Adel Bassily-Marcus

Pulmonary Hypertension in Pregnancy: Critical Care Management

Pulmonary hypertension is common in critical care settings and in presence of right ventricular failure is challenging to manage. Pulmonary hypertension in pregnant patients carries a high mortality rates between 30–56%. In the past decade, new treatments for pulmonary hypertension have emerged. Their application in pregnant women with pulmonary hypertension may hold promise in reducing morbidity and mortality. Signs and symptoms of pulmonary hypertension are nonspecific in pregnant women. Imaging workup may have undesirable radiation exposure. Pulmonary artery catheter remains the gold standard for diagnosing pulmonary hypertension, although its use in the intensive care unit for other conditions has slowly fallen out of favor. Goal-directed bedside echocardiogram and lung ultrasonography provide attractive alternatives. Basic principles of managing pulmonary hypertension with right ventricular failure are maintaining right ventricular function and reducing pulmonary vascular resistance. Fluid resuscitation and various vasopressors are used with caution. Pulmonary-hypertension-targeted therapies have been utilized in pregnant women with understanding of their safety profile. Mainstay therapy for pulmonary embolism is anticoagulation, and the treatment for amniotic fluid embolism remains supportive care. Multidisciplinary team approach is crucial to achieving successful outcomes in these difficult cases.

Use of echocardiography and modalities of patient monitoring of trauma patients.

Purpose of review Trauma patients require evaluation of the anatomic structure as well as the hemodynamic profile of the heart to improve effectiveness of resuscitation. They are prone to hemodynamic instability and must be monitored with various modalities to detect deterioration early. Newer, less invasive ultrasound technologies are replacing familiar ‘gold standard’ modalities of the past. This article reviews the indications, roles, imaging approaches, and limitations of modern echocardiography. A brief review of other ICU monitoring modalities is also presented. Recent findings Echocardiography has emerged as a first-line diagnostic tool for assessment of trauma patients, especially those with hemodynamic compromise. It yields crucial information about structural damage as well as the hemodynamic profile and can be performed through either the transesophageal or transthoracic route. Quick and systematic use of echocardiography for diagnosis and management of critically injured patients may lead to improved outcomes. Summary Echocardiography plays an important role in the trauma bay for diagnosis of thoracic injury and at the bedside in the ICU for evaluation of the hemodynamic profile.

Effect of lower limb compression devices on thermodilution cardiac output measurement.

Objective:The aim of this study was to determine whether lower limb (calf) sequential compression devices (SCDs) have a significant effect on thermodilution cardiac output measurements using a pulmonary artery catheter. Design:Prospective clinical investigation. Setting:Surgical and neurosurgical intensive care units in a university hospital. Patients:A total of 43 patients with pulmonary artery catheters and bilateral lower limb SCDs. Measurements and Main Results:Cardiac output was measured (average of three) when the SCDs were off (T1), during the first 2–4 secs of the inflation cycle (T2), during seconds 4–8 of the inflation cycle (T3), and when the SCDs were off again (T4). Cardiac output measurements were consistently lower when measured during the SCD inflation cycle. The decrease in cardiac output ranged from 7.58% to 49.5%, with a mean reduction of 24.51% in the first 2–4 seconds and 20.61% during seconds 4–8 (p < .001). Two patients displayed an increase in cardiac output during the inflation cycle; one patient had an increase of 2.78% and the other an increase of 13.5%. In 11 patients, measurements were also made using a pulse contour–analysis cardiac output device, but no changes in pulse contour–analysis cardiac output were observed during the same time period. Conclusions:Thermodilution cardiac output measurements via a pulmonary artery catheter should not be done during the inflation cycle of lower limb SCDs because they produce a falsely low cardiac output.

