Biloma: multiple organ failure after laparoscopic cholecystec-tomy

Abstract
Multiple organ failure and septic shock due to a biloma secondary to laparoscopic cholecystectomy (LC) is an infrequent and rare complication of this procedure. We present the case of a patient that presented to the emergency department with septic shock and multiple organ failure after undergoing LC two weeks prior to admission. An abdominal computerized tomography (CT) depicted a large biloma. The patient underwent ultrasound guided percutaneous drainage, with follow up by an endoscopic retrograde cholangiopancreatography and a laparotomy.


Incidence of circulatory shock after spontaneous intracerebral hemorrhage and impact on case-fatality: a multi-center cohort study

Abstract
Objective: The epidemiology of circulatory shock after spontaneous intracerebral hemorrhage (ICH) is unknown. We sought to determine its incidence, risk factors, and effect on case-fatality.
Design: Retrospective multi-center cohort study.
Setting: 83 ICUs in the United States from 2003-2008.
Patients: Subjects with ICH >17 years of age admitted to an ICU. Shock was defined as sustained systolic blood pressure <90 mmHg for ≥1 hour despite vasopressors. Interventions: None. Measurements and results: A total of 4,192 ICH patients. Median age was 67 yrs (IQR 54-77), 2221 (53%) were male, and 3030 (75%) were white. Median APACHE-II score was 15 (interquartile-range [IQR] 11-21) and Glasgow Coma Scale (GCS) was 11 (IQR 6-14). Incidence of shock after ICH was 5% (212/4192). Case-fatality was 72% among shock vs. 30% without shock (p<0.0001). In multi-variable analysis the following were associated with increased case-fatality: age (OR 1.01, 95%CI:1.01-1.02), DNR status (OR 1.8, 95%CI:1.3-2.6), GCS<8 (OR 11.4, 95%CI:8.4-15.4), GCS 8-12 (OR 2.1, 95%CI:1.5-2.9), mechanical ventilation (OR 2.0, 95%CI:1.6-2.5), organ dysfunction (OR 1.7, 95%CI:1.4-2.0), spontaneous hypothermia (OR 7.3, 95%CI:2.8-19.3), APACHE ≥15 (OR 2.9, 95%CI:2.2-3.7), and shock (OR 1.9, 95%CI:1.2-3.0). EVD placement was associated with survival (OR 0.8, 95%CI:0.6-0.9). Conclusion: Circulatory shock after ICH is rare and associated with increased case-fatality. Incidence of circulatory shock after spontaneous intracerebral hemorrhage and impact on case-fatality- a multi-center cohort study


Hyperoxia is associated with higher case-fatality in ventilated patients with intra-cerebral hemorrhage

Abstract
Objectives: To test the hypothesis that hyperoxia was associated with higher in-hospital case-fatality in ventilated patients with ICH admitted to the Intensive Care Unit (ICU).
Methods: Admissions of ventilated ICH patients within 24 hours of admission to the ICU at 77 United States hospitals between 2003-2008. Patients were divided into three exposure groups: hyperoxia (PaO2≥300 mmHg), hypoxia (PaO2<60 mmHg or PaO2/FiO2 ratio ≤300), and normoxia, not defined as hyperoxia or hypoxia. The primary outcome was in-hospital case-fatality. Results: 1,388 ventilated ICH patients. Mean age 63 years (SD 15), 47% (653/1388) female, and median GCS 5 (IQR 3-8). The overall case-fatality was 59% (812/1388). Upon admission to the ICU, 36% (492/1388) were normoxic, 47% (641/1388) were hypoxic, and 17% (238/1388) were hyperoxic on ABGt1. ABGt2 was accomplished in 780 patients, of whom 46% (352/780) were normoxic, 45% (352/780) were hypoxic, and 9% (67/780) were hyperoxic. Of the initially admitted hyperoxic patients, 15% (21/138) remained hyperoxic and had a case-fatality of 82% (18/21) as compared to 49% (67/138) who became normoxic and had a case-fatality of 46% (32/67) (crude OR 6.6, 95%CI:1.8-25, χ2=9.4, p=0.002). In a multivariable analysis controlling for other predictors of poor outcome and hospital specific characteristics, and a propensity-score, failure to correct hyperoxia was associated with higher case-fatality (adjusted OR 2.5, 95%CI:1.1-6.1, p=0.04). Conclusion: In ventilated ICH patients, failure to normalize hyperoxia was associated with higher case-fatality. These data underscore the need for studies of controlled re-oxygenation in ventilated ICH patients. Hyperoxia is associated with higher case-fatality in ventilated patients with intra-cerebral hemorrhage


Nitroglycerin, stroke and hypertension: a word of caution

The ENOS trial investigators performed a large multicenter trial investigating the role of a daily nitroglycerine patch in hypertensive patients with an acute stroke. (1) The reasoning for the choice of this agent in patients with an acute stroke is puzzling. Nitroglycerine is a potent veno-dilator and only in high doses does this drug reduce arterial tone. (2) This agent reduces blood pressure predominantly by reducing venous return and cardiac output. (2) It would appear counter-institutive to use a drug which reduces cardiac output, and therefore organ blood flow, in patients who have suffered an acute ischemic stroke. Rashid and...
Nitroglycerin, stroke and hypertension- a word of caution


Severe dermatological presentation of graft vs host disease

A 67-year-old Caucasian female presented to the Surgical Intensive Care Unit (SICU) with an extensive dermatological manifestation of Graft vs. Host Disease (GVHD). She was transferred from the Bone Marrow Transplant (BMT) floor to the SICU for expertise in wound management and burn care. The patient had a past medical history of diffuse B-cell lymphoma for which she had undergone chemotherapy, achieving remission. Unfortunately, a year later she experienced recurrence of her cancer and underwent an autologous stem cell transplant. She subsequently developed an expanding skin rash, which upon biopsy revealed GVHD. Her disease progressed despite treatment with standard outpatient...
Severe dermatological presentation of graft vs host disease