Rajiv Malhotra

Octreotide for left ventricular assist device-related gastrointestinal hemorrhage: can we stop the bleeding?

Left ventricular support devices (LVADs) are associated with a propensity toward gastrointestinal bleeding. A postulated mechanism is related to gastrointestinal arteriovenous malformations secondary to nonpulsatile flow. We describe a case of LVAD-related, gastrointestinal bleeding successfully treated with a combination of subcutaneous and intramuscular depot formulations of octreotide.

Tolerability and Biological Effects of Long-Acting Octreotide in Patients With Continuous Flow Left Ventricular Assist Devices

Patients with implanted continuous, nonpulsatile, left ventricular assist devices (LVADs) have increased the occurrence of gastrointestinal bleeding (GIB). Although the pathophysiology is multifactorial, there are few treatments beyond supportive care. Octreotide acetate is a somatostatin analog that reduces GIB in various patient populations. However, there are sparse case series that suggest octreotide acetate may reduce GIB in LVAD patients. This 10 patient, 28 week phase I study evaluated the safety and tolerability of octreotide acetate long-acting release (LAR) 20 mg depot injection every 4 weeks until week 16 after LVAD placement. Secondary aims were occurrence of GIB and measurement of vascular endothelial growth factor, fibrinogen, von Willebrand factor, and platelet aggregation across the study period. Ten patients were enrolled, and eight completed the study. The two study dropouts were not related to octreotide. None of the patients experienced side effects or safety concerns related to octreotide nor did GIB occur in the study population. Vascular endothelial growth factor levels were maintained in the reference range throughout the duration of the study. There did appear to be laboratory evidence of acquired von Willebrand syndrome, with mildly low platelet aggregation studies. In conclusion, octreotide acetate LAR 20 mg depot injection was safe and effective in this population.

Intravenous vitamin C as adjunctive therapy for enterovirus/rhinovirus induced acute respiratory distress syndrome

We report a case of virus-induced acute respiratory distress syndrome (ARDS) treated with parenteral vitamin C in a patient testing positive for enterovirus/rhinovirus on viral screening. This report outlines the first use of high dose intravenous vitamin C as an interventional therapy for ARDS, resulting from enterovirus/rhinovirus respiratory infection. From very significant preclinical research performed at Virginia Commonwealth University with vitamin C and with the very positive results of a previously performed phase I safety trial infusing high dose vitamin C intravenously into patients with severe sepsis, we reasoned that infusing identical dosing to a patient with ARDS from viral infection would be therapeutic. We report here the case of a 20-year-old, previously healthy, female who contracted respiratory enterovirus/rhinovirus infection that led to acute lung injury and rapidly to ARDS. She contracted the infection in central Italy while on an 8-d spring break from college. During a return flight to the United States, she developed increasing dyspnea and hypoxemia that rapidly developed into acute lung injury that led to ARDS. When support with mechanical ventilation failed, extracorporeal membrane oxygenation (ECMO) was initiated. Twelve hours following ECMO initiation, high dose intravenous vitamin C was begun. The patient’s recovery was rapid. ECMO and mechanical ventilation were discontinued by day-7 and the patient recovered with no long-term ARDS sequelae. Infusing high dose intravenous vitamin C into this patient with virus-induced ARDS was associated with rapid resolution of lung injury with no evidence of post-ARDS fibroproliferative sequelae. Intravenous vitamin C as a treatment for ARDS may open a new era of therapy for ARDS from many causes.

Endobronchial ultrasound diagnosis of pulmonary embolism.

A 68-year-old woman presented for mediastinal lymph node sampling while undergoing work up for a solitary pulmonary nodule. During endobronchial ultrasound examination of the airways, an echogenic abnormality was noted within the right pulmonary artery. The patient underwent computed tomography angiography of the chest, and diagnosis of pulmonary embolism was confirmed. We describe endobronchial ultrasound evaluation of a pulmonary embolus.

Mechanical Circulatory Support Devices in the ICU

The medical community has used implantable mechanical circulatory support devices at increasing rates for patients dying from heart failure and cardiogenic shock. Newer-generation devices offer a more durable and compact option when compared with bulky early-generation devices. This article is a succinct introduction and overview of the hemodynamic principles and complications after device implantation for ICU clinicians. We review the concepts of device physiology, clinical pearls for perioperative management, and common medical complications after device implantation.