Bronchiolitis obliterans organizing pneumonia after orthotopic liver transplantation

Bronchiolitis obliterans organizing pneumonia (BOOP) has been described after bone marrow, lung, heart‐lung, and renal transplantation, but rarely after orthotopic liver transplantation (OLT). We report a case of BOOP after OLT to emphasize BOOP as an under diagnosed and treatable cause of nonresolving pneumonia, which may not be preventable by maintenance low‐dose prednisone. A 48‐year‐old man was hospitalized for dyspnea and cough one month after OLT. Among his medications were tacrolimus and prednisone. Physical examination was significant for lung crepitations and bilateral leg edema. Chest x‐ray revealed bilateral infiltrates. Computed tomography (CT) of the chest demonstrated bilateral diffuse infiltrates with areas of sparing and nodularities. Bronchoscopy was normal and bronchoalveolar lavage was negative. Lung biopsy was performed and demonstrated serpiginous plugs of fibroblastic tissue filling the alveolar spaces, focal fibrosis of some alveolar septa, and reactive pneumocytic hyperplasia consistent with BOOP. Methylprednisolone was continued with clinical improvement and weaning from the ventilator, but subsequent sepsis and multisystem organ failure finally led to the patients death. (Liver Transpl 2004;10:456–459.)

Enteral nutrition administration in a surgical intensive care unit: Achieving goals with better strategies

AIM To evaluate the impact of an enteral feeding protocol on administration of nutrition to surgical intensive care unit (SICU) patients. METHODS A retrospective chart review was conducted on patients initiated on enteral nutrition (EN) support during their stay in a 14 bed SICU. Data collected over a seven-day period included date of tube feed initiation, rate initiated, subsequent hourly rates, volume provided daily, and the nature and length of interruptions. The six months prior to implementation of the feeding protocol (pre-intervention) and six months after implementation (post-intervention) were compared. One hundred and four patients met criteria for inclusion; 53 were pre-intervention and 51 post-intervention. RESULTS Of the 624 patients who received nutrition support during the review period, 104 met the criteria for inclusion in the study. Of the 104 patients who met criteria outlined for inclusion, 64 reached the calculated goal rate (pre = 28 and post = 36). The median time to achieve the goal rate was significantly shorter in the post-intervention phase (3 d vs 6 d; P = 0.01). The time to achieve the total recommended daily volume showed a non-significant decline in the post-intervention phase (P = 0.24) and the overall volume administered daily was higher in the post-intervention phase (61.6% vs 53.5%; P = 0.07). While the overall interruptions data did not reach statistical significance, undocumented interruptions (interruptions for unknown reasons) were lower in the post-intervention phase (pre = 23/124, post = 9/96; P = 0.06). CONCLUSION A protocol delineating the initiation and advancement of EN support coupled with ongoing education can improve administration of nutrition to SICU patients.

Frequency and Outcomes of Hyperlactatemia After Neurosurgery A Retrospective Analysis

Objectives. The aim of this study was to evaluate the incidence and significance of elevated serum lactate and its impact on outcome in postoperative neurosurgical patients admitted to neurosurgica...

Critical care management and intensive care unit outcomes following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

AIM To study the early postoperative intensive care unit (ICU) management and complications in the first 2 wk of patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS Our study is a retrospective, observational study performed at Icahn School of Medicine at Mount Sinai, quaternary care hospital in New York City. All adult patients who underwent CRS and HIPEC between January 1, 2007 and December 31, 2012 and admitted to ICU postoperatively were studied. Fifty-one patients came to the ICU postoperatively out of 170 who underwent CRS and HIPEC therapy during the study period. Data analysis was performed using descriptive statistics. RESULTS Of the 170 patients who underwent CRS and HIPEC therapy, 51 (30%) came to the ICU postoperatively. Mean ICU length of stay was 4 d (range 1-60 d) and mean APACHE II score was 15 (range 7-23). Thirty-one/fifty-one (62%) patients developed postoperative complications. Aggressive intraoperative and postoperative fluid resuscitation is required in most patients. Hypovolemia was seen in all patients and median amount of fluids required in the first 48 h was 6 L (range 1-14 L). Thirteen patients (25%) developed postoperative hypotension with seven requiring vasopressor support. The major cause of sepsis was intraabdominal, with 8 (15%) developing anastomotic leaks and 5 (10%) developing intraabdominal abscess. The median survival was 14 mo with 30 d mortality of 4% (2/51) and 90 d mortality of 16% (8/51). One year survival was 56.4% (28/51). Preoperative medical co morbidities, extent of surgical debulking, intraoperative blood losses, amount of intra op blood products required and total operative time are the factors to be considered while deciding ICU vs non ICU admission. CONCLUSION Overall, ICU outcomes of this study population are excellent. Triage of these patients should consider preoperative and intraoperative factors. Intensivists should be vigilant to aggressive postop fluid resuscitation, pain control and early detection and management of surgical complications.

