Saqib I. Dara

Fresh frozen plasma transfusion in critically ill medical patients with coagulopathy

Objective:Although restrictive red cell transfusion practice has become a standard of care in the critically ill, data on the use of fresh frozen plasma (FFP) are limited. We hypothesized that the practice of FFP transfusion in the medical intensive care unit is variable and that liberal use may not be associated with improved outcome. Design:Retrospective cohort study. Setting:A 24-bed medical intensive care unit in a tertiary referral center. Patients:All patients admitted to a medical intensive care unit during a 5-month period who had abnormal coagulation defined as international normalized ratio (INR) of ≥1.5-times normal. Interventions:None. Measurements and Main Results:We collected data on demographics, severity of illness as measured by Acute Physiology and Chronic Health Evaluation (APACHE) III scores, INR, bleeding episodes, and transfusion complications. We identified 115 patients with coagulopathy (INR of ≥1.5) but without active bleeding. A total of 44 patients (38.3%) received FFP transfusion. INR was corrected in 16 of 44 patients (36%) who received transfusion. Median dose of FFP was 17 mL/kg in patients who had INR corrected vs. 10 mL/kg in those who did not (p = .018). There was no difference in age, sex, APACHE III scores, liver disease, Coumadin treatment, or INR level between those who did and did not receive FFP. Invasive procedures (68.2% vs. 40.8%, p = .004) and history of recent gastrointestinal bleeding (41% vs. 7%, p < .001) were more frequent in the group with transfusion. Although there was no difference in new bleeding episodes (6.8% in transfused vs. 2.8% in nontransfused group, p = .369), new onset acute lung injury was more frequent in the transfused group (18% vs. 4%, p = .021). Adjusted for severity of illness, hospital mortality and intensive care unit length of stay among survivors were not different between the two groups. Conclusion:The risk–benefit ratio of FFP transfusion in critically ill medical patients with coagulopathy may not be favorable. Randomized controlled trials evaluating restrictive vs. liberal FFP transfusion strategies are warranted.

Worldwide disaster medical response: an historical perspective.

Objective:Disaster medicine and disaster medical response is a complex and evolving field that has existed for millennia. The objective of this article is to provide a brief review of significant milestones in the history of disaster medicine with emphasis on applicability to present and future structures for disaster medical response. Results:Disaster medical response is an historically necessary function in any society. These range from response to natural disasters, to the ravages of warfare, and most recently, to medical response after terrorist acts. Our current disaster response systems are largely predicated on military models derived over the last 200 yrs. Their hallmark is a structured and graded response system based on numbers of casualties. In general, all of these assume that there is an identifiable “ground zero” and then proceed with echelons of casualty retrieval and care that proceeds rearward to a hospital(s). In a civil response setting, most civilian models of disaster medical response similarly follow this military model. This historical approach may not be applicable to some threats such as bioterrorism. A “new” model of disaster medical response for this type of threat is still evolving. Using history to guide our future education and planning efforts is discussed. Conclusion:We can learn much from an historical perspective that is still applicable to many current disaster medical threats. However, a new response model may be needed to address the threats of bioterrorism.

Original ResearchPulmonary Vascular DiseaseUse of Intermittent Pneumatic Compression and Not Graduated Compression Stockings Is Associated With Lower Incident VTE in Critically Ill Patients: A Multiple Propensity Scores Adjusted Analysis

BACKGROUND A limited amount of data exist regarding the effect of intermittent pneumatic compression (IPC) and graduated compression stockings (GCS) on the incidence of VTE in the ICU setting. The objective of this study was to examine the association of mechanical thromboprophylaxis with IPC or GCS with the risk of VTE and hospital mortality among critically ill medical-surgical patients. METHODS In this prospective cohort study of patients admitted to the ICU of a tertiary-care medical center between July 2006 and January 2008, we used multiple propensity scores adjustment to examine the association of IPC and GCS with VTE. The primary outcome was incident VTE, including DVT and pulmonary embolism. The following data were collected: patient demographics, admission physiologic data, VTE risk factors, pharmacologic thromboprophylaxis, and mechanical thromboprophylaxis. RESULTS Among 798 patients enrolled in the study, incident VTE occurred in 57 (7.1%). The use of IPC was associated with a significantly lower VTE incidence compared with no mechanical thromboprophylaxis (propensity scores adjusted hazard ratio, 0.45; 95% CI, 0.22-0.95; P=.04). GCS were not associated with decreased VTE incidence. No significant interaction was found between the mechanical thromboprophylaxis group and the type of prophylactic heparin used (P=.99), recent trauma (P=.66), or recent surgery (P=.07) on VTE risk. CONCLUSIONS The use of IPC, but not GCS, was associated with a significantly lower VTE risk. This association was consistent regardless of the type of prophylactic heparin used and was not modified by trauma or surgical admission.

Prolonged coma from refractory status epilepticus

ObjectiveStatus epilepticus is a life-threatening medical condition. In its most severe form, refractory status epilepticus (RSE) seizures may not respond to first and second-line anti-epileptic drugs. RSE is associated with a high mortality and significant medical complications in survivors with prolonged hospitalizations.MethodsWe describe the clinical course of RSE in the setting of new onset lupus in a 31-year-old male who required prolonged barbiturate coma.ResultsSeizure stopped on day 64 of treatment. Prior to the resolution of seizures, discussion around withdrawal of care took place between the physicians and patients family. Medical care was continued because of the patients age, normal serial MRI studies, and the patients reversible medical condition.ConclusionFew evidence-based data exist to guide management of RSE. Our case emphasizes the need for continuous aggressive therapy when neuroimaging remains normal.

