Critical Care and Shock, Volume 13

Volume 13

  • November 2010, Volume 13, No. 4
    • Hyperoxia and cardiopulmonary resuscitation outcome: where is the data?:

      This work by Kilgannon and coworkers is the first multicenter study to question the effects of hyperoxia in adults after resuscitation and, as such, is of particular interest. However, inferring that post-resuscitation hyperoxia is detrimental based on this study alone is premature. Retrospective analysis of existing data is always limited by the structure of the database which was not necessarily constructed to address the particular question at hand and this study clearly presents some of the limitations of this method. One of the inclusion criteria was cardiopulmonary resuscitation within the 24 hours prior to ICU admission; some of the patients may have been admitted a significant time after the resuscitation.

    • Impact of length of stay in emergency department on the outcome in patients with severe sepsis:

      Objective: The impact of emergency department length of stay (EDLOS) on outcome in critically ill patients is debatable. The factors that impact on mortality and the measures to improve survival have been widely studied. However, the association between EDLOS and outcome in the group of critically ill patients with severe sepsis requiring intensive care has not been investigated.
      Methods: We performed a retrospective observational study over a 3-year period in a metropolitan 360-bed teaching hospital that has a 10-bed general intensive care unit (ICU). Adult patients presenting to emergency department during the study period with severe sepsis requiring ICU admission were included. The effect of EDLOS on in-hospital mortality, intensive care unit length of stay (ICULOS) and hospital length of stay (HLOS) was investigated.
      Results: During the study period 117 patients were admitted to ICU from the emergency department (ED) with severe sepsis. The mean age of the patients was 64.7 years and the sex ratio was comparable (51% male patients). The mean APACHE II score was 18.3. The median EDLOS was 8.3 hours. The median ICULOS and HLOS were 3 and 12 days respectively. The hospital mortality was 21.3%. There was no association between EDLOS and in-hospital mortality, ICULOS or HLOS.
      Conclusion: Our study revealed that in patients with severe sepsis, the duration of EDLOS had no effect on in-hospital mortality, ICULOS or HLOS.

    • A national point-prevalence survey of the practice of sedation, analgesia, neuromuscular blockade and delirium assessment:

      Introduction: The aim of this survey is to establish current practices of sedation, analgesia, neuromuscular-blockade use and delirium assessment in adult ICUs in Singapore.
      Methods: All adult ICUs from the government-restructured hospitals were invited to participate in a point-prevalence survey on the 30th October 2008, under the direction of the Society of Intensive Care Medicine’s National Investigators for Clinical Epidemiology and Research. Data collected for all adult ICU inpatients included demographics, practices on sedation, analgesia and neuromuscular blockade as well as delirium assessment and management.
      Results: There were 93 patients from 11 ICUs. The mean age was 61.2 years with a predominance of Chinese (76.3%) and a slight male predominance of 57.0%. Sedation was administered in 25.8% of the patients with the use of sedation scales in 75.0%. Only 20.8% of the sedated patients were on a sedation protocol. The majority of patients had daily interruption of sedation. Analgesia assessment was done in most patients (78.5%) with the use of analgesia scales. Analgesia was used in approximately one third of patients. Only 2 patients were on neuromuscular blockade. There was no usage of any formal delirium assessment tools at all with almost one third of patients being physically restrained.
      Conclusions: This national multi-centre study reveals several deficits in the adult ICU with regards to sedation and delirium assessment and management. Several initiatives should be implemented to improve patients’ safety and quality of care in the ICU.

    • Incidental nephrograms in acute renal failure:

      A 33-year-old African-American female was admitted to the hospital for the evaluation of severe dyspnea, chest and back pain, nausea, vomiting, diarrhea, and fever. She reported a vague history of renal disease and systemic lupus erythematosus, and had a creatinine of 0.65 mg/dL on admission. Her chest pain and dyspnea rapidly worsened, and she required emergent intubation after her oxygen saturation dropped to 72% while breathing room air. Assisted mechanical ventilation was started. She underwent blood, urine and sputum cultures and empiric antibiotics were begun. In addition her initial blood pressure was 80/50 torr. She remained hypotensive despite fluid administration, with persistent systolic blood pressure of 70 torr.

    • A very vascular right hemithoracic opacity:

      A 78-year-old lady with a history of hypertension presented to the emergency department (ED) with complaints of chest pain and shortness of breath. On physical examination, her heart rate was 110/min, blood pressure 70/40 mmHg, respiratory rate 28/min, oxygen saturation while breathing room air of 88%. Supplemental oxygen was provided and intravenous access attempted peripherally. Placement of central venous line utilizing the anterior approach of jugular vein cannulation was complicated by difficulty in threading the guide wire. An immediate portable upright chest radiograph revealed right lung collapse associated with pleural effusion and a 9 cm opacity on the left hemithorax (Figure 1).

