1/15. Severe non-infectious circulatory shock related to hypopituitarism.The authors report a case of refractory non-infectious circulatory shock with catecholamine and massive fluid loading-resistant features related to hypopituitarism. A 76-year-old man was admitted for shock after suffering from gastroenteritis for 3 days. He was pale and had sparse axillary and pubic hair and small testes. Right catheterization showed shock with low preload pressure and a low oxygen extraction ratio relevant for septic shock. Ultrasound tomography revealed a distended gallbladder due to a stone without peritoneal effusion. A non-inflammatory hydrops of the gallbladder was removed surgically. No microorganism was isolated. Cerebral computed tomography (CT) scan showed a pituitary mass. In the post-surgical period the shock became uncontrollable. Cortisol replacement therapy was instituted and clinical and hemodynamic improvement occurred after 2 h. Hormonal screening on admission before catecholamine administration showed a major decrease in all the hypothalamic-pituitary hormone concentrations. The patient died on day 15 with multiple organ failure. hypopituitarism, probably owing to pituitary adenoma, was the only disease identified in this case. hormone replacement therapy dramatically improved the clinical and hemodynamic status, although the role of an abdominal sepsis could not be eliminated. Arguments that pituitary hormone deficiency might increase the hemodynamic consequences of adrenal deficiency are discussed.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
2/15. Bedside endosonography and endosonography-guided fine-needle aspiration in critically ill patients: a way out of the deadlock?endosonography and endosonography-guided fine-needle aspiration (EUS-FNA) are now established diagnostic techniques, which are performed electively in endoscopy suites. We report here the bedside use of EUS-FNA in three critically ill patients in an intensive-care unit, with a significant impact on the outcome. A mediastinal abscess after percutaneous dilational tracheotomy was aspirated in one patient, leading to appropriate antibiotic therapy and complete recovery. A paratracheal hematoma compressing the right main bronchus was aspirated in a patient with polytrauma, relieving the pressure effects. The third patient, who had end-stage dilated cardiomyopathy and was being evaluated for cardiac transplantation, was found to have an apical lung lesion suspicious for bronchogenic carcinoma. EUS was performed to exclude mediastinal metastasis and allow simultaneous resection at the time of transplantation. Although a metastasis was excluded by EUS-FNA, the patient died while awaiting surgery. We conclude that bedside EUS-FNA is a feasible procedure, and in experienced hands it can offer an alternative in life-threatening situations.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
3/15. acinetobacter calcoaceticus pneumonia and the formation of pneumatoceles.Pneumatoceles are cystic lesions of the lungs often seen in children with staphylococcal pneumonia and positive-pressure ventilation. acinetobacter calcoaceticus is an aerobic, short immobile gram-negative rod, or coccobacillus, which is an omnipresent saprophyte. The variant anitratus is the most clinically significant pathogen in this family, usually presenting as a lower respiratory tract infection. Acinetobacter has been demonstrated to be one of the most common organisms found in the ICU. We present three critically ill surgery patients with Acinetobacter pneumonia, high inspiratory pressures, and the subsequent development of pneumatoceles. One of these patients died from a ruptured pneumatocele, resulting in tension pneumothorax. Treatment of pneumatoceles should center on appropriate intravenous antimicrobial therapy. This should be culture directed but is most often accomplished with imipenem. Percutaneous, computed tomographic-guided catheter placement or direct tube thoracostomy decompression of the pneumatocele may prevent subsequent rupture and potentially lethal tension pneumothorax.- - - - - - - - - - ranking = 2keywords = pressure (Clic here for more details about this article) |
4/15. life-threatening hyperkalaemia following therapeutic barbiturate coma.OBJECTIVE: To report the occurrence of life-threatening hyperkalaemia following treatment with therapeutic thiopentone coma. SETTING: The neurosurgical intensive care units of Royal North Shore Hospital and Liverpool Hospital, Sydney, australia. patients: Three patients treated with theraputic thiopentone coma. One patient with raised intracranial pressure secondary to a severe traumatic brain injury and two patients with refractory vasospasm secondary to subarachnoid haemorrhage. Two of the three patients developed hypokalaemia on starting thiopentone, which was resistant to potassium supplementation. All three patients developed severe hyperkalaemia during the recovery phase of coma. This was life-threatening in all three patients and fatal in one. CONCLUSIONS: Severe hypokalaemia refractory to potassium therapy may occur during therapeutic thiopentone coma. Severe rebound hyperkalaemia may occur after cessation of thiopentone infusion. Protocols for the management of patients with therapeutic barbiturate coma should recognise this potentially serious complication.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
5/15. Pressure care in the paediatric intensive care unit.nursing staff in paediatric intensive care units (PICUs) regularly face a complex combination of nursing problems when admitting critically ill children. The assessment of skin integrity might not always be a priority during the initial period following admission. This article outlines some of the difficulties facing nurses involved in the care of critically ill children and reviews the literature on pressure ulcer assessment, highlighting the lack of a universal tool for risk assessment in this area. It also shows how a simple audit changed practice and reduced the incidence of pressure ulcer development in the PICU of the Royal Belfast Hospital for Sick Children over a two-year period.- - - - - - - - - - ranking = 2keywords = pressure (Clic here for more details about this article) |
