Abdulaziz H. Alzeer

Effect of classic heatstroke on serum procalcitonin.

OBJECTIVE Procalcitonin, the precursor peptide of calcitonin, has been shown to be a serum marker of the severity and mortality of several systemic inflammatory response syndromes. This study addressed the correlation of serum procalcitonin with the course of classic (nonexertional) heatstroke. DESIGN Serum samples were collected prospectively every 6 hrs for 24 hrs. SETTING Heatstroke treatment unit, Makkah, Saudi Arabia. PATIENTS A total of 25 patients were admitted during the annual Hajj pilgrimage in 1994. Ten patients evaluated in the same treatment center with minor illnesses and without pyrexia served as controls. INTERVENTIONS Patients were cooled according to an established evaporation method. MEASUREMENTS AND MAIN RESULTS Standard critical care parameters including continuous rectal temperature. A rapid immunochemical assay for serum procalcitonin was utilized. The mean serum procalcitonin was elevated 20-fold on admission in patients with heatstroke compared with controls (p < .011). The procalcitonin concentration subsequently increased to a plateau by 6 hrs and remained increased at 24 hrs, compared with the admission level (p < .0001). In this study, 77% of the patients with heatstroke survived. A subgroup analysis demonstrated that the patients who survived had a significantly higher procalcitonin concentration than those patients who died of heatstroke; a procalcitonin concentration of >0.5 ng/mL (>0.15 nmol/L) at 6 hrs predicted survival (p = .02). CONCLUSION Classic heatstroke is associated with increased concentrations of serum procalcitonin, particularly among survivors. Further studies are required to elucidate the source and action(s) of procalcitonin as well as its relationship to cytokine activation.

Prediction of Pulmonary Hypertension in Patients with or without Interstitial Lung Disease: Reliability of CT Findings

PURPOSE To study the reliability of pulmonary vascular measurements based on computed tomography (CT) in the prediction of pulmonary hypertension (PH) in patients with advanced interstitial lung disease (ILD) compared with those without ILD. MATERIALS AND METHODS The study was approved by the Institutional Review Board. All patients gave written informed consent. A prospective study of 134 patients who underwent right-sided heart catheterization and chest CT scanning within 72 hours of admission was conducted. Patients were divided into two groups-one with ILD (group A, n = 100) and one without ILD (group B, n = 34). CT measurements of the main pulmonary artery diameter (PAD), the ratio of PAD to the ascending aorta diameter (AAD), right pulmonary artery diameter (RPAD), and left pulmonary artery diameter (LPAD) were obtained. Univariate logistic regression analysis was performed, and receiver operating characteristic curves were constructed to assess the predictive ability of vascular measurements obtained by using CT in the identification of PH. RESULTS Main PAD was significantly greater in patients with PH than in those without PH in both groups (group A, P = .008; group B, P = .02). A PAD greater than 25 mm in patients with ILD was predictive of PH, with a sensitivity of 86.4% (32 of 37), a specificity of 41.2% (26 of 63), a positive predictive value of 46.3% (32 of 69), and a negative predictive value of 83.8% (26 of 31). In patients without ILD, a PAD greater than 31.6 mm and an LPAD greater than 21.4 mm were predictive of PH (sensitivity, 47.3% [nine of 19]; specificity, 93.3% [14 of 15]; positive predictive value, 90.0% [nine of 10]; and negative predictive value, 58.3% [14 of 24]). CONCLUSION CT-derived vascular measurements were of limited utility in the prediction of PH in patients with ILD compared with those without ILD.

Nitric oxide production is enhanced in patients with heat stroke

Objective: To determine whether nitric oxide (NO) production is increased in heat stroke (HS) patients. Design: A prospective analysis of nitrite and nitrate (NO·2/NO3) levels in ten HS patients was performed at the HS center in Makkah, Saudi Arabia. Methods: Plasma (NO·2/NO3) levels were determined spectrophotometrically before cooling (0 time), and at 6, 12, and 24 h post-cooling. Results: The mean level of NO in the ten HS victims before cooling was significantly higher than in eight control patients (35.6 ± 37.0 vs 3.0 ± 4.2 μmol/l; p < 0.01). The levels were higher in non-survivors than in survivors. NO also correlated positively with the Acute Physiology and Chronic Health Evaluation II score (r = 0.72, p < 0.018). There was no correlation between the NO level before cooling and blood pressure, rectal temperature, or cooling time. Conclusion: HS is associated with excessive NO production, the magnitude of which is proportional to the severity of illness. NO may be an important mediator and integral part of the pathophysiological processes resulting in HS and may be a central factor linking the neurological and cardiovascular abnormalities observed in HS.