Bronchoscopic blood patch for treatment of persistent alveolar-pleural fistula.

Airway pleural fistulas remain a significant treatment challenge despite improved antimicrobial therapy and surgical techniques. We present a case of a 56-year-old female who was admitted with severe bilateral cavitary pneumonia requiring mechanical ventilation. The patient suffered bilateral pneumothoraces related to necrotic pneumonia resulting in bilateral chest tube placement. Despite conservative measures, the air leak persisted preventing chest tube removal. Bronchoscopy with Fogarty balloon (Edwards) occlusion was performed in attempts to isolate an airway responsible for the air leak. No one single airway could be bronchoscopically occluded to isolate the right-sided fistula. Efforts were focused on the left airway where the fistula could be isolated to the anteromedial basal segment. Several alternating layers of an absorbable hemostat (knitted fabric prepared by controlled oxidation of cellulose-Surgicel; Ethicon) were placed within the left anteromedial basal segment using bronchoscopy forceps. Through a cut Fogarty balloon, 3 mL of the patients blood was delivered onto the absorbable hemostat to create an occluding blood patch. No air leak was present at the completion of the procedure. While on mechanical ventilation, the left chest tube was removed 2 days later without radiographic recurrence of her pneumothorax.

Exophytic Tracheal Mass. A Rare Presentation of Rosai–Dorfman Disease

A 77-year-old female with a history of previously treated breast cancer presented with intractable cough for 6 weeks and no other associated symptoms. Physical examination disclosed coarse breath sounds throughout both lung fields, but no wheezing or stridor. Routine laboratory studies were notable only for an elevated white blood count of 12,400/ml with 86.3% neutrophils. Computed tomographic chest imaging (Figure 1) showed a roughly spherical exophytic mass arising from the anterior wall of the trachea with near occlusion of the airway. Associated mediastinal and left hilar adenopathy was also observed. Given the history of breast cancer, metastatic disease was considered a strong possibility. A primary tracheal malignancy was also considered as part of the differential diagnosis. As the patient was stable, flexible fiberoptic bronchoscopy was performed in the bronchoscopy suite under moderate sedation. The lesion was visualized in the mid-trachea (Figure 2). An electrocautery snare (Olympus, Center Valley, PA) was then used to ablate and debulk the mass (Figure 3). The patient tolerated the procedure uneventfully. The next day, she was taken to the operating room. With the assistance of an anesthesiologist, she underwent direct intubation with a rigid tracheoscope (BryanDumon 12/11 mm; Bryan Corporation, Woburn, MA) under general anesthesia. Jet ventilation was used throughout the procedure. The remaining tumor was cored out with the rigid scope. A Xomed microdebrider (Medtronic, Minneapolis, MN) was used to further shave down the tumor along the anterior and lateral walls of the trachea. Argon plasma coagulation was used on the residual tumor surface to achieve coagulation (Figure 4). There was no bleeding and the patient was extubated uneventfully. Histological examination of biopsy samples showed that the mass consisted predominantly of large histiocytes with ample finely vacuolated eosinophilic cytoplasm. A mixed inflammatory infiltrate consisting of lymphocytes, plasma cells, and neutrophils was interspersed in between the large cells. Emperipolesis was noted (Figure 5). Immunohistochemical stains were positive for CD68 and S-100 (Figure 5) and negative for pan-cytokeratin AE1/AE3 and pan-melanoma cocktail. The morphology and immune profile of the mass confirmed a diagnosis of Rosai–Dorfman disease. Adjunct treatment with prednisone (60 mg daily for 2 wk) was initiated and she was discharged home. Repeat imaging 5 months later showed that the tumor had regrown. Low-dose radiation therapy (20 Gy

Airway complications of total artificial heart

The total artificial heart is the mechanical device which is used as a bridge to the heart transplant in patients with biventricular failure. Due to the mechanical nature of the device, patients receiving total artificial heart (TAH) require to be on anticoagulation therapy. Hemorrhage and coagulopathy are few of the known complications of TAH.