An Unusual Presentation of Staphylococcal Induced Paravertebral Myositis Causing Septic Shock

Background: Paravertebral myositis is uncommon, and this case highlights a number of important therapeutic and diagnostic considerations. We discuss the role of appropriate antimicrobial therapy and the potential dilemma regarding the use of immunoglobulin in the septic patient. The key elements of treatment are early recognition, and the early initiation of appropriate antibiotics, typically a β-lactamase resistant anti-staphylococcal agent and clindamycin. Clindamycin is added to anti-staphylococcal treatment due to its ability to reduce exotoxin production, a result of its ability to suppress translation of toxin genes.
Methods: We present a case report of a Staphylococcus aureus (S. aureus) induced paravertebral myositis resulting in septic shock.
Conclusions: It remains that the role of IVIG in the management of sepsis is as yet not clearly defined, at present it is neither advocated nor dismissed by current guidelines, given the presence of both positive and negative findings in recent metaanalysis.

Asynchronous Independent Lung Ventilation in the Management of Bronchopleural Fistula

Ventilation of lungs with parenchymal injury which can be caused by either disease or trauma has always been a diffi cult task for both respiratory therapists and physicians. There have been great many advances made in mechanical ventilators and ventilator modes over last decade. This has included the introduction of modes such as High Frequency Oscillator Ventilation (HFOV) [1] and Airway Pressure Release Ventilation (APRV).
Coupled with these new modes has also been a better understanding of how to best recruit and stabilize the lungs [2] and how to best use therapist driven protocols which may help to decrease the percentage of Acute Lung Injury (ALI) that we see today. Sometimes as respiratory care practitioners, we are exposed to trauma patients, which may present with massive amounts of parenchymal damage to the lungs, which we may have to modify on how to ventilate and oxygenate these patients. Some patients may have such severe unilateral lung pathology, that it will be difficult to oxygenation and ventilate, we should make a better effort to avoid high peak pressures and thus decrease the risk of barotrauma to uninjured lung tissue. In such a case, we may wish to consider asynchronous independent lung ventilation with one of these new modes.

Measurement of Central Venous Pressure via the Femoral Route in Abdominal Compartment Syndrome

Introduction: Femoral vein catheterization provides an alternative route of access to central veins, is technically easy and relatively safe. There is good evidence of a general agreement between intrathoracic central venous pressure (CVP) and CVP measured in the iliofemoral veins or inferior vena cava in critically ill patients. This agreement is not well documented when intra-abdominal pressure is raised.
Methods: Intra-abdominal and intrathoracic venous pressures were measured in two cases of abdominal compartment syndrome (ACS), who both had intrathoracic and femoral central venous catheters in place for clinical management. A PUBMED search was conducted to identify relevant studies or reports documenting the relationship between intrathoracic and intra-abdominal CVP, with special reference to conditions of raised intraabdominal pressure or ACS.
Results: There are several sources of data confirming that under conditions of normal to moderately raised intra-abdominal pressure there is a close relationship between intrathoracic CVP and intraabdominal CVP in critically ill patients, even during mechanical ventilation. There is little data documenting the relationship under conditions of raised intra-abdominal pressure, and no data under conditions of ACS. The two cases reported suggest that the normal close relationship is completely lost under conditions of ACS.
Conclusions: Vascular catheters inserted via the femoral route can be routinely used to measure CVP in most critically ill patients with normal or moderately raised intra-abdominal pressure (<15-20 mmHg), but should not be used to measure CVP in patients with abdominal compartment syndrome.