Survival of bronchiectatic patients with respiratory failure in ICU

BackgroundThe outcome of patients with bronchiectasis during and after their stay in the intensive care unit (ICU) has seldom been reported in the literature. Managing these patients in the ICU can be challenging because of the complex nature of their disease. This study aims to identify the in-hospital and long-term outcome of patients with bronchiectasis and respiratory failure (RF) in ICU.MethodsA retrospective study was carried out by studying all bronchiectatic patients admitted to the medical ICU for RF over a 10-year period (1995–2004).ResultsThe mean (± standard deviation) age of 35 patients was 63.5 ± 11.7 years and APACHE score was 22.3 ± 7.3. The 4-year mortality was 60%. Among the variables observed, age > 65 years (hazard ratio (HR): 4.15; 95% confidence interval (CI): 3.2–5.1), APACHE II score > 24 (2.6, 95% CI 1.7–3.5), intubation (2.81, 95 %CI 1.9–3.7), inotropic support (2.9, 95% CI 2.0–3.7), Home-O2 (4.0, 95% CI 2.7–5.2) and activity index (4.0, 95% CI 2.8–5.3) were associated with diminished survival in univariate analysis by Cox regression. By long rank test, survival probabilities were significantly low at these strata. Multivariate analysis of Cox proportional hazard model showed that age > 65 years (HR: 5.4, 95% CI 1.9–15.7); activity index (HR: 4.8, 95% CI 1.4–16.6); and inotropic support (HR: 3.8, 95% CI 1.5–10.1) were independently associated with reduced survival.ConclusionThe decreased survival of ICU patients was associated with age > 65 years, activity index (bedridden or wheelchair-bound) and use of inotropic support.

HRCT score in bronchiectasis: Correlation with pulmonary function tests and pulmonary artery pressure

BACKGROUND: High-resolution CT scan (HRCT) and its score have an important role in delineating pathological changes and pulmonary functional impairment in patients with bronchiectasis. AIMS: To assess pulmonary function tests (PFTs) in patients with cystic and cylindrical bronchiectasis. To correlate HRCT score with PFTs and systolic pulmonary artery pressure (SPAP) in both radiological types. MATERIALS AND METHODS: A cross-sectional study of patients with bronchiectasis diagnosed by HRCT was conducted at King Khalid University Hospital, Riyadh, Saudi Arabia. PFTs, HRCT score and SPAP were measured in both types. RESULTS: We studied 94 patients with bronchiectasis; 62 were cystic and 32 were cylindrical. Their mean age was 53.4 ± 17.5 SD years. Forced vital capacity (FVC%) and forced expiratory volume in 1 second (FEV1%) were significantly lower in cystic patients (P < 0.0001) as compared with cylindrical patients; and diffusion capacity of carbon monoxide (DLCO%) was also significantly lower (P < 0.01). In the cystic group, PaO2 was significantly lower; and PaCO2, higher (P < 0.0001). HRCT score was correlated with FEV1% (r = −0.51). HRCT score was significantly lower in the cystic group (P = 0.002) and correlated with SPAP (r = 0.23). Global HTCT score of 10.3 ± 2.5 was associated with SPAP ≥40 mm Hg (P = 0.011). CONCLUSION: Patients with cystic bronchiectasis have significantly higher impairment of pulmonary physiology as compared with those with cylindrical bronchiectasis patients. HRCT score correlated with PFTs and SPAP.

Protocolized eye care prevents corneal complications in ventilated patients in a medical intensive care unit.

