Raed Alalawi

Hyperthyroidism and Pulmonary Hypertension: An Important Association

Pulmonary hypertension is a complex disorder with multiple etiologies. The World Health Organization Group 5 (unclear multifactorial mechanisms) includes patients with thyroid disorders. The authors reviewed the literature on the association between hyperthyroidism and pulmonary hypertension and identified 20 publications reporting 164 patients with treatment outcomes. The systolic pulmonary artery (PA) pressures in these patients ranged from 28 to 78 mm Hg. They were treated with antithyroid medications, radioactive iodine and surgery. The mean pretherapy PA systolic pressure was 39 mm Hg; the mean posttreatment pressure was 30 mm Hg. Pulmonary hypertension should be considered in hyperthyroid patients with dyspnea. All patients with pulmonary hypertension should be screened for hyperthyroidism, because the treatment of hyperthyroidism can reduce PA pressures, potentially avoid the side-effects and costs with current therapies for pulmonary hypertension and limit the consequences of untreated hyperthyroidism. However, the long-term outcome in these patients is uncertain, and this issue needs more study. Changes in the pulmonary circulation and molecular regulators of vascular remodeling likely explain this association.

Severe reversible myocardial depression in a patient with Pseudomonas aeruginosa sepsis suggesting tako-tsubo cardiomyopathy

Acute coronary syndromes are not uncommon in medical intensive care units. Multiple molecular, pharmacologic, and hemodynamic mechanisms may contribute to the pathogenesis resulting in increased mortality in this setting. Tako-tsubo cardiomyopathy is a recently defined uncommon cardiac syndrome with characteristic features often encountered in patients with hyperadrenergic situations such as emotional stress. Although myocardial depression in sepsis can be expected in previously healthy individuals; tako-tsubo cardiomyopathy is rarely reported in septic patients. In this case report we present a 52 year-old man with sepsis secondary to Pseudomonas pneumonia who developed significant segmental wall motion abnormalities during the disease course. The patients myocardial function recovered completely soon after the sepsis resolved. Clinical, echocardiographic, and coronary angiographic findings suggested the diagnosis of tako-tsubo cardiomyopathy in this patient.

Acute effect of sildenafil on central hemodynamics in mechanically ventilated patients with WHO group III pulmonary hypertension and right ventricular failure necessitating administration of dobutamine

BACKGROUND/OBJECTIVESnSildenafil decreases pulmonary vascular resistance index (PVRI), in patients with pulmonary hypertension (PH). We investigated sildenafils effects on central hemodynamics of mechanically ventilated patients with WHO group-III PH and RV failure necessitating dobutamine administration.nnnMETHODSnProspective non-controlled study involving 12 (9 males, 59 ± 4 years old), patients with the above characteristics. All patients in phase-1 (days 1-2) received dobutamine (5 μg/kg/min IV). During phase-2 (days 3-6), sildenafil was started via nasogastric tube (80 mg/day) and dobutamine discontinuation was attempted. Patients were designated responders or non-responders based on whether dobutamine could be stopped or not. Phase-3 lasted from day 7 to day of weaning from mechanical ventilation; or if weaning failed, until day 20 following admission (end-of-study). Invasive and echocardiographic parameters were repeatedly recorded throughout the study.nnnRESULTSnSignificantly changed parameters (P<0.025) from baseline to phase-1, -2 and -3 (%change of mean ratios), in responders (n=7) included among others PVRI (-40%, -51%, -42%), RV stroke work index (RVSWI: 43%, 79%, 41%) and cardiac index (49%, 54%, 48%), which also differed significantly from non-responders (N=5). In phases-1 and -3 non-responders had not significant changes, in phase-2 PVRI (27%) and RVSWI (-22%) changed significantly. In contrast to non-responders, all responders were weaned from mechanical ventilation until the end-of-study (P<0.025).nnnCONCLUSIONSnSildenafil may improve central hemodynamics and RV function indices in ventilated patients with WHO group-III PH and RV failure requiring dobutamine infusion, when they respond favorably to the latter. Accordingly, an adequate RV systolic reserve may be mandatory for sildenafil to exert its actions.

