Angiokeratomas in the Intensive Care Unit

Case presentation
A 35-year-old Latin-American gentleman male with a history of Fabry’s disease presented for continuation of recombinant ceramide trihexosidase infusion therapy. Because of a prior allergic reaction, the patient was admitted to the intensive care unit during his infusion. He was first diagnosed in 2000, by genetic testing due to a strong male family history of the disease and had been receiving infusions every two weeks since 2007. Alphagalactosidase A level was 0.001%. He reported a history of anhidrosis, blurry vision, fatigue, headache, acroparesthesia, vertigo and diffuse angiokeratomas. These angiokeratomas (Figures 1 and 2), had a “bathing-trunk” distribution, but were also present in the inner labial mucosa as well as palms of the hands.

Angiokeratomas in the Intensive Care Unit


An unusual area for calciphylaxis in a critically ill patient

Case presentation
A 53-year-old gentleman with history of end-stage renal disease (ESRD) secondary to hypertension followed by a gunshot wound to the left flank region, presented to the hospital with complaints of fever, chills and severe pain in the groin area. In the emergency department he was found to have a blood pressure (BP) of 70/40 mmHg, heart rate (HR) of 130/min, respiratory rate (RR) 22/min and a temperature of 38 °C. The rest of his physical examination was significant for a toxic-appearing gentleman in mild distress. Lungs were clear to auscultation and percussion. His heart sounds were distant, but had normal characteristics and no murmurs were auscultated.

An unusual area for calciphylaxis in a critically ill patient


Less oxygen for cardiac arrest patients is better

Abstract
There is no doubt that oxygen is necessary to sustain life. We have been using oxygen since the late 19th century with its use taken for granted. However, administering oxygen above atmospheric concentration should be prescribed as a medication accounting for potential adverse effects. Exposure to high dose of supplemental oxygen has been associated with pulmonary and cardiac toxicity. Moreover, an increase in oxygen radicals was found to be involved in cell death after cerebral ischemia. Cardiac arrest, both in and out of hospital, is a major cause of death worldwide. Brain injury, myocardial dysfunction and multi-organ failure comprise post cardiac arrest syndrome and reactive oxygen species play a central role in initiating and exacerbating the damage. Studies in animal models of cardiac arrest have found that the administration of 100% oxygen following return of spontaneous circulation (ROSC) may cause neurological harm in comparison to low-dose oxygen. Hyperoxia (PaO2>300 mmHg) is not uncommon among patients after ROSC however, since oxygen therapy is considered integral during resuscitation and post resuscitation care there are no large randomized controlled trials in humans. The existing data from retrospective studies demonstrates correlation between hyperoxia after ROSC and increased in-hospital mortality as well as poor neurological outcome. Hence, we should regard oxygen therapy carefully and use the lowest fraction of inspired oxygen to ensure adequate arterial saturation while avoiding hyperoxia and hypoxia.

Less oxygen for cardiac arrest patients is better


Procalcitonin levels as predictors of neurological outcome in patients with cardiac arrest treated with mild therapeutic hypothermia: a retrospective study

Abstract
Background/objective: Procalcitonin (PCT) is a biomarker widely used to identify bacterial infections, diagnostic tool for sepsis, monitor response to antibacterial therapy, and to assess general inflammatory response. Our goal was to assess the relationship between PCT levels and neurological outcome in patients who suffered cardiac arrest (CA), and underwent mild therapeutic hypothermia (TH) at 32 °C for a period of 24 hours.
Methods: 55 patients with CA who underwent mild TH were enrolled. Three PCT measurements were obtained (PCT-1 prior to TH, PCT-2 during TH and PCT-3 after TH). Neurological outcome was evaluated with the Cerebral Performance Category (CPC) score. Descriptive statistics and analysis of variance (t-test and ANOVA) were used.
Results: From our cohort, 58.6% had a CPC≥3, 29.3% CPC 1 and 6.9% CPC 2. Mean PCT levels for each group were: PCT CPC 1 2.43 (+3.940 SD), PCT CPC 2 5.49 (+1.516 SD), and PCT CPC>3 4.077 (+8.805 SD). ANOVA between PCT-1 and CPC scores was F=0.354 (p=0.697), PCT-2 and CPC scores F=0.71 (p=0.501), and PCT-3 and CPC scores F=0.710 (p=0.496).
Conclusion: Our small sample size led to a significant difference of distribution. Further prospective studies with bigger samples are needed in order to obtain better results when assessing the significance of PCT levels as predictors of neurological outcome after CA and TH.

Procalcitonin levels as predictors of neurological outcome in patients with cardiac arrest treated with mild therapeutic hypothermia- a retrospective study