    • Gastric volvulus herniation in the chest:

      An 80 year-old lady with a history of hypertension and hypothyroidism presented to emergency department (ED) with complaints of shortness of breath, epigastric discomfort, difficulty swallowing and poor appetite for a period of three weeks. She was only able to eat a soft diet and clear liquids. A chest radiograph in the ED revealed a large hernia, which was seen extending from the right hemidiaphragm across the midline into the left hemidiaphragm, likely representing a combination of a diaphragmatic hernia with a hiatal hernia and possible gastric volvulus (Figure 1).

  • August 2010, Volume 13, No. 3
    • Hypokalemia after cessation of the therapeutic barbiturate coma- an unusual complication:

      Barbiturate coma is one of the treatment modalities used to prevent secondary brain damage in refractory malignant intracranial tension both in traumatic and non-traumatic brain injuries. Complications such as hypotension, myocardial suppression, hepatorenal dysfunction and delayed return of consciousness have been reported following barbiturate coma therapy. In addition, potassium changes have also been reported, in particular hypokalemia during barbiturate coma therapy and a rebound hyperkalemia after cessation of therapy. We however report an unusual complication of refractory hypokalemia occurring after stopping barbiturate therapy. A 24-year-old patient was treated with a thiopentone infusion for management of increased intracranial pressure after severe head injury. The patient developed persistent hypokalemia (1.6 mmol) 8 hours after withdrawing thiopentone infusion. Severe disturbance of plasma potassium balance is a rare but life-threatening complication of therapeutic barbiturate coma. We recommend that clinicians be aware of the potential occurrence of severe hypokalemia, which is rare but fatal, not only during barbiturate coma therapy but also following cessation of thiopentone infusion. We recommend close monitoring of serum potassium during as well as after discontinuing barbiturate coma therapy in order to prevent fatal complications secondary to potassium abnormalities. Further studies are needed to elucidate the precise mechanism of this clinical event.

    • Case report: methylene blue for cardiogenic shock:

      Background: Cardiogenic shock after acute myocardial infarction is a cause of elevated morbidity and mortality in coronary intensive care units. The pathophysiology of cardiogenic shock involves both heart failure and increased afterload, but sometimes, not frequently may present as a vasodilatory state secondary to systemic inflammation, which requires treatment with high doses of inotropics and vasopressors.
      Objective: We present 3 cases of patients with myocardial infarction who developed cardiogenic shock resistant to vasopressors, who were treated with methylene blue and who showed improved clinical outcomes.
      Data sources: Several studies have demonstrated that methylene blue increases systemic vascular resistance reflected by an increase in mean arterial pressure, or from a reduction in vasopressors requirements in patients with septic shock. It also improves myocardial contractility and oxygen delivery, although this is controversial. There is evidence that an inflammatory response with activation of inducible nitric oxide synthase might be responsible for the deleterious effects and persistent vasodilation in patients with cardiogenic shock resistant to vasopressors.
      Conclusions: We review briefly the changing paradigm in the use of nitric oxide antagonists in treating patients suffering cardiogenic shock.

    • The effect of the Medical Emergency Team on unexpected cardiac arrest and death at the VA Caribbean Healthcare System:

      Objectives: To determine the effect of the implementation of a medical emergency team on the incidence of unexpected cardiorespiratory arrest, unexpected death, unplanned ICU admissions, and advance directive status.
      Design, setting, and patients: This is a single center, retrospective, electronic medical record review. Adult patients admitted to regular ward between November 2007 to February 2008 and November 2008 to February 2009 at the VA Caribbean Healthcare System were evaluated. Medical emergency team education and program rollout occurred from February through June 2008.
      Main outcome measures: Unexpected inhospital cardiorespiratory arrest, death, and unplanned ICU admission rates.
      Results: There was no effect on unexpected death (p=0.23) nor 48 hour survival after the intervention (p=0.37). There was no change in DNR status previous to MET (p=0.18) and after MET implementation (p=0.32). There was no change of unexpected cardiorespiratory arrest (p=0.16), although lower rates of non-ICU codes were observed (31 versus 25) during the study time period.
      Conclusion: The implementation of the MET in our institution was not associated with a decrease on rate of unexpected cardiorespiratory arrest, unexpected death, 48 hour survival after the intervention or change of DNR status.

    • Early goal-directed therapy in the management of severe sepsis/septic shock in an academic emergency department in Malaysia:

      Introduction: Early goal-directed therapy (EGDT) is a haemodynamic optimization protocol that is proven to reduce mortality in cases of severe sepsis/septic shock.
      Objective: The objective of this study is to determine whether EGDT can be implemented successfully in an academic hospital emergency department with the existing resources and expertise.
      Methods: A prospective study was conducted at Emergency Department of Universiti Kebangsaan Malaysia Medical Centre (ED UKMMC) from March until May 2009. Sixteen patients were enrolled in this study. The patients were subjected to EGDT with the aim to achieve all defined haemodynamic endpoints within the first 6 hours of diagnosis. Data was collected regarding achievability of these endpoints.
      Results: The mean age of the patients was 58.4±17.4 and the mean APACHE II score on arrival was 24.2±7.6. The diagnosis of severe sepsis was made at a mean time of 1.2±1.0 hours from the time of arrival to the emergency department. All patients successfully had a central venous line inserted within 6 hours of diagnosis and the mean time to insertion was 0.7±0.8 hour. The target CVP range was achieved within an average of 2.1±2.2 hours from diagnosis. Out of the 16 patients, 12 (87.5%) achieved the target CVP goal. All patients achieved an MAP of 65 mmHg within the first 6 hours of diagnosis with an average time of 1 hour from time of diagnosis. Eleven (68.8%) patients successfully achieved the target central vein oxygen saturation of 70% and the mean time to achieve this goal was 1.3±0.9 hours. Mean ScvO2 achieved was 81.6±6.7. Thus, the success rate for achieving all EGDT goals within the first 6 hours of diagnosis was 62.5% (n=10).
      Conclusion: This study demonstrates that EGDT can be implemented in the ED with the current resources and expertise.