Prolonged acute care in a 52-year-old man with respiratory failure: Lessons learned from 70-day intensive care unit hospitalization

PURPOSEnThis study was undertaken to record the experiences of a patient who survived prolonged intensive care unit (ICU) care secondary to acute respiratory failure.nnnMATERIALS AND METHODSnThe patients medical record was summarized, and the patient was interviewed with audio recording and transcription. He completed several surveys, including the ICU memory tool, the 14-question Posttraumatic Stress Syndrome Questionnaire, the Impact of Event Scale-Revised Questionnaire, and the Hospital Anxiety and Depression Scale Questionnaire.nnnRESULTSnThe patient had little factual recall of his prolonged ICU care but had multiple delusional memories from this period. The Impact of Event Scale-Revised results indicate that this hospitalization had significant impact. However, his scores on the 14-question Posttraumatic Stress Syndrome and Hospital Anxiety and Depression Scale questionnaires indicate that his risk for posttraumatic stress disorder, anxiety, and depression is low. These outcomes were attributed, in part, to his willingness to discuss his ICU care and experiences with health care workers, family, and friends.nnnCONCLUSIONSnPatient debriefing may improve outcomes after prolonged acute care. Current survey instruments provide a good estimate of a patients mental status. Patients themselves can provide important information about hospital care and areas needing improvement.

Prolonged Refractory Hypotension Secondary to Amlodipine Overdose A Therapeutic Challenge

Calcium channel blocker overdose is one of the leading causes of overdose death among cardiovascular medications. We present a patient with the highest reported dose of amlodipine ingestion in combination pill. She was asymptomatic initially and soon became hypotensive and obtunded. She was intubated for airway protection, gastric lavage was done, and activated charcoal was given. She was resuscitated with 4L 0.9% normal saline, calcium chloride, glucagon, insulin, and glucose infusions. Her hypotension worsened necessitating use of norepinephrine 200 µg/min, phenylephrine 200 µg/min, dopamine 50 µg/kg/min, and vasopressin 0.06 U/min concurrently. She continued to improve and was weaned off vasopressors and mechanical ventilation. Few cases of extremely high-dose ingestion have been reported. Patients may be normotensive but rapidly progress to shock depending on ingested dose. High doses are associated with shock, bradycardia, pulmonary edema, renal failure, and heart failure. The primary goal is to main...

Pheochromocytoma Presenting as Systemic Inflammatory Response Syndrome and Lactic Acidosis

Pheochromocytomas can secrete catecholamines, hormones, and cytokines, and the patterns of secretion strongly influence the complexity of the clinical presentation. We now report a patient who presented with abdominal pain, fever, leukocytosis, and tachycardia. In addition, he had lactic acidosis without shock. Our review of the literature indicates that this patient had systemic inflammatory response syndrome most likely secondary to high levels of IL-6 and that he had type B lactic acidosis secondary to high circulating levels of epinephrine. The combined presentation is unique and resolved with successful surgery. Pheochromocytoma should be included in the differential diagnosis of SIRS and of lactic acidosis.

Cuff Leak Tests at the Time of Extubation Correlate With Voice Quality Assessment

Background. Endotracheal intubation frequently causes laryngeal injury, including edema, ulceration, and vocal cord immobility. These problems can complicate the immediate postextubation course. Methods. The authors measured the cuff leak and made bedside assessment of the voice in 51 patients requiring mechanical ventilation for acute respiratory failure. Results. The median tidal volume was 450 mL (range = 300-600 mL). The median duration of ventilation was 3 days (range = 0-19 days). The median cuff leak was 180 mL (range = −33 to 460 mL); the median percentage cuff leak was 40.9% (range = −7.75% to 99.2%). Women had significantly smaller cuff leaks (18.6% of tidal volume vs 50.3% in men, P = .01). Patients with hoarseness frequently had smaller cuff leaks (median 24.1% vs. 46.7% in nonhoarse patients). Eleven patients (84.6%, 11/13) with a cuff leak 15% had hoarseness (P = .01). Four patients had stridor, and all had a cuff leak >15% of the ti...

Platelet Function Analysis Using PFA-100 Tests in Patients With Acute Gastrointestinal Bleeding

Aim. To investigate platelet function in patients with acute gastrointestinal bleeding. Methods. We prospectively studied platelet function using the PFA-100 test in a convenience sample of patients with gastrointestinal bleeding admitted to the medical ICU from July 2010 to August 2011. Patients on warfarin or heparin were excluded. Results. In all, 41 patients (30 men) participated in the study. The mean age was 55 years (range 25-74 years). Most patients (31/41) presented with blood in their stools as at least one of their presenting symptoms. Fourteen of the 41 patients were on aspirin, 4 on nonsteroidal anti- inflammatory drugs, and 5 on clopidogrel or other antiplatelet drugs. The average hemoglobin was 9.2 g/dL (range 5.1-16.1 g/dL). The average platelet count was 170 kU/L (range 41-496 kU/L). The average international normalized ratio was 1.37(range 1.01-2.08). Analysis of platelet function was performed in 9 patients (22%). These patients had closure times which ranged from 98 to >300 seconds wit...