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.


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Critical care pharmacotherapy: description of an innovative pediatric residency elective experience utilizing clinical pharmacy faculty as preceptor

Abstract
Objective: The objective of this brief report is to describe a pediatric pharmacotherapy curriculum pilot rotation experience for medical residents using a clinical pharmacy faculty preceptor. The goal of the experience was for the resident to gain additional training in drug use in critically ill children, as specific training in this area for medical residents may be inadequate.
Setting: The medical resident and clinical pharmacy faculty member rotated in a multi-disciplinary 18 bed Pediatric Intensive Care Unit (PICU). Patient-specific drug therapy plans were developed and discussed in depth along with various topic discussions covering common pediatric intensive care issues.
Conclusions: This pilot experience demonstrates the use of pediatric critical care pharmacotherapy education in an elective rotation. This experience has the potential to be significantly expanded to include more residents, a longer duration, and an examination of its impact on clinical knowledge. This is the first report of clinical pharmacy faculty acting as a preceptor in a pediatric rotation.


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Phenobarbital toxicity from a highly concentrated veterinary formulation: review and case report

Abstract
Introduction: Phenobarbital, a barbiturate traditionally used in the treatment of seizure disorders, is considered safe and effective when its serum concentration is maintained between 10 to 40 mcg/mL. Toxic levels can induce coma, respiratory failure or shock syndromes. Strategies to manage phenobarbital overdose are necessary due to its potential for abuse and serious adverse effects.
Case presentation: We present an acute case of intoxication from high-concentration veterinary acquired phenobarbital, complicated by ethanol abuse in a 47-year-old male. He presented to the hospital with an initial phenobarbital serum concentration of 124 mcg/mL. Patient was status-post motor vehicle accident and unresponsive with an initial Glasgow Coma Scale (GCS) score of 3. On day two of hospitalization, hemodialysis (HD) was initiated due to the patient’s persistent comatose state. The phenobarbital serum level declined from 112 mcg/mL to 62 mcg/mL and GCS score improved to 10 after one 4-hour session of HD. On hospital day three, a second HD accelerated the removal of phenobarbital from a serum concentration of 59 mcg/mL to 30 mcg/mL and resulted in a GCS score of 14. On hospital day six, the patient’s phenobarbital serum level measured 24 mcg/mL and neurological status significantly improved, prompting his hospital discharge.
Discussion: The history and pharmacokinetic properties of the barbiturate class are discussed, with an emphasis on phenobarbital. Modalities for management of phenobarbital toxicity are reviewed from the medical literature and compared to our case. Patient specific factors influencing the case are further discussed, leading to the decision for hemodialysis treatment.
Conclusion: In severe phenobarbital intoxication, hemodialysis is a safe and effective method of extracorporeal elimination.


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Invasive pulmonary aspergillosis in an immunocompetent host

Abstract
Invasive pulmonary aspergillosis (IPA) is a rare opportunistic mycosis with a usually fatal ending if misdiagnosed or untreated. Environmental exposure to species of the Aspergillus genus is almost never an issue for immunocompetent hosts and no disease will develop from it, however, when a patient’s immune system is impaired, the fungus will be able to invade the host’s system and the invasive mycosis will ensue. We report a patient with no important past medical history, chronic infections requiring prolonged antibiotic therapy or steroid dependent diseases, that presented to our facility to be treated for chronic sphenoid sinusitis secondary to Aspergillus fumigatus, and was later on found to have IPA.
Invasive pulmonary aspergillosis in an immunocompetent host


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Psychological ventilator dependence: A case report

Abstract
Weaning a patient off mechanical ventilation, especially when they have been dependent on it for a long time, can be a difficult task. Many physical and psychological factors contribute towards dependence on the ventilator. We report a case of a 28-year-old female patient that developed anxiety and a psychological dependence on the ventilator thereby making weaning off difficult. Timely psychiatric intervention resulted in successful weaning off the ventilator.

