Abdominal Compartment Syndrome: Case Report

Abdominal compartment syndrome (ACS) was originally described in trauma patients but is now known to occur in critically ill patients with a myriad of acute illnesses. Recent epidemiological studies have characterized the prevalence of intraabdominal hypertension (defi ned as an intraabdominal pressure [IAP] measured at the urinary bladder ¡Ý12 mmHg) between 2% and 33% [1,2] and the prevalence of ACS (defi ned as an IAP ¡Ý20 mmHg and associated organ system dysfunction) between 1% and 15%. These prevalences are similar to those quoted for sepsis and septic shock in trauma patients. Multiple studies have shown that massive fl uid resuscitation is the most common risk factor for ACS. The rise in intraabdominal pressure causes worsening of the capillary leak as a consequence of their primary illness, further decreasing vital organ perfusion and resulting in multiple organ dysfunction syndrome (MODS). Management includes hemodynamic support and abdominal decompression. Because of its protean manifestations, a high index of suspicion and frequent monitoring of the IAP in high-risk patients are the best preventive measures. Our case report shows the clinical features of a patient with ACS. The diagnosis was made early in the clinical source, yet appropriate management was deferred because of the uncertainty management in this critically ill patient.


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Perforated Pre-pyloric Ulcer Presenting with ST elevation on EKG

A 66 year-old female with long-standing history of rheumatoid arthritis on chronic steroid therapy, presented for routine kyphoplasty for a compression fracture of L1 and L2. Pre-operative electrocardiogram (EKG) revealed a normal sinus rhythm and no abnormalities. Her intra-operative course was complicated by severe hypotension. A post operative EKG revealed ST elevation in inferior and lateral leads with ST changes. She underwent a left heart catheterization that revealed normal coronary arteries and an ejection fraction of 70%. Because of concomitant abdominal discomfort, a computed tomography of abdomen was obtained and revealed a perforated viscus.


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Changing Medical ICU Environment and the Impact on Nosocomial Infection

Nosocomial infections (NIs) are one of the most common complications that occur in ICU patients and confer an increased relative risk of 3.5 for mortality. These types of infections may affect from 5 to 35% of patients who are admitted to ICU’s. Guidelines for Environmental Infection Control in Health-Care Facilities by the CDC, and the Healthcare Infection Control Practices Advisory Committee [HICPAC] guidelines have become standard. These recommendations have been tested in clinical trials of routine infection control surveillance. Also, a revised policy for antimicrobial therapy has proved a reduction in ICU acquired infections and mortality. An extensive review of the principles of infection control in the ICU has been published elsewhere.


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Massive Pericardial Effusion as a Presentation of Hypothyroidism

A 46 year-old Hispanic female with no past medical history, and no history of trauma presented to the hospital with complaints of shortness of breath worsening gradually over past two months. The patient’s physical examination was remarkable for diminished heart sounds at auscultation. A complete blood count chemistry was within normal limit. Collagen vascular profi le was negative. A chest x-ray revealed enlarged cardiac shilloute suggestive of pericardial effusion. A computed tomography (CT) scan of chest showed massive pericardial effusion. A 2D-echocardiogram confi rmed the massive pericardial effusion without any evidence of right ventricular collapse. Pericardiocentesis was performed draining 2800 ml of straw-colored fl uid. Cultures and cytology of the pericardial fl uid were negative. Additional blood workup revealed an elevated thyroid stimulating hormone level. The patient was started on thyroid replacement therapy and had an uneventful recovery.