Diltiazem versus Amiodarone for New-Onset Atrial Arrhythmias in Non-Cardiac Post Surgical Patients: A Cohort Study

Objective: To evaluate safety and efficacy of diltiazem versus amiodarone for conversion of atrial arrhythmias in non-cardiac post-surgical critically ill patients.
Design: A cohort study of non-cardiac post surgical patients admitted to the surgical intensive care unit with new-onset atrial tachyarrhythmias which were treated by protocol. In the first year patients were treated with diltiazem, and amiodarone was used in
the second year.
Setting: Thirty-eight bed surgical intensive care unit in a university medical center. Patients and participants: Sixty-one patients were treated for new-onset atrial tachyarrhythmias: 31
received diltiazem and 30 received amiodarone.
Interventions: Diltiazem loading dose 0.25 mg/kg and continuous infusion or amiodarone 150 mg loading dose and continuous infusion.
Measurements and results: Both groups had comparable demographics. Neither 24-hour conversion rates (diltiazem 87.1%, amiodarone
86.7%, p =0.96) nor mean times (±Standard Deviation) to conversion were statistically different (diltiazem 6.9±6.3 hours versus amiodarone 5.0±4.2 hours, p =0.52). Three patients developed hypotension (diltiazem 1, amiodarone 2, p =0.57).
Conclusions: Amiodarone and diltiazem led to no differences for treating atrial tachyarrhythmias in non-cardiac surgical patients based on safety and efficacy. Randomized controlled studies are
needed to compare diltiazem versus amiodarone for conversion of postoperative atrial fibrillation.

Fat Embolism Syndrome

The classical syndrome of fat embolism is characterized by the triad of respiratory failure, neurologic dysfunction and the presence of a petechial rash. Fat embolism syndrome (FES) occurs most commonly following orthopedic trauma, particularly fractures of the pelvis or long bones, however non-traumatic fat embolism has also been known to occur on rare occasions. Because no definitive consensus on diagnostic criteria exist, the accurate assessment of incidence, comparative research and outcome assessment is difficult. A reasonable estimate of incidence in patients after long bone or pelvic fractures appears to be about 3-5%. The FES therefore remains an important cause of morbidity and mortality and warrants further investigation and research to allow proper recognition as well as the development of preventive and therapeutic strategies. Early fracture fixation is likely to reduce the incidence of fat embolism syndrome and pulmonary complications; however the best fixation technique remains controversial.
The use of prophylactic corticosteroids may be considered to reduce the incidence of FES and in selected high-risk trauma patients but effects on outcome are not proved. New reaming and venting techniques have potential to reduce the incidence of FES during arthroplasty. Unfortunately, no specific therapies have been proven to be of benefit in FES and treatment remains supportive with priority being given to the maintenance of adequate oxygenation.

Information Exchange in Critical Care for a Better Future

In the year 2008, knowledge and technology develop continually in every field of our lives, and, with no exception, in critical care medicine as well. This continuous growth is implicit in our daily activities. We could not imagine our lives today without it. Nowadays, as health care professionals, we surely do not want a fever to last for one week before we can make a diagnosis of typhoid fever for our patients. We can use some simple tests instead and institute prompt therapy.
We believe that these rapid developments in the acute care medicine fi elds motivated Dr. Iqbal Mustafa 11 years ago to found this Critical Care and Shock Journal; a Journal that despite many other similar journals has persisted and evolved. It was Dr. Mustafa who realized that the development of international communications would only give benefit to mankind if it could be spread out, especially within the scientific community. Dr. Mustafa’s knowledge and ability in critical care medicine as well as his willingness to promote Indonesia and other Asia Pacific countries in that field, and good relationship with his colleagues worldwide have made this Journal publication easier.
Against this backdrop many foremost authorities in critical care medicine submitted their articles to be published in Critical Care and Shock. A few years later this Journal was adopted as one of the official journals of the Asia Pacific Association of Critical
Care Medicine (formerly known as the Western Pacific Association of Critical Care Medicine). Uniquely, as we previously wrote in Critical Care and Shock Vol. 7 No. 3, the authors from many countries were brought together in a yearly medical conference in Bali, which we all know as the International Symposium on Critical
Care and Emergency Medicine.
The year 2008 marks the fifteenth anniversary of this conference; we still wish that our goal to academic and clinical progress will be achieved through the exchange of information in this international, multidisciplinary conference. We would like to take this opportunity to thank all the speakers and participants who are
willing to contribute their invaluable knowledge and time in this prestigious event. Congratulations to the Organizing and Scientific Committees on their tireless efforts to organize this meeting yearly.