Ludwig's angina complicated by fatal cervicofascial and mediastinal necrotizing fasciitis

A 54-year-old man, with a history of poorly controlled diabetes mellitus, presented to the emergency room with a three-day history of severe, progressive swelling of his neck associated with odynophagia. Oral cavity examination was remarkable for trismus with mouth opening limited to two fingers, edematous floor of the mouth, drooling and a carious second lower molar tooth. Physical exam was consistent with bilateral swelling of the neck, severe tenderness and symmetric induration in the submandibular area consistent with Ludwigs angina. On admission, leukocyte count was 7300/μL increasing to 26,000. Neck CT displayed gas in the fascial planes and musculature consistent with necrotizing fasciitis descending into the mediastinum and anterior chest (Fig. 1, Fig. 2). Blood cultures were negative and wound cultures were positive for an alpha-hemolytic streptococcus not further speciated and Actinomyces meyeri. Fig. 1 CT showing presence of gas in the anterior cervical space. Fig. 2 CT showing air dissecting into the anterior mediastinum. Broad-spectrum antimicrobials with Vancomycin and Imipenem/cilastatin were initiated; emergent surgical debridement and tracheostomy were performed (Fig. 3). During the hospital course he required multiple debridements and extraction of an infected second lower molar tooth. The clinical course was complicated by septic shock, acute respiratory distress syndrome and acute renal failure. Despite aggressive medical and surgical intervention, the patient expired from multisystem organ failure on day thirteen. Fig. 3 Extensive debridement with exposed sternomastoids and tracheostomy in situ. Ludwigs angina is an aggressive, potentially fulminant, deep neck infection often caused by dental infection/abscess from polymicrobial organisms [1]. It presents with fever, chills, mouth pain, drooling and dysphagia. Cervicofascial necrotizing fasciitis is rarely seen in patients with Ludwigs angina [2]. Clinical course and prognosis of patients with both conditions is determined by their immune status. Ludwigs angina superimposed by cervicofascial necrotizing fasciitis is a surgical emergency with a mortality rate of approximately >50%. The cornerstone of the treatment is securing the airway, providing efficient drainage, appropriate antimicrobials, and improving immunologic status [3]. Clinical presentation of Ludwigs angina can be subtle even in immunocompromised individuals with extensive underlying tissue destruction as seen in our case. It is important to maintain a high index of suspicion for necrotizing fasciitis in the setting of Ludwigs angina. Delay in the diagnosis and treatment is associated with a high mortality and morbidity [4].

Early detection of deteriorating patients: leveraging clinical informatics to improve outcome*.

976 www.ccmjournal.org April 2014 • Volume 42 • Number 4 an important factor. Sepsis is frequently accompanied by systolic and diastolic ventricular dysfunction (8–10). The cause is once again uncertain, but seems likely to be multifactorial (11), and can occur in previously healthy hearts and even in children with septic shock (12). However, since the prevalence of diastolic dysfunction may be as high as 27% in the general population (13), it is possible that preexisting heart failure could be a factor. Similarly, patients with chronic lung disease may have an increased prevalence of right ventricular dysfunction. A better understanding of the underlying causes of cTn elevation in septic and other critically ill patients is clearly important as we strive to optimize treatment (2). There is some debate whether plasma cTn is an independent prognostic marker in sepsis or simply a surrogate for overall severity of illness (4, 6). cTn abnormalities are also common in the postoperative setting (14), but some clinicians have argued that routine testing may simply increase the risk of harm from inappropriate treatment for myocardial infarction (15). However, the work by Landesberg et al suggests that there may be value in investigating the cause of cTn abnormalities in sepsis using echocardiography to identify and assess potential targets for therapy.

An electronic antimicrobial stewardship intervention reduces inappropriate parenteral antibiotic therapy

adverse events. Most respondents recognized that blood cultures are ordered to help with antibiotic treatment decisions. Close monitoring of broad-spectrum antibiotic use and antibiotic deescalation should occur if interventions to limit blood culture testing are implemented. Our study was performed at a single center and we cannot exclude volunteer bias. However, there was balanced representation from the different groups surveyed and a wide range of years of experience. In summary, more specific guidance with indications for blood cultures may help reduce unnecessary blood cultures, and interventions should include all providers, including consulting physicians.