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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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Hyperthyroidism Presenting as Acute Muscular Weakness

A 25 year-old Hispanic gentleman without any significant past medical history, presented to the emergency department with a 3 hour history of sudden onset shortness of breath and acute progressive quadriparesis. He specifically denied any recent viral infection, recent travel or illicit drug use. He worked as a "chef" in a local restaurant. On initial physical examination, the patient was a slender male in moderate-to-severe respiratory distress. Blood pressure was 160/90 mmHg, heart rate 150 bpm, respiratory rate 32/minute, temperature 38.5 oC and oxygen saturation by pulse oximetry of 98%. Bilateral exophthalmos was noted and homogenous enlargement of thyroid gland palpated without tenderness. Lung examination was unremarkable despite his respiratory distress. Heart sounds were normal and no murmurs were heard. Muscle strength in the lower extremities was 0/5, and upper extremities were 2/5. Sensory system examination and deep tendon reflexes appeared within normal limits. After administration of oxygen and the initiation of an intravenous line, an electrocardiogram was obtained revealing a second degree heart block, right bundle branch block and U waves. Initial laboratory data revealed severe hypokalemia with potassium level of 1.3 mmol/L and a phosphorous of 0.7mg/dL Thyroid stimulating hormone (TSH) level was <0.01 uIU, and T4 level was 23.8 ug/dl (normal: 4.5- 12.0). A subsequent electrocardiogram revealed no further U waves few hours after potassium supplementation. The patient was started on propylthiouracil (PTU) 100mg every eight hours, propranolol 40 mg three times per day for a confirmed diagnosis of thyrotoxicosis, and was discharged home 2 days later for out patient follow up. Hypokalemic periodic paralysis may be associated with hyperthyroidism (thyrotoxicosis-periodic paralysis), especially among Asian men. The nature of relationship between hyperthyroidism and periodic paralysis is not well established, but a mutation in a potassium channel gene (R83H-KCNE3) has been identified in one man with both disorders.


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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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Berlin Questionnaire and Portable Monitoring Device for Diagnosing Obstructive Sleep Apnea: A Preliminary Study in Jakarta, Indo

Study objective: to evaluate patients who came with the history of snoring with Berlin Questionnaire and sleep study using portable monitoring device. Setting: Mitra International Hospital, Jakarta, Indonesia. Material and methods: This was a preliminary study in 15 patients who came to the Respiratory Clinic with the history of snoring and suspicion of having obstructive sleep apnea (OSA). They were intended to undergo a sleep study using a portable device (PM). All patients were screened with Berlin Questionnaire and continued with application of portable monitoring device for one night stay at the hospital. Parameters recorded during examination were body mass index (BMI), apnea/hypopnea index (AHI), oxygen saturation, oxygen desaturation during sleep and lowest oxygen desaturation during sleep. Results: There were 14 (93.3%) male and only 1 female (6.7%) joined the study; the mean age was 48.93 year old, with age ranged between 16-74 year old. Only 2 patients with BMI 18-23 and 13 others had BMI >23. Three patients were not assessed by Berlin Questionnaire, 1 patient was disconnected from oxygen accidentally during sleep. From 12 patients screened with Berlin Questionnaire, 9 patients (75%) had high risk and 3 patients (25%) had low risk. Based on AHI, there were 4 patients with AHI < 5, 3 patients with mild OSA (AHI 5-15), 3 patients with moderate OSA (AHI 15- 30), and 5 patients had severe OSA (AHI >30). Oxygen saturation recorded by pulse oxymeter (SpO2) ranged between 81.6% to 98.0%, while the lowest SpO2 during sleep ranged between 68.0% to 89.1%. Oxygen desaturation (OD) ranged between 4.40% to 9.40%. Only 4 patients (2 moderate OSA, 2 severe OSA) can be followed of using continuous positive airway pressure (CPAP) machine after the test. There was improvement in patient using CPAP. In patients with severe OSA, AHI improved to 5-15, while in moderate OSA AHI was improved to <5. Conclusion: Berlin Questionnaire is quite reliable to determine which patient need further evaluation of OSA and portable monitoring device may be used for diagnosing sleep apnea since in 4 patients with moderate (AHI 15-30) and severe OSA (AHI >30) were all improved with CPAP. Based on this preliminary study, portable monitoring device can be used in the situation where no sleep laboratory available or in patient refused to be assessed with attended full polysomnography.


