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.


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Year in Review 2006: The Critically Ill Patient in the Pediatric ICU

The care of the critically ill patient in the pediatric intensive care unit (PICU) has remained an important topic for those health care providers dealing with children. The purpose of this article is to introduce to the reader a summary of selected papers which we consider relevant to the care of the pediatric critically ill patient and that were published in the year 2006. These articles were selected on the basis of application to the PICU, overall importance and are not to be solely considered authoritative in their field. There are many other useful articles. We have attempted to choose those articles with scientific merit and rigorous methodology that we believe present interesting data in the field.


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Effectiveness Study of rHuEPO in the ICU

Purpose: To evaluate the clinical outcomes and resource use in ICU patients receiving rHuEPO in a naturalistic setting. Methods: A retrospective, case-matched (1:2 ratio) study compared patients receiving rHuEPO to a control group. Patients admitted between January 2000 and July 2002 with an ICU length of stay (LOS) ¡Ý3 days were identifi ed by an electronic data repository. Patients, who received rHuEPO prior to ICU admission, had chronic renal failure or were <18 years of age were excluded. Patients were matched by age (¡À5 years), sex, admission year and ICU type. Collected data included patient demographics, admission date, ICU and hospital mortality and LOS, mechanical ventilation days, serum creatinine concentration, hemoglobin concentration, number of blood transfusions, and ICU resource use. Results: rHuEPO-treated patients (n=391) were matched with 782 controls. Patients receiving rHuEPO had higher Simplifi ed Acute Physiology Scores II (46.2 vs 38.8; p <0.001) and received signifi cantly more blood transfusions than control patients (19 vs 6; p <0.001). After adjusting for severity of illness in a linear regression model, rHuEPO was signifi cantly associated with increased blood transfusions and higher mortality risk. Patients receiving rHuEPO had signifi cantly longer hospital and ICU LOS, mechanical ventilation duration, and higher hospital and ICU mortality rate and hospital resource use (p <0.001). Conclusions: In this real-world retrospective analysis, critically ill patients treated with rHuEPO did not experience clinical benefi ts; however, patients were sicker and received rHuEPO late in their ICU stay. Monitoring prescribing patterns and patient selection of rHuEPO treatment in critically ill patients in clinical practice is recommended to optimize rHuEPO use and outcomes.


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Critical Care of the Liver Transplant ICU Patients: A Pittsburgh “Point of View”

The purpose of this review is to summarize the advances in critical care management of the liver transplant ICU patients (patients with end stage liver disease, before and after orthotopic liver transplant). The review is based on search of Medline literature, with a focus on liver failure patients and critical care issues around liver transplantation. Starzl Transplantation Institute at the University of Pittsburgh Medical Center is one of the global leaders in the treatment of end stage liver disease (ESLD). This review is in part based on our work in the 28-bed liver transplant ICU at Montefi ore Hospital, University of Pittsburgh Medical Center, in Pittsburgh, PA. Over the past few years, our understanding of the several important pathophysiologic markers of end stage liver disease has been signifi cantly improved. For example, we do now much better understand hyperdynamic circulation of liver failure, hepatorenal syndrome and its consequences, the role of TIPSS (transjugular intrahepatic portosystemic shunt) and adrenal insuffi ciency in liver failure patients. The management and prophylaxis of variceal bleeding and subacute bacterial peritonitis (SBP), has been successfully standardized. These and other advances in understanding of ESLD pathophysiology and its clinical results, have certainly contributed to more promising outcomes in the ICU management of these complex patients.


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Abdominal Sarcoidosis

Abdominal sarcoidosis is an uncommon form of sarcoidosis. The clinical presentation of esophageal, gastric, small bowel, colon, appendicular, spleen, pancreas, and abdominal aortic sarcoidosis are discussed in this review. The differential diagnosis of abdominal sarcoidosis is extensive. Other granulomatous diseases including tuberculosis, fungal infections, parasitic diseases, infl ammatory bowel disease, and Whipple’s disease should be excluded before making the diagnosis of gastrointestinal sarcoidosis. Corticosteroid therapy is the mainstay of medical therapy in abdominal sarcoidosis. Second line agents such as methotrexate are also discussed. Surgical intervention may be necessary in patients with bowel obstruction, perforation, or massive hemorrhage. The authors also provide their experience regarding preoperative pulmonary evaluation of patients with pulmonary sarcoidosis undergoing surgery.


