Volume 13

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.