Paul E. Marik

Bench-to-bedside review: Rhabdomyolysis -- an overview for clinicians.

Rhabdomyolysis ranges from an asymptomatic illness with elevation in the creatine kinase level to a life-threatening condition associated with extreme elevations in creatine kinase, electrolyte imbalances, acute renal failure and disseminated intravascular coagulation. Muscular trauma is the most common cause of rhabdomyolysis. Less common causes include muscle enzyme deficiencies, electrolyte abnormalities, infectious causes, drugs, toxins and endocrinopathies. Weakness, myalgia and tea-colored urine are the main clinical manifestations. The most sensitive laboratory finding of muscle injury is an elevated plasma creatine kinase level. The management of patients with rhabdomyolysis includes early vigorous hydration.

Pulmonary Complications of Novel Antineoplastic Agents for Solid Tumors

Antineoplastic agent-induced pulmonary toxicity is an important cause of respiratory failure. Although the incidence of antineoplastic agent-induced pulmonary toxicity seems to be low, more cases can be expected, with increasing numbers of patients receiving the new generations of antineoplastic agents. Antineoplastic agents have previously been associated with bronchospasm, hypersensitivity reactions, venous thromboembolism, and pulmonary hemorrhage. Physicians should be aware of the clinical and radiographic presentations of the pulmonary toxicities associated with the newer antineoplastic agents. The approach to diagnosis, risk factors, and possible mechanisms of antineoplastic agent-induced pulmonary toxicity are discussed in this article.

Multidisciplinary Family Meetings in the ICU Facilitate End-of-Life Decision Making

Objective: The aim of this study was to assess the feasibility of establishing a multi-disciplinary family meeting (MDFM) program and the impact of such a program on the end-of-life decision making in the setting of an ICU. Methods: During the study period MDFMs were scheduled for patients requiring mechanical ventilation for 5 or more days. The meeting followed a structured format. The pertinent details of the meeting as well as the treatment goals were recorded. Results: Twenty-nine patients were enrolled in this study. Thirty-five MDFM’s were held on 24 patients. A meeting could not be arranged for four patients. All meetings addressed patient’s diagnosis, prognosis and goals of care. Fifteen (52%) patients (9 of whom had metastatic malignancy) had life support withdrawal and died a mean of 4.8 + 4.2 days after the first family meeting. In the remaining 9 patients (3 with localized cancer and 6 with non-cancer diagnoses), the plan following the family meeting was to continue supportive care; all of these patients survived to hospital discharge. Conclusions: Proactive MDFM’s improve communication and understanding between patients’ family and the treating team and facilitates end-of-life decision making.

A 56-Year-Old Man With Multiple Airway Procedures With Fever, Cough, and Dyspnea

(CHEST 2008; 134:1332–1335) A 56-year-old man was admitted to hospital with a 1-week history of worsening cough and dyspnea on exertion. He also complained of pleuritic chest pain with fever and chills of 2 days in duration. He had a history of chronic cough with clear-to-yellowish sputum turning purulent with infection. His exercise tolerance had been diminishing over the years, currently less than a city block. He had three-pillow orthopnea but no paroxysmal nocturnal dyspnea. He denied any hemoptysis or weight loss. His medical history was significant for COPD and multiple upper airway procedures including a temporary tracheostomy with biopsy (Fig 1) in 1989, and a right upper lobectomy for adenocarcinoma in 1994. He was a 100–pack-year smoker and admitted to occasional cocaine use. Both his father and sister were heavy smokers and had lung cancer. On examination, the patient had a temperature of 38.0°C, respiratory rate of 24 breaths/min, heart rate of 108 beats/min, and BP of 130/70 mm Hg with an oxygen saturation of 88% while breathing room air. Head, ear, nose, and throat examination was unremarkable. The neck was supple, and no lymphadenopathy was noted. Cardiovascular system examination was normal other than sinus tachycardia. Chest examination revealed a thoracotomy scar on the right side with bilateral middle and lower zone midinspiratory crackles. Extremities revealed finger clubbing but no peripheral edema. No skin lesions were