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Severe Complications of Herbal Medicines

Herbal medicines are being increasingly used for treatment of variety of disorders. Herbal medicines are generally thought to lack severe side effects. Despite of the general belief, herbal medicines are known to cause serious side effects and toxicities. On the other hand, physicians’ knowledge of herbal medicines and their potential toxicities are generally limited. Neurotoxicity, cardiac toxicity, pulmonary toxicity, hepatotoxicity, and nephrotoxicity are potential severe complications of herbal medicines.


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Sublingual Capnometry: A Non-invasive Measure of Microcirculatory Dysfunction in Sepsis

Sepsis is among the most common reason for admission to intensive care units throughout the world. Sepsis is characterized by a generalized microcirculatory injury, which results in tissue dysoxia. Tissue dysoxia is believed to be the causation of multiorgan dysfunction syndrome (MODS) which commonly complicates the course of sepsis. The expedient detection and correction of tissue dysoxia may limit the development of MODS. The standard oxygenation and hemodynamic variables (blood pressure, arterial oxygenation, cardiac output) which are monitored in critically ill patients are “upstream” markers and provide little information as to the adequacy of tissue oxygenation. Global “downstream” markers of tissue dysoxia such as mixed venous oxygen saturation and blood lactate are insensitive indicators of the extent of the microcirculatory injury in patients with sepsis. Sublingual/buccal mucosal PCO2 is a regional marker of microvascular perfusion and tissue dysoxia that holds great promise for the risk stratifi cation and endpoint of goal-directed resuscitation in patients with sepsis.


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Cardiopulmonary Emergencies in Sarcoidosis

Sarcoidosis is a systemic disease that commonly involves the lungs and the heart. Although rare, lifethreatening cardiopulmonary emergencies can occur. Acute respiratory failure, massive hemoptysis, and cardiac emergencies are described in sarcoidosis. These clinical manifestations can be the first clinical presentation of sarcoidosis. The subject of cardiopulmonary sarcoidosis is reviewed.


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Clevidipine: A Unique Agent for the Critical Care Practitioner

Clevidipine is a new third generation intravenous dihydropyridine calcium channel blocker. It is a specific arterial vasodilator developed for the acute reduction and control of arterial blood pressure in the perioperative period. This drug has an extremely short half life and is rapidly metabolized by tissue and plasma esterases. Clevidipine is a potent arterial vasodilator with very little or no effect of the myocardial contractility and venous capacitance and also minimal side effects. Clevidipine can also theoretically help to protect against organ reperfusion injury. Theoretically, this effect resides in the capacity of this agent to debilitate oxygen free radical-mediated toxicity, cell calcium overload and augment endothelial nitric oxide bioavailability through antioxidative actions. As a result it may diminish the severity of low flow myocardial ischemia and preserve the coronary endothelial function thereby reducing the infarct size. Due to all the characteristics of this parenteral agent it promises to be the drug of choice for the critical care practitioner for the strict control of blood pressure in different clinical scenarios.


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Cardiac troponin I elevation in subarachnoid hemorrhage: Should we worry?

Troponin I can be used as a marker not only for cardiac outcome in patients with SAH; but also as predictive for complications such as DCI, hypotension and pulmonary edema. More over it can be used as a prognostic factor in terms of functionality.


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Hyperglycemia after trauma: Physiologic and tolerable or a possible threat that needs to be corrected?

Admission hyperglycemia is associated with an increased morbidity and mortality in the critically ill trauma population studied by Sung and coworkers. There are a variety of mechanisms involved and attempts to control the glycemic index should become routine in the management of these patients.


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