6/15. The critically ill liver patient: the variceal bleeder.Esophageal varices develop in patients with cirrhosis once portal pressure, measured by hepatic venous pressure gradient, and exceeds 10 mm Hg. At a portal pressure of 12 mm Hg, variceal bleeding may develop that is associated with a mortality of 30% to 50% per episode. In addition to an elevated portal pressure, other risk factors for the development of variceal hemorrhage include: variceal size, endoscopic features on the variceal wall (i.e., red wales), and child-Pugh class. In patients with suspected variceal hemorrhage, the treatment of the acute episode includes intravascular volume expansion, hemostasis through the use of pharmacological agents and endoscopy, and the prevention and treatment of potential complications associated with variceal hemorrhage such as aspiration pneumonia, spontaneous bacterial peritonitis and hepatic encephalopathy. Given a high rate of rebleeding, long-term prevention through secondary prophylaxis should be instituted in all patients who have survived an episode of variceal bleeding. Current prophylactic options include: non-selective beta-blockers alone (first line) or in combination with long-acting nitrates (isosorbide mononitrate) and/or endoscopic variceal obliteration achieved through sclerotherapy or preferably, band ligation.- - - - - - - - - - ranking = 4keywords = pressure (Clic here for more details about this article) |
7/15. Focal neuropathy in children with critical illness.Four children are described who developed focal lower limb nerve palsies following critical illness. Two had clinical and/or neurophysiological evidence of simultaneous generalised critical illness polyneuropathy. The diagnosis was delayed in three patients due to the presence of central motor abnormalities and slow motor recovery. Follow-up from seven months to three years showed minimal or no recovery. In three, a vasculitic skin infarct, compartment syndrome and focal myositis could have caused nerve compression. We suggest that in critical illness peripheral nerves have an increased susceptibility to damage by local pressure.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
8/15. mars therapy in critically ill patients with advanced malignancy: a clinical and technical report.BACKGROUND/methods: Molecular Adsorbent Recirculating System (mars) was used in three consecutive critically ill patients at the singapore General Hospital with advanced malignancy and acute liver failure (ALF). Case 1 was a male patient with hepatocellular carcinoma (HCC) for which initial right hepatectomy was followed by left hepatectomy 5 months later for recurrent HCC. The postoperative course following second surgery was complicated by severe methicillin-resistant staphylococcus aureus (MRSA) sepsis, mild azotaemia and subacute cholestatic liver failure. mars was used thrice in this patient. Case 2 was a female patient with advanced acute lymphoblastic leukaemia (ALL) with post bone marrow transplantation (BMT) acute haemolytic-uraemic syndrome (HUS) secondary to cyclosporin A (Cy A), cytomegalovirus (CMV) infection, severe nosocomial pneumonia, acute renal failure (ARF) treated with continuous haemofiltration and acute veno-occlusive disease resulting in budd-chiari syndrome. The latter precipitated ALF. mars was instituted twice. Case 3 was a male patient with advanced, refractory Hodgkin's disease previously treated with multiple courses of chemotherapy. ALF developed secondary to acute viral hepatitis b flare. He was given a trial of mars once in the ICU. All the three patients eventually died. RESULTS: Mean mars intradialytic systemic pressures were as follows: systolic pressure range was 95 /- 17 to 128 /- 17 mmHg and diastolic pressure range was 51 /- 5 to 67 /- 7 mmHg. Pressure at albumin dialysate exit point from dialyser 1 (Ae) ranged from 253 /- 11 to 339 /- 15 mmHg and that at albumin dialysate entry point into dialyser 1 (Aa) ranged from 142 /- 11 to 210 /- 6 mmHg. ultrafiltration (UF) was 633 /- 622 mL over mean treatment duration of 6.3 /- 0.9 h with a total heparin dose of 1583 /- 817 IU. Coagulation status pre- and 6-h post-mars was similar: aPTT (P=0.116) and platelet count (P=0.753). There were no bleeding complications or circuit thromboses. mars had a significant de-uraemization effect (pre- and post-mars serum creatinine and urea: P=0.046 and 0.028, respectively) but did not significantly attenuate blood lactate, ammonia or total bilirubin levels. Albumin dialysate (Ae - Aa) urea and creatinine concentrations appeared to be sharply attenuated after 6 h of mars. In contrast, the removal of total bilirubin by albumin dialysate from the blood compartment appeared to plateau after 4 h of continuous mars operation. CONCLUSIONS: mars was well-tolerated in critically ill patients with advanced and complicated cancer. Low-dose heparin was safe and did not compromise mars circuit integrity. Although mars had a significant de-uraemization effect, this appeared to be limited by the duration of mars operation. Our data suggested that such a limit was reached earlier for total bilirubin. More data are needed to confirm the present findings and further delineate the saturation limit of mars for different toxins that accumulate in ALF. This would affect the optimal duration of mars therapy.- - - - - - - - - - ranking = 3keywords = pressure (Clic here for more details about this article) |
9/15. Pressure-flow signatures of central-airway mucus plugging.SETTING: Medical Intensive Care Unit of Regions Hospital, a University of minnesota-affiliated teaching hospital. PATIENT: Mechanically ventilated woman with status asthmaticus and acute respiratory failure. INTERVENTION: Observations of airway pressure and flow tracings before and after bronchoscopic inspection and airway lavage. MAIN RESULTS: Four newly observed signs were recorded that may serve to identify occult central airway mucus plugging in the ventilated asthmatic patient.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
10/15. Pulmonary arteriovenous malformation causing massive haemoptysis and complicated by coronary air embolism.We report the case of a 20-year-old man with possible Osler-Rendu-Weber syndrome (hereditary haemorrhagic telangiectasia) who developed an episode of massive haemoptysis from a bleeding pulmonary arteriovenous malformation in the left lower lobe of his lung. During the acute haemorrhage, he also appeared to suffer a coronary air embolism, possibly due to introduction of air into the bleeding arteriovenous malformation during intermittent positive pressure ventilation through the endotracheal tube. His electrocardiogram showed extensive ST elevation (>2 mm) in the inferolateral leads associated with raised troponin i and creatine kinase levels. These changes resolved within thirty minutes. The pulmonary arteriovenous malformation was successfully treated with a combination of alcohol injection and coil embolization.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
| | Next -> |