Amit Frenkel

Positive fluid balance as a major predictor of clinical outcome of patients with sepsis/septic shock after ICU discharge

INTRODUCTION Sepsis and septic shock continue to be syndromes that carry a high mortality rate worldwide. Early aggressive fluid and vasopressor support have resulted in significant improvement in patient outcomes. The prognostic clinical significance of a positive fluid balance in septic intensive care unit (ICU) patients remains undetermined. METHODS We collected data from 297 septic patients hospitalized in our general and medical ICUs at Soroka Medical Center between January 2005 and June 2011 and divided the 4 study groups into the following 4 fluid balances: group 1, patients with fluid balance at discharge from ICU (FBD) less than 10 L; group 2, patients with an FBD of 10 to 20 L; group 3, patients with an FBD of 20 to 30 L; and group 4, patients with FBD in excess of 30 L. RESULTS The ICU and in-hospital mortality rate was also significantly higher in groups 2 to 4 as compared with group 1 (P < .001 for both ICU and in-hospital mortality). The positive cumulative FBD was found to be an independent predictor of ICU mortality (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.02-1.06; P < .001; Table 3) and in-hospital mortality (OR, 1.06; 95% CI, 1.03-1.08; P < .001; Table 5) and also to constitute a risk factor for new organ system dysfunction at hospital discharge (OR, 1.01; 95% CI, 1.01-1.013; P < .001; Table 6) in critically ill patients with severe sepsis/septic shock. CONCLUSIONS Although it is a monocentric retrospective study, we suggest that positive cumulative fluid balance is one of the major factors that can predict the clinical outcome of critically ill patients during their ICU stay and after their discharge from the ICU.

An outbreak of varicella in staff nurses exposed to a patient with localized herpes zoster

Abstract An outbreak of varicella occurred in an internal medicine ward. The outbreak comprised 3 nurses, 2 of whom were directly exposed to an immunocompetent patient with localized herpes zoster. Our observation provides an argument for airborne precautions in hospitalized patients with localized herpes zoster.

Multidrug Resistance Acinetobacter Bacteremia Secondary to Ventilator-Associated Pneumonia: Risk Factors and Outcome

Purpose: Acinetobacter baumannii is a multidrug resistant (MDR), gram-negative bacterium commonly implicated in ventilator-associated pneumonia (VAP) in critically ill patients. Patients in the intensive care unit (ICU) with VAP often subsequently develop A baumannii bacteremia, which may significantly worsen outcomes. Materials and Methods: In this study, we retrospectively reviewed the clinical and laboratory records of 129 ICU patients spanning 6 years with MDR A baumannii VAP; 46 (35%) of these patients had concomitant MDR A baumannii bacteremia. Results: The ICU mortality rate was higher in patients with VAP having A baumannii bacteremia compared to nonbacteremic patients (32.4% vs 9.6% respectively, P < .005). Age >65 years, an Acute Physiology and Chronic Health Evaluation II (APACHE-II) score higher than 20, a Sequential Organ Failure Assessment (SOFA) score higher than 7 on the day of bacteremia, and the presence of comorbid disease (chronic obstructive pulmonary disease [COPD] and chronic renal failure) were found to be independent risk factors for in-hospital mortality in this population. Multidrug resistant A baumannii was not an independent risk factor for mortality. Conclusion: Although the presence of comorbid diseases (COPD and chronic renal failure) and severity of disease (APACHE > 20 and SOFA >7) were found to be independent risk factors for ICU mortality, MDR A baumannii bacteremia was not an independent risk factor for mortality in our critically ill population.