Acute Sin Nombre Hantavirus Infection Complicated by Renal Failure Requiring Hemodialysis

To the Editor : The hantavirus pulmonary syndrome (HPS), a zoonotic viral infection transmitted by rodents, is an unusual cause of acute respiratory failure and is rarely associated with renal insufficiency. We report a case of infection with Sin Nombre hantavirus complicated by acute respiratory failure and renal failure requiring hemodialysis. Report of a Case. A 57-year-old man was transferred to Saint Marys Hospital in Rochester, Minn, because of respiratory insufficiency and altered mental status. He described a flulike illness beginning in late October and progressing over 1 week. Symptoms included headache, fever, chills, and difficulty thinking clearly. He had cleaned his garage several days before the onset of illness. He had no recent history of trauma, travel, or exposure to illness. He had donated his left kidney to his brother earlier in the year. A review of systems was otherwise unremarkable. His shortness of breath worsened, and he required supplemental oxygen. On physical examination, the patient’s heart rate was 127 beats/min, and supine blood pressure was 100/63 mm Hg. His skin showed signs of dehydration without rash. Crackles were noted bilaterally on chest auscultation. Findings on abdominal examination were normal. Laboratory evaluation revealed a white blood cell count of 10.3 × 10/L with 85% neutrophils, a platelet count of 67 × 10/L, and a normal hemoglobin concentration. The serum creatinine level was 1.9 mg/dL. Urinalysis showed an elevated protein-osmolality ratio of 0.65 (normal, 0.12). Chest radiography revealed diffuse pulmonary infiltrates. Arterial blood gas studies yielded a Pa O 2 of 65 mm Hg while the patient received 5 L of oxygen via nasal cannula. Computed tomography of the head showed normal findings, but computed tomography of the chest, abdomen, and pelvis revealed bilateral perihilar infiltrates in the mid and upper lung fields with stranding in the retroperitoneum bilaterally. Blood was withdrawn for cultures. Lumbar puncture revealed a cerebrospinal fluid protein level of 58 mg/dL and a glucose concentration of 80 mg/dL. Antibiotic therapy was initiated with levofloxacin, cefepime, metronidazole, and doxycycline. Two days later, the patient’s increased oxygen requirements and hypotension led to transfer to the medical intensive care unit (MICU), where he underwent endotracheal intubation and mechanical ventilation with 100% oxygen. Intravenous fluids and infusions of vasopressin and phenylephrine were administered. Echocardiography showed a left ventricular ejection fraction of 65% to 70% with mild hypokinesia of the basal to inferolateral portions of the left ventricular wall. Bronchoalveolar lavage fluid obtained on arrival at the MICU showed no growth on cultures. Because of persistent hypotension, a pulmonary artery catheter was inserted. The cardiac index was 2.03 L/min per m , the pulmonary artery occlusion pressure was 22 mm Hg, and the systemic vascular resistance index was 2125 dyne • s • cm • m. The serum creatinine concentration increased to 3.5 mg/dL, and the serum bicarbonate level was 12 mEq/L. The calculated urinary fractional excretion of sodium was 0.11. Continuous venovenous hemodialysis was initiated after nephrology consultation. Five days after MICU admission, vasopressors were tapered and discontinued. Multiple fungal, viral, and bacterial serologies yielded normal findings. Blood culture results remained negative, and antibiotics were discontinued. On day 12 of the MICU stay, the patient was extubated successf ully, and continuous dialysis was replaced with intermittent hemodialysis. Two days later, viral serologies sent to the Centers for Disease Control and Prevention were reported to be positive for Sin Nombre virus, with an IgM titer of 1:6400 and an IgG titer of 1:1600, both consistent with acute hantavirus infection. Supportive therapy was continued, and the patient remained in the MICU for 5 more days. He returned home 3 weeks later. At the time of discharge, his renal function had not fully recovered, but he did not require hemodialysis. Two months later, his renal function had returned to baseline. Discussion. Hantavirus pulmonary syndrome was first recognized after an outbreak of severe respiratory illness in the southwestern United States in May 1993 that was traced to the Sin Nombre virus. 1 Subsequently, other strains of hantaviruses were isolated in the United States, Canada, and South America. In the United States, the deer mouse ( P romyscus maniculatus ) is the rodent host for Sin Nombre virus. Outside the United States, a common presentation of hantavirus infection is hemorrhagic fever with renal syndrome (HFRS), a group of similar illnesses that include Korean hemorrhagic fever, epidemic hemorrhagic fever, and nephropathia epidemica. 2,3 Although hantavirus infection can occur without severe pulmonary symptoms, most patients with HPS experie nce pulmonary and hemodynamic compromise and require ICU admission and mechanical ventilation. 4 In contrast to patients with septic shock, those with HPS reportedly have high vascular resistance and low cardiac output. Laboratory findings commonly include thrombocytopenia, leukocytosis with myeloid precursors, increased hematocrit level, and coagulopathy. Typically, renal function is only mildly impaired. Only 20% of patients with HPS have serum creatinine values higher than 2.0 mg/dL. 5 However, renal failure requiring dialysis has been described in patients infected with hantavirus strains other than Sin Nombre in the United States, and elsewhere renal impairment is a prominent feature of HFRS and HPS. 5,6