Raymonde Jean

Outcome of Morbid Obesity in the Intensive Care Unit

This was a retrospective chart review of consecutive obese patients admitted to the medical intensive care unit. Patients were divided into 2 groups: mild to moderately obese (group 1, body mass index =30-40 kg/m2) and morbidly obese (group 2, body mass index >40 kg/m2). Acute Physiology and Chronic Health Evaluation II scores were not significantly different between the 2 groups. Morbidly obese patients (group 2) had higher rates of mortality and nursing home admission. They also showed higher rates of intensive care unit complications including sepsis, nosocomial pneumonia, acute respiratory distress syndrome, catheter infection, tracheostomy, and acute renal failure. Their median length of mechanical ventilation was longer (2 days, range 2-12 vs 9 days, range 1-37, P = .009). In a logistic regression analysis, morbid obesity remained a significant predictor of death or disposition to nursing home even after controlling for age ( P = .019, odds ratio = 7.60, 95% confidence interval = 1.39-41.6). Morbidly obese patients (body mass index >40 kg/m2) admitted to intensive care units have higher rates of mortality, nursing home admission, and intensive care unit complications and have longer stays in the intensive care unit and time on mechanical ventilation.

Efficacy of deep venous thrombosis prophylaxis in the medical intensive care unit.

The purpose of this study was to determine the incidence of deep venous thrombosis in medical intensive care unit patients receiving deep venous thrombosis prophylaxis. This was a prospective cohort study of 141 consecutive adult patients anticipated to remain in the medical intensive care unit for >48 hours. Deep venous thrombosis prophylaxis was provided using subcutaneous unfractionated heparin or a sequential compression device according to risk-stratified protocol. Compression ultrasound was performed. Fourteen patients (9.9%) developed deep venous thrombosis on follow-up studies. Incidence of deep venous thrombosis was 7.9% per person year (95% confidence interval, 4.8-12.8). Two of 14 developed pulmonary embolism. Eight patients required full anticoagulation with intravenous heparin or coumadin. In-hospital mortality was similar in both groups. Patients with deep venous thrombosis had a statistically higher risk of pulmonary embolism: 14.2% (95% confidence interval, 2.0-43.0) versus 0.0% (95% confidence interval, 0-3; P = .009). Incidence of deep venous thrombosis is high in medical intensive care unit patients receiving standard prophylaxis. Adherence to strict deep venous thrombosis prophylaxis protocol and exploration of other prophylaxis regimens should be pursued.

'Chasing the dragon': new knowledge for an old practice.

Heroin administration by “chasing the dragon,” whereby the user places freebase heroin on aluminum foil, heats it below with a flame, and inhales the pyrolysate through a straw, can be associated with the rare development of a delayed-onset spongiform leukoencephalopathy. We report the case of a 46-year-old woman with a psychiatric diagnosis of depression and heroin dependence by “chasing the dragon” admitted with features of altered mental status and later development of catatonia, abulia, and akinetic mutism. A brain magnetic resonance image evidenced bilateral symmetric high-signal lesions in the white matter of the cerebrum and cerebellum on T2-weighted images compatible with toxic leukoencephalopathy. The patients condition resolved after a hospital stay of 2 months with supportive treatment. Acute onset of neurobehavioral changes, including confusion, apathy, and cerebellar signs in a person with exposure to heroin, should prompt one to consider toxic leukoencephalopathy as a cause of presentation.

Cardiac Arrest Following Massive Pulmonary Embolism During Mechanical Declotting of Thrombosed Hemodialysis Fistula: Successful Resuscitation With tPA:

Percutaneous declotting of a thrombosed fistula or graft is standard of care and is a safe procedure. Subclinical pulmonary embolism (PE) during this procedure occurs commonly, but symptomatic PE is extremely rare. The authors report a case of declotting-associated massive PE with cardiopulmonary arrest and successful resuscitation. The patient developed a new right-axis deviation and right-bundle branch block. Diagnosis of PE was confirmed with a computed tomography (CT) angiogram, and the patient received tissue plasminogen activator (tPA) and heparin. She required norepinephrine and dobutamine temporarily and was subsequently extubated successfully. Massive PE is a very rare complication of this procedure. Given the grave outcome, the clinical signs and symptoms should be recognized immediately and treatment instituted early.

