventricular collapse. Pericardiocentesis was performed draining 2800 ml of straw-colored fl uid. Cultures and cytology of the pericardial fl uid were negative. Additional blood workup revealed an elevated thyroid stimulating hormone level. The patient was started on thyroid replacement therapy and had an uneventful recovery.

• Severe Complications of Herbal Medicines:

  Neurotoxicity, cardiac toxicity, pulmonary toxicity, hepatotoxicity, and nephrotoxicity are potential severe complications of herbal medicines.

• Sublingual Capnometry: A Non-invasive Measure of Microcirculatory Dysfunction in Sepsis:

  Sublingual/buccal mucosal PCO2 is a regional marker of microvascular perfusion and tissue dysoxia that holds great promise for the risk stratifi cation and endpoint of goal-directed resuscitation in patients with sepsis.