Psychological ventilator dependence: A case report


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Fatal hyperthermia following acute cervical spinal cord and head injury

Abstract
A 22-year-old man with schizophrenia presented with cervical spine damage caused by a crush injury. Upon admission, we performed anterior cervical decompression and fusion of vertebrae C5, C6, and C7. The patient experienced treatment-resistant hyperthermia with a body temperature >40°C. He did not show any evidence of drug use that might induce malignant hyperthermia. He also did not exhibit symptoms of common forms of malignant hyperthermia, including rigidity of the arms and legs, myoglobin in the urine, or anesthesia toxicity. The patient’s condition did not improve, and he died of hypotension 15 hours after admission. We speculate that the cause of death was malignant hyperthermia due to acute cervical spinal cord injury. The physiological origin of hyperthermia in this patient is unknown. Recognition of hyperthermia symptoms and risk factors in patients with cervical spinal cord injury may enable early intervention to prevent progression to fatal fever.
Fatal hyperthermia following acute cervical spinal cord and head injury


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Pseudo hydropneumothorax: The importance of history taking in critical care

Abstract
History taking is an important part of the diagnosis of every patient. With the advancement of technology and limited time, this art seems forgotten. We hereby present an image of pseudo hydropneumothorax, which can have wide differential diagnoses. Proper history taking in critical care setting can help in early diagnosis; decrease length of hospital stay and diagnostic costs.
Pseudo hydropneumothorax- The importance of history taking in critical care


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Therapeutic hypothermia in cardiogenic shock post cardiac arrest supported with left ventricular assist device (Impella 5.0 LP)

Abstract
We report a 48-year-old male suffering from cardiac arrest secondary to ventricular fibrillation. After the return of spontaneous circulation, the therapeutic hypothermia protocol was initiated (33 oC). However, given the persistent cardiogenic shock, the hypothermia protocol was interrupted. A decision was made to insert an Impella 5.0 LP for hemodynamic support via the left femoral artery. After stabilization, cooling was resumed (Arctic sun) for 24 hours, which was well tolerated hemodynamically. After 5 days of support, patient was weaned off all vasopressors. The Impella was removed, after which the patient was awoken and extubated with complete neurological recovery.


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Toxic epidermal necrolysis

The case
A 36-year-old lady presented with history of intermittent high-grade fever for the last 5 days. There was also history of yellowish discolouration of skin and sclera for the last 3 days, generalized body swelling and hemorrhagic rashes all over the body for the last 1 day. On further probing it was found that she had received an unknown intravenous antibiotic 2 days back from a local physician. She was intubated and mechanically ventilated as she became hypoxic due to airway edema. Other supportive measures were administered. The skin lesions initially presented as erythematous rashes, which over the next few days progressed, to urticarial plaques, bullae, followed by epidermal sloughing. A diagnosis of toxic epidermal necrolysis secondary to idiosyncratic drug reaction was made.
Toxic epidermal necrolysis


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Clinical improvement of multiple sclerosis after implementation of mild therapeutic hypothermia: A case report

Therapeutic hypothermia is the latest, revolutionary therapy, mostly used in intensive care units after out-of-hospital, and sometimes in-hospital, cardiac arrest due to its neuroprotective effect. This therapeutic intervention has also been used to improve neurological outcome after cerebrovascular accidents and other neurological catastrophes. Multiple sclerosis is one of the main diseases that cause neurological dysfunction in young adults due to its irreversible autonomic nervous system damage. Its main symptoms are tremors, sensory loss, weakness, ataxia and diplopia, and the progression of these end up disabling the patient permanently, sometimes even with the implementation of immunotherapy. We report a patient with a longstanding history of relapsing-remitting multiple sclerosis, with frequent attacks every 1-3 months, that underwent therapeutic hypothermia for 96 hours after in-hospital cardiac arrest; her neurological recovery was outstanding with no neurological deficits caused by the cardiac arrest, and surprisingly, when she was assessed months after the ischemic insult, it was found that she hadn't presented a relapse of multiple sclerosis since hypothermia was implemented.
Clinical improvement of multiple sclerosis after implementation of mild therapeutic hypothermia- A case report


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Uncommon presentations of choriocarcinoma

Choriocarcinoma is a rare disease in the young population. It uncommonly occurs after a normal full term pregnancy or in men. In the report, we presented two uncommon manifestations of choriocarcinoma. In the first case, a young woman developed choriocarcinoma metastasis after a normal full term pregnancy. She was treated with chemotherapy after the diagnosis and finally recovered. In the second case, a young man suffered from severe respiratory failure due to lung pathology and finally succumbed. The diagnosis of pulmonary choriocarcinoma could only be made after postmortem examination. Both cases illustrated atypical presentations of this malignant but curable disease.
Uncommon presentations of choriocarcinoma


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Posttraumatic cerebral infarction caused by hemodynamic shearing stress following hemorrhagic shock

Background: Posttraumatic cerebral infarction (PTCI) is very rare and its pathogenesis is not well defined. In the case presented here, hemorrhagic shock was strongly suspected to be associated with the development of PTCI. Therefore, we hypothesized that a powerful shearing stress affected the pathogenesis of vulnerable endothelium causing damage and resulting in PTCI. By elucidating these mechanisms, it may be possible to predict the occurrence of PTCI.