Background: Eye care is an essential component in the management of critically ill patients. Standardized eye care can prevent corneal complications in ventilated patients. Objective: This study was designed to compare old and new practices of corneal care for reduction in corneal complications in ventilated patients. Methods: This study was done in three phases each of six month duration. Phase 1 was the ongoing practice of eye care in the unit. Before the start of phase 2, a new protocol was made for eye care. Corneal complications were observed in terms of haziness, dryness, and ulceration. All nursing staffs were educated and made compliant with the new protocol. In phase 2, a follow-up audit was done to check the effectiveness and compliance to protocol. In phase 3, a follow-up audit was started 3 months after phase 2. Results: In phase 1, total ventilated patients were 40 with 240 ventilator days. The corneal dryness rate was 40 per 1000 ventilator days while the haziness and ulceration rate was 16 per 1000 ventilator days each. In the second phase 2, total ventilated patients were 53 making 561 ventilator days. The rate of corneal haziness and dryness was 3.52 and 1.78 per 1000 ventilator days, respectively, with no case of corneal ulceration. In phase 3, the number of ventilated patients was 91 with 1114 ventilator days. The corneal dryness rate was 2.69 while the haziness and ulceration rate was 1.79 each. Conclusion: Protocolized eye care can reduce the risk of corneal complications in ventilated patients.

Subacute sclerosing panencephalitis presenting as acute disseminated encephalomyelitis: A case report

Subacute sclerosing panencephalitis is characterized by the insidious onset of diffuse cerebral dysfunction associated later with myoclonus and typical electroencephalographic changes. The disease progresses relentlessly to coma and death within 2 years. We report a case of acute onset and rapid course associated with atypical CSF, EEG and MRI features simulating acute disseminated encephalomyelitis. Brief review of relevant literature is presented.

Bronchoscopy as a rescue therapy in patients with status asthmaticus: Two case reports and review of literature

Management of status asthmaticus requires more than guidelines-guided therapy. Occasionally, uncommon therapeutic interventions and procedures may provide significant benefits. The role of bronchoscopy in fatal asthma is still not clearly defined. We illustrate two cases of severe status asthmaticus on mechanical ventilation who showed remarkable improvement after therapeutic bronchoscopy.

Outcome of patients with severe asthma in the intensive care unit.

BACKGROUND Because little has been reported about the outcome of severe asthma outside the US and western Europe, we performed a retrospective case analysis of patients treated in the medical intensive care unit (MICU) of a university hospital in Riyadh, Saudi Arabia, to determine the management, complications and outcome of severe asthma requiring ICU admission. METHODS The records of patients with severe asthma admitted to the MICU between the periods of January 1996 to December 2003 were reviewed. Sixty-one episodes from 54 patients were studied, of which 27 (44%) were male. RESULTS All patients were hypercapnic; 23 (38%) were ventilated. The Acute Physiological and Health Evaluation (APACHE) score II was significantly higher in the ventilated group (P<0.0001). The pH was significantly lower and PaCO2 was significantly higher in the ventilated group (P<0.0001). All patients survived. Only 42% of patients our series received inhaled corticosteroids before admission. CONCLUSION Our results suggest that severe asthma requiring ICU admission is now safely managed in ICUs. Our results are comparable to recently published data on the treatment of severe asthma in the ICU.

Unusual case of central alveolar hypoventilation

Central alveolar hypoventilation is rarely encountered. This case report describes a young woman who was recently diagnosed with hypertension and ischemic heart disease. She presented to the emergency room with hypercapnic respiratory failure, for which she was mechanically ventilated. This was preceded by an acute upper respiratory tract infection. She was initially suspected to have Guillain-Barré syndrome, but further investigations ruled out neuromuscular or autoimmune disorders. Sleep-related hypoventilation was suspected after she experienced recurrent apneas at night that resulted in re-intubation. Polysomnographic studies confirmed episodes of central apnea and hypopnea during sleep, with significant carbon dioxide retention and oxygen desaturations. She required nocturnal ventilation via a tracheostomy tube until a diaphragmatic pacer could be placed. Using bi-level positive airway pressure and average volume-assured pressure support together with the diaphragmatic pacer, adequate ventilation during sleep was achieved.