    • Outcomes of acute renal failure patients having received renal replacement therapy in the intensive care unit:

      Objective: The aim of the present study was to investigate both the outcomes and prognostic factors of ARF patients requiring RRT in our Intensive Care Unit.
      Design: It was a retrospective observational study.
      Setting: Pamela Youde Nethersole Eastern Hospital, a 20-bed medico-surgical ICU.
      Patients and participants: ARF patients who had received RRT from January 2005 to December 2006 were recruited.
      Interventions: The primary outcome was hospital mortality. Secondary outcomes were: dialysis dependency at hospital discharge, ICU and hospital length of stay. Relationship between demographics, premorbidities and clinical parameters with primary outcome was studied.
      Measurements and results: One hundred and thirty-five patients were included in the final analysis. Hospital mortality rate was 63.7%. The median survival was 24 days (IQR 7 to 746 days). Mechanical ventilation (HR 2.96, 95% CI 2.04 to 3.89) and hepatorenal syndrome (HR 2.29, 95% CI 1.63 to 2.95) were independently associated with hospital mortality. Dialysis dependency rate after hospital discharge as on day 60 was 4.1%.
      Conclusion: ARF in ICU was associated with a high mortality rate which was correlated with hepatorenal syndrome and mechanical ventilation. Most of the hospital survivors were free from dialysis.

    • Use of venturi entrainment to deliver nasal high flow oxygen:

      Objective: To evaluate the use of an adjustable venturi device with standard wall oxygen supply to deliver nasal high flow oxygen.
      Design: We set up a circuit using a standard 15 L/min oxygen rotameter connected to a wall outlet, 2 m standard oxygen tubing, an adjustable venturi device, humidification chamber and nasal high flow circuit and cannulae. Delivered FiO2 and total gas flow rates were measured over a range of oxygen flow rates and venturi settings. The study was conducted in two parts - a bench-top study to define the usable range and using a human subject to assess loaded performance of the circuit.
      Setting: Royal Adelaide Hospital Intensive Care Unit.
      Participants: One study author.
      Results: A clinically useful range of total flow rates (30-50 L/min) and delivered FiO2 (0.4-0.6) was achieved using the circuit described. The variation in performance seen with loading of the circuit was clinically insignificant. We have calibrated this ‘Fisher and Paykel’ adjustable venturi device for use with the Fisher and Paykel heater chamber and circuit.
      Conclusion: We demonstrated that nasal high flow oxygen can be delivered in a clinically useful and predictable manner using a venturi entrainment device.

    • The Medical Emergency Team and prevention of sudden cardiac death: where is the data?:

      Traditionally, cardiopulmonary resuscitation (CPR) has been the main tool for treating victims of cardiac arrest. This therapeutic modality has been known for millennia, and despite its widespread use for the last five decades, it has had only few modifications. The popular belief that CPR is an effective approach for patients with cardiopulmonary arrest has been supported by television medical drama series that always show CPR as a medical icon. (1) However, even when CPR is performed by trained providers, the outcomes remain quite poor, with most patients who require in-hospital CPR dying before hospital discharge, with survival to discharge rates that range from 1 to 20%.

  • May 2010, Volume 13, No. 2
    • Induced hypothermia in cardiogenic shock: a case report:

      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.

    • White lung: the effects of trauma:

      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.

    • The use of dexmedetomidine for refractory agitation in substance abuse patient:

      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.

    • Therapeutic hypothermia after cardiac arrest in a Philippine tertiary hospital: a retrospective cohort study:

      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.

    • Clinical application, the use of dexmedetomidine in intensive care sedation:

      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.

    • Therapeutic hypothermia in the year 2010: it is about time!
  • February 2010, Volume 13, No. 1
    • Why ICU’s different
    • Successful recruitment in severe unilateral pneumonia using airway pressure release ventilation and lateral decubitus position:

      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.

    • Acute transverse myelitis in systemic lupus erythematosus: report of a case:

      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.

    • Repeated acute respiratory failure: the strongyloidiasis hyperinfection syndrome
    • Traumatic pneumomediastinum
    • An unusual cause of dyspnea:

      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.

    • Increased serum cystatin C is a predictive factor for renal outcome in non-cardiac critically ill patients:

      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.