Life Threatening Idiopathic Recurrent Angioedema Responding to Cannabis

We present a case of a 27-year-old man with recurrent episodes of angioedema since he was 19, who responded well to treatment with medical grade cannabis. Initially, he responded to steroids and antihistamines, but several attempts to withdraw treatment resulted in recurrence. In the last few months before prescribing cannabis, the frequency and severity of the attacks worsened and included several presyncope events, associated with scrotal and neck swelling. No predisposing factors were identified, and extensive workup was negative. The patient reported that he was periodically using cannabis socially and that during these periods he was free of attacks. Recent data suggest that cannabis derivatives are involved in the control of mast cell activation. Consequently, we decided to try a course of inhaled cannabis as modulators of immune cell functions. The use of inhaled cannabis resulted in a complete response, and he has been free of symptoms for 2 years. An attempt to withhold the inhaled cannabis led to a recurrent attack within a week, and resuming cannabis maintained the remission, suggesting a cause and effect relationship.

Epidemiology of new-onset paroxysmal atrial fibrillation in the General Intensive Care Unit population and after discharge from ICU. A retrospective epidemiological study

BACKGROUND Evidence of various cardiac arrhythmias in septic patients has been demonstrated by multiple clinical reports and observations. Most cardiac arrhythmias in sepsis are new-onset and may be related to sepsis-induced myocardial dysfunction. We propose to investigate and analyze data of new-onset paroxysmal atrial fibrillation (AF) in a critically ill septic population. METHODS This is a retrospective epidemiologic study. We collected clinical data from two hundred septic patients who developed a new episode of atrial fibrillation during their hospitalization in General Intensive Care Unit (GICU) between January 2007 and June 2013. RESULTS Of these 200 septic patients, 81 septic patients developed a new episode of AF and included in the present study. Thirty-seven patients had no past medical history of atrial fibrillation (AF) or antiarrhythmic therapy (new episode of atrial fibrillation, Group 1) and 44 had previously known episodes of atrial fibrillation and were prescribed antiarrhythmic therapy at home (Group 2). Group 2 patients had longer duration of recurrent episodes of atrial fibrillation compared to patients in Group 1 (11.07 ± 8.7 vs. 7.4 ± 6.1 days; P = 0.013). The overall ICU and in-hospital mortality rate was similar in both study groups. There was no significant difference in new stroke and pulmonary embolism (PE) between both study groups (P > 0.05). CONCLUSION In the present study we demonstrated no difference in morbidity and mortality rate in-ICU and after discharge between septic patients who had previous AF episodes and patients who had no previous past medical history of any cardiac arrhythmias.

Traumatic Page Kidney Induced Hypertension in Critical Care: Immediately Resolved or Long-Term Resistant Problem

Page kidney is a well-known phenomenon causing hypertension, due to compression of renal parenchyma by a subcapsular hematoma, of either traumatic or non-traumatic origin. The main therapeutic approach is based on surgical approach (nephrectomy or hematoma evacuation) and antihypertensive treatment. In this paper we present a post-traumatic case of Page Kidney in a Critical Care unit. We discuss different therapeutical opportunities to extremely elevated systemic blood pressure resistant to traditional drug therapy.

Inguinal Herniation of the Urinary Bladder Presenting as Recurrent Urinary Retention

Herniation of the urinary bladder into the inguinal canal is an uncommon finding, observed in 0.5–4% of inguinal hernias (Curry (2000)). It is usually associated with other conditions that increase intra-abdominal pressure such as bladder neck obstruction due to prostatic hypertrophy. Consequently, in men, it is usually associated with some degree of urinary retention. We present a 42-year-old man in whom herniation of the urinary bladder was the cause of urinary retention, and not vice versa. The patient was on tumor necrosis factor alpha antagonist (TNFA) (Etanercept) for severe Ankylosing spondylitis. Initially, the urinary retention was thought to be a side effect of the medication, but after the drug was discontinued, urinary retention persisted. CT and MRI demonstrated huge herniation of the urinary bladder into the inguinal canal. Immediately after the hernia was repaired, bladder function was restored. TNF treatment was restarted, and no further urinary symptoms were observed in the next two years of follow-up. In this case, the primary illness and its treatment were distracting barriers to early diagnosis and treatment. In younger patients with a large hernia who develop unexpected urinary retention, herniation of the urinary bladder should be highly considered in the differential diagnosis.