Cardiac Tamponade in a Patient With Dengue Fever and Lupus Nephritis: A Case Report

Cases of small pericardial effusion have been reported in association with dengue fever (DF), largely with dengue hemorrhagic fever during epidemic outbreaks. However, cardiac tamponade developed by a patient with DF has not yet been reported in the English literature. We report a case of cardiac tamponade in a patient with DF and lupus nephritis. We describe the characteristic features to differentiate pericardial effusion of lupus origin from that of viral etiology. A 59-year-old Hispanic woman presented to the emergency department with complaints of 5 to 6 days of fever, myalgia, headache, and retro-orbital pain. Her symptoms started 3 days after returning from the Dominican Republic, where a dengue outbreak was reported. Her past medical history was significant for hypertension and lupus nephritis diagnosed 3 months earlier. On day 2, patient developed a large pericardial effusion that progressed to tamponade over the next 2 days, requiring surgical drainage. Subsequently, the patient improved; however, serological analysis did not suggest any lupus flare-up. Pericardial fluid analysis showed hypocellularity without lupus erythematosus cell and biopsy revealed only reactive mesothelial cells suggestive of viral etiology. Dengue serology was reported as markedly elevated, supporting a diagnosis of classic DF (both immunoglobulin M [IgM] titer 2.93 and IgG titer 12.13 by enzyme-linked immunosorbent assay [ELISA]; reference range: <0.90 for both). Absence of rise in serum antinuclear antibody (ANA) titer correlated with lack of inflammatory changes on the pericardium favored viral etiology over lupus origin. This differentiation is pertinent from a management perspective.

Amiodarone-induced Acute Respiratory Distress Syndrome Masquerading as Acute Heart Failure

BACKGROUND Amiodarone use has been rarely associated with the development of acute respiratory distress syndrome (ARDS), usually in association with surgery or pulmonary angiography. In patients with preexisting left ventricular dysfunction, the diagnosis may be overlooked. CASE REPORT A 92-year-old woman with a history of atrial fibrillation who was on low-dose amiodarone presented to the Emergency Department with sudden onset of shortness of breath. The patient was started on treatment for acute heart failure based on the physical examination and the elevated brain natriuretic peptide level. Despite adequate diuresis, the patient showed no improvement. A chest computed tomography scan revealed acute interstitial pneumonitis. The patient received corticosteroids due to suspected amiodarone-induced acute interstitial pneumonitis resulting in ARDS. She returned to her baseline activity within 2 weeks of the therapy. CONCLUSION Although rare, clinicians should be vigilant for amiodarone-induced acute interstitial pneumonitis resulting in ARDS, as delay in treatment may result in a high risk of mortality. In addition, the development of ARDS occurred in our patient in the absence of precipitating factors such as surgery or pulmonary angiography.

Improvement in Physical Activity in Persons With Obstructive Sleep Apnea Treated With Continuous Positive Airway Pressure

BACKGROUND Exercise improves sleep quality, yet people with untreated obstructive sleep apnea (OSA) may engage in less physical activity (PA) due to fatigue and daytime sleepiness. We examined changes in PA and sleep quality before and after treatment with continuous positive airway pressure (CPAP) in OSA patients. METHODS In this prospective longitudinal study, persons with a primary diagnosis of OSA were enrolled at a community-based hospital in New York City. At 3 time intervals pre- and post-CPAP (3-8 months), we measured sleep quality using validated questionnaires, perceived PA using the International Physical Activity Questionnaire (IPAQ), and actual PA using pedometer steps per day. We sought to investigate how CPAP use and changes in sleep quality impacted the number of steps taken, as recorded in pedometer steps. RESULTS In total, 62 patients were enrolled in the study from March 2012 to July 2014. In all, patients averaged 53 years of age, and 26 patients (42%) were female. Among all participants, 86% of persons had moderate to severe sleep apnea (AHI ≥15). Approximately 73% of participants were compliant with CPAP use. Poor sleep quality correlated with lower actual PA (P = .004) at baseline. At 3 and 7 months, there was significant improvement in sleep quality (Δ -2.63 ± 3.4 and Δ -3.5 ± 3.8; P < .001) and actual PA (Δ 840 ± 1313 and Δ 1431 ± 1419 steps/day, P < .001) compared with baseline. On multivariate analyses, participants with a higher waist circumference had a significantly greater increase in actual PA (P = .018). CONCLUSION Treatment of OSA with CPAP had a progressive incremental improvement in sleep quality and actual PA.