Case: An 80-year-old woman was transferred to the emergency room after a traffic accident where her car collided against a wall. Upon admission, it was confirmed that she had a low Glasgow Coma Score (GCS); however, neither hemorrhage nor infarction appeared on initial brain computed tomography (CT) scans. Additionally, she had hemorrhagic shock (blood pressure 88/52 mmHg) causing hemothorax with multiple rib fractures, as well as fractures in the left humerus and thighbone. The patient did not seem to be able to move the left half of her body because of pain, and still had a low GCS 12 h after admission. Hence, diffusion-weighted magnetic resonance imaging (MRI) was performed and revealed acute cerebral infarction in the right temporal lobe, and MR angiography demonstrated moderate stenosis of the horizontal portion of the right middle cerebral artery.

Conclusions: To our knowledge, sudden hypotension following hemorrhagic shock produced a strong shear stress, which induced platelet aggregation and lead to the development of a cerebral infarction in our case.


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Red blood cell fragmentation in acute respiratory distress syndrome following Candida dubliniensis pneumonia

Background: The mechanisms underlying red blood cell fragmentation in intensive care patients remain controversial. Candida dubliniensis infection is very rarely reported in the world, and which has primarily been restricted to patients with a weak­ened immune system, and there is limited clinical information about the virulence of C. dubliniensis for hemolytic activity.

Case: A 79-year-old man, who had recovered from acute respiratory distress syndrome (ARDS), pre­sented with severe sepsis and was transferred to the emergency room. The ratio of arterial oxygen partial pressure to the fraction of inspired oxygenation (FiO2) (P/F ratio) in the arterial blood gas analysis was low (77%). Immediate treatment included in­tubation and antibiotic infusion. However, after 17 days, his general condition deteriorated suddenly, and red blood cell fragmentation was observed upon hematological examination. We treated him with an infusion of 4 units of packed red blood cells and 4000 units of haptoglobin. However, 3 days later, the patient died of multiple-organ failure and dissemi­nated intravascular coagulation. Throughout the treatment period, C. dubliniensis pneumonia was detected twice in the examination of his sputum.

Conclusion: To our knowledge, this is the first case report of red blood cell fragmentation in ARDS fol­lowing C. dubliniensis pneumonia in Japan.

Red blood cell fragmentation in acute respiratory distress syndrome following Candida dubliniensis pneumonia


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Obstructive and severe septic shock following a ruptured mature mediastinal teratoma

Most mature mediastinal teratomas are not symptomatic until they rupture, and the mechanisms underlying their rupture remain controversial. A 40-year-old woman was admitted to the emergency room with increasing respiratory distress 24 h before admission. Her clinical examination results indicated systemic inflammatory response syndrome with jugular venous distension and bilateral pitting edema on her lower extremity. Thoracic computed tomography confirmed a well-defined anterior mediastinal giant heterogenous mass (22 x 17 x 15 cm) with fluid content that had the same density of pleural effusion. In the culture examination of both sputum and pleural effusion, Streptococcus pneumonia was detected. Surgical findings showed that the tumor contained sebaceous material with some hair and teeth. No teratoma-pulmonary fistula was detected, but oozing through the thin and fragile microscopic hole on the tumor wall was observed. We describe a rare case of a patient with both obstructive and severe septic shock following a ruptured teratoma.

Obstructive and severe septic shock following a ruptured mature mediastinal teratoma


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The migrating filter: Inferior vena cava to superior vena cava

A 75-year-old male with past medical history significant for severe chronic obstructive pulmonary disease was admitted to the intensive care unit with respiratory failure. He was found to have an acute deep venous thrombosis (DVT) and pulmonary embolus (PE). A permanent vena cava filter was deployed in the infrarenal inferior vena cava (IVC) at L3 level. A new cavogram confirmed the position of the filter in the inferior vena cava with tip of the filter at the level of the inflow of the left renal vein. Thirty minutes post placement, a routine chest x-ray revealed migration of the filter into the superior vena cava (Figure 1). Unsuccessful attempts were performed to remove the filter through the right internal jugular vein. The patient remained asymptomatic with stable vital signs, no pain or distress. It was elected to leave the migrated inferior vena cava filter in the superior vena cava.The migrating filter: Inferior vena cava to superior vena cava


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