Use of early inhaled nitric oxide therapy in fat embolism syndrome to prevent right heart failure.

Fat embolism syndrome (FES) is a life-threatening condition in which multiorgan dysfunction manifests 48–72 hours after long bone or pelvis fractures. Right ventricular (RV) failure, especially in the setting of pulmonary hypertension, is a frequent feature of FES. We report our experience treating 2 young, previously healthy trauma patients who developed severe hypoxemia in the setting of FES. Neither patient had evidence of RV dysfunction on echocardiogram. The patients were treated with inhaled nitric oxide (NO), and their oxygenation significantly improved over the subsequent few days. Neither patient developed any cardiovascular compromise. Patients with FES that have severe hypoxemia and evidence of adult respiratory distress syndrome (ARDS) are likely at risk for developing RV failure. We recommend that these patients with FES and severe refractory hypoxemia should be treated with inhaled NO therapy prior to the onset of RV dysfunction.

Elevated CPK levels after hydrazine inhalation exposure in an F16 aircraft technician

Hydrazine is a hazardous material that is commonly used in the pharmaceutical industry, as well as in rocket and jet fuels, including the emergency power unit of F-16 model jets. We present four ground crew technicians who were exposed to hydrazine for less than one minute, due to a voltage fall in an F-16 jet. Physical examinations were normal and none of the technicians were symptomatic for toxicity. One of the technicians had abnormal blood chemistry levels for liver and muscle enzymes: serum glutamic-oxaloacetic transaminase(SGOT)-321U/L, serum glutamate-pyruvate transaminase (SGPT)-123U/L, and creatine phosphokinase (CPK) 3300U/L. The CPK level peaked during hospitalization to 20960U/L at 36 h after the exposure, and subsequently declined. Upon release from the hospital, 48 h after the exposure, the CPK level -was 9429U/L. In repeated tests one week and one year after exposure, liver function and CPK levels were normal. We conclude that evaluation of blood tests is important, in addition to a physical examination, in asymptomatic persons following exposure to even short term highly elevated levels of hydrazine.

The Clinical Outcome of Postoperative Invasive Fungal Infections Complicating Laparoscopic Sleeve Gastrectomy

PurposePeritonitis is a major complication of bariatric surgery due to direct damage to the natural barriers to infection. Most such secondary peritoneal infections are caused by Gram-negative microorganisms; however, under certain conditions, Candida species can infect the peritoneal cavity following bariatric surgery.Materials and MethodsWe retrospectively analyzed the clinical and microbiological data of morbidly obese patients who suffered infectious complications following laparoscopic sleeve gastrectomy (LSG) at the Soroka Medical Center between January 2010 and June 2015.ResultsOut of 800 patients who underwent LSG, 43 (5.3%( developed secondary peritonitis and were admitted to our General Intensive Care Unit during the study period. Intraperitoneal leaks, intraabdominal abscesses and pleural effusions were significantly more common in patients with fungal infection than in those with non-fungal infections (p values 0.027, < 0.001, and < 0.014, respectively). Leaks situated at the suture line of gastro-esophageal area occurred much more frequently in the fungal infection group than in the non-fungal infection group (94.7 vs 41.7%, p < 0.001). Microbiological analysis of the abdominal and pleural fluids of patients with invasive fungal infectious complications showed the presence of commensal polymicrobial bacterial infections—mainly Streptoccocus constellatus and coagulase negative Staphylococcus spp. Leakage at the suture line of gastro-esophageal area (upper suture part) and administration of parenteral nutrition were found to be independent predictors for invasive fungal infections after LSG.ConclusionOur study demonstrates that invasive fungal infection is a significant postoperative infectious complication of bariatric LSG surgery in morbidly obese patients.