Deepak K. Bhasin

Brain death—think twice before labeling a patient ☆

Brain death is defined as the cessation of cerebral and brainstem function. A 12-year-old boy presented with alleged history of snake bite. He was brain dead with Glasgow Coma Score of 3 and absent corneal reflexes. However, it was only neuroparalytic effect of the venom, which improved in due course of time with antivenoms. This case highlights the occurrence of both internal and external ophthalmoplegia, which would mimic brain death in many ways, thus prompting an intensivist to consider withdrawing ventilatory support, which would be disastrous.

An Intriguing Cause of Dysphagia

DIS 5.4.0 DTD YGAST60909 proof 3 May 2017 5:03 pm ce 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 Question: A 64-year-old man presented with intermittent episodes of dysphagia to solids, which has been nonprogressive over the past 3 months. He denied any history of chest pain, vomiting, reflux symptoms, loss of appetite, or loss of weight. He is on treatment with 5 mg of amlodipine for hypertension and has had 3 episodes of transient ischemic attacks in past 2 years. For his neurologic symptoms, he has been extensively evaluated and is on treatment with 75 mg aspirin and 10 mg atorvastatin. 91 92 93 94 95 96 For dysphagia, he underwent multiple gastroscopies and biopsies of the esophagus which were reported as normal. His barium swallow showed indentations on the posterior wall of the esophagus (Figure A, white arrows). Contrast-enhanced magnetic resonance imaging of the neck confirmed the findings on barium swallow (Figure B, white arrows). What is your clinical diagnosis? Look on page 000 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. 97 98 99 100 Conflicts of interest The authors disclose no conflicts. 101 102 103 104 He was extensively evaluated for his neurologic symptoms and was treated with 75 mg aspirin and 10 mg atorvastatin.

Parenteral polymyxins: assessing efficacy and safety in critically ill patients with renal dysfunction.

Objectives: Studies have established the effectiveness and safety of polymyxins in treating multidrug resistant (MDR) pathogens. However, the challenge is whether these nephrotoxic drugs can be administered in compromised renal states. The present study was undertaken to establish their role in such patients. The effectiveness and nephrotoxicity of polymyxins in critically ill-patients harboring MDR Gram-negative bacteria with already compromised renal functions was compared with those with normal renal functions. Materials and Methods: This retrospective cohort study (March 2008-March 2010) was conducted in the intensive care unit of a tertiary care hospital. A total of 48 eligible critically ill-patients receiving polymyxins were enrolled. A comparison was carried out (length of stay in hospital, mortality, renal function) between patients with acute kidney injury (AKI, n = 18; defined by the RIFLE classification) and patients with normal renal function (non-AKI, n = 30). Results: Patients with baseline AKI had a significantly higher adjusted mortality rate at admission when compared with the non-AKI group. At the end of therapy with polymyxins, 26.66% non-AKI patients developed renal dysfunction while 38.88% of patients in the AKI group had worsening of renal function (P = 0.006). However, there was no significant difference in the length of hospital stay (23.9 ± 13.24 vs. 30.5 ± 22.50; P = 0.406) and overall mortality (44.4% vs. 36.7%; P = 0.76) between two groups. Conclusion: Polymyxins can be administered in AKI patients with favorable results provided used judiciously with strict monitoring of renal functions, dose modification according to creatinine clearance and aggressive fluid management.