Severe lenalidomide-induced interstitial pneumonitis requiring mechanical ventilation: Case report and review of literature

To illustrate recognition of drug-induced lung injury and review of all published cases of lenalidomide-induced interstitial pneumonitis. Lenalidomide is an immunomodulatory thalidomide analog currently approved for the treatment of myelodysplastic syndrome and refractory multiple myeloma. Lenalidomide-induced pulmonary toxicity presenting as interstitial pneumonitis has been rarely reported. We report the case of a 62-year-old man with recent diagnosis of myelodysplastic syndrome and concomitant treatment with lenalidomide, presenting with dyspnea, weakness, cough, fever, and diffuse interstitial opacities on chest computed tomography. His symptoms became severe enough to require mechanical ventilation and intubation for respiratory failure, however, showed some response to intravenous corticosteroids. Failure to improve on antibiotics and an extensive work-up that was negative for infectious etiologies, combined with a resurgence of complaints after restarting lenalidomide treatment, led to the diagnosis of severe lenalidomide-induced lung disease. Physicians should recognize drug-induced lung disease and pursue aggressive work-up for definite diagnosis to provide appropriate treatment and prevent fatal recurrences.

THE IMPLEMENTATION OF A MULTI-DISCIPLINARY PULMONARY EMBOLISM RESPONSE TEAM (PERT) IN A NEW YORK CITY TEACHING HOSPITAL CENTER

METHODS: A multi-disciplinary PERT was assembled to respond to PE in two sites of an academic hospital center, comprised of attending physicians in Pulmonary/Critical Care, Interventional Radiology, and Cardiothoracic Surgery. Critical care consultations for submassive or massive PE lead to activation of the PERT, available 24 hours a day. A secure encrypted messaging application is used to share information, including clips of the CT angiogram and transthoracic echocardiogram (TTE) images. This allows the involved specialties to review relevant information, ask questions and give input in real-time. Once a consensus is reached the PERT leader, assigned weekly, directly contacts the intensivist who activated the PERT (ultimately the decision belongs to this intensivist). Fellows are also included in this group for their education and involvement.

485: SLEEP IN THE ICU

Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) early after TBI paralleling increased expression of inflammatory cytokines. Methods: Sprague-Dawley rats (Post Natal Day-17,N=72) were randomized 2:1 to controlled cortical impact vs sham, sacrificed at 3, 12, 24, 72, 168, and 336 hr post TBI, and mRNA was isolated from the ipsilateral hippocampus of each rat. Following a review of the literature, a panel of 36 transporters, biomarkers, and transcription regulators was developed for absolute quantification on the nCounter® Analysis System. Transcript counts over time for TBI rats were compared with sham for fold change with the False Discovery Rate (FDR) to correct for multiple comparisons. Results: At 3, 12, and 24 hr post TBI, 9 transporters showed a decrease in expression and 3 showed increased expression (FDR<0.05). At 72, 168, and 336 hr only 1 transporter had reduced expression, while 6 transporter showed increased expression (FDR<0.05). Slc22a6 had a >10 fold decrease in expression at 12 h (FDR=0.01) and 24 hr (FDR=0.04). Abcb1b had >2 fold decrease in expression at 12 (FDR=0) and 24 hr (FDR=0) post TBI. These were met with changes in transcription factors, including IL-6 with a 93.9 fold increase in expression at 3 hr (FDR=0) and a 7.6 fold increase at 12 h (FDR=0.04). Conclusions: Transporter expression generally decreases early after TBI, and increases in the weeks following. Slc22a6 and Abcb1b showed large changes, suggesting that TBI impairs the ability of the brain to remove xenobiotics and toxic solutes. Brain detoxification and transporter-mediated drug pharmacokinetics may be altered in time dependent manner.