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Undetected Atrial Myxoma Presenting as Severe Dyspnea

Myxomas are the most common type of primary cardiac tumors, comprising 30-50% of the total in most pathological series. The incidence of atrial myxomas ranges between 0.5 and 1 per million of population/year.


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Percutaneous Common Carotid Artery Access for Stenting of a Critical Left Internal Carotid Artery Stenosis in a Nonagenarian: A

Purpose. To describe the successful endovascular treatment using direct carotid artery access in a high risk elderly patient with symptomatic internal carotid artery stenosis. Case Report. A 98 year-old man who was independent and lived alone was admitted to our hospital for symptoms of progressive weakness, associated with disorientation and difficulty with speech. Duplex carotid ultrasound was performed which revealed a totally occluded right internal carotid artery and high grade stenosis of the left internal carotid artery. Because of his advanced age he was deemed to be at high surgical risk for a standard endarterectomy, thus he was referred for carotid artery stenting.Using the femoral artery approach, multiple guiding catheters and sheaths were advanced to the left common carotid artery. Adequate support for intervention could not be obtained. The procedure was aborted and the patient was referred for carotid endarterectomy. However, due to his advanced age, he felt that surgery was too high risk thus he chose an alternative attempt to endovascular carotid stenting.Therefore, he was brought back to the catheterization laboratory two days later for direct carotid access. Carotid artery stenting was accomplished with a 6F sheath, a cerebral protection device and a Nitinol stent all percutaneously via the left common carotid artery. The patient was discharged the following day without complications. At 3-month follow-up, the patient is functional and independent without recurrence of symptoms. Conclusion. Direct carotid access can be successfully accomplished in patients if the femoral artery approach is anatomically prohibitive. In those of advanced age or other high risks for surgery, direct carotid access can be considered an option for revascularization.


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Predictor of Mortality and Rehospitalization of Acute Decompensated Heart Failure at Six Months Follow Up

Objective. To look for predictors of mortality and rehospitalization, we conducted a prospective study using fifty variables from history, physical examination, ECG, CXR, Echocardiography and blood test (N Terminal proBNP, hsCRP, and lactate level) that suspected as predictors in heart failure Design. Blinded prospective cohort study Setting. Emergency room of Harapan Kita National Heart Center, Jakarta-Indonesia as entry site, with ICCU, wards, and OPD for evaluation. Patients population for study. All consecutive patients with acute decompensated heart failure class III-IV that were hospitalized. Exclusion criteria were other concomitant severe diseases. Measurements and result. Of 97 patients enrolled, variables were measured using standard protocols. During follow up period of six months, 11 (11.3%) patients died of cardiac origin and 29 (29.9%) rehospitalized. Logistic regression analysis revealed BMI >30 kg/m2 with edema had OR 6.6 (95% CI: 1.33- 32.72, p=0,021), acute lung edema had OR 3,65 (CI 0,99-13,35, p=0,037), NYHA class IV had OR 5,42 (CI 95% : 1,11-26,59, p=0,037), left ventricle wall thickness >11 mm had OR 0,79 (CI 95 %: 0,63-1,00, p= 0,05), using beta-blocker had OR 0,09 ( CI 95%: 0,01- 0,74, p= 0,025), hemoglobin <12 g/dL had OR 4,53 (CI 95%: 1,24-16,56, p= 0,022), sodium <130 mmol/dL had OR 3,78( CI 95%: 1,02-14,03,p=0,047), NT proBNP >17,860 pg/mL on admission had OR 9,02 (CI 95%: 2.30-35.30, p=0,02) or NT proBNP > 8,499 pg/dL at discharge had OR 13,2 (CI 95%: 1,32-132,01, p=0,028) and served as predictors of mortality respectively. Using Cox Proportional Hazards and Kaplan Meier survival analysis and log rank test it were found that NT proBNP level >17.860 pg/ml on admission had a HR of 7.15 (95%CI 2.08-24.56, p=002) for mortality, while NT proBNP level >8.499 at discharged showed a HR of 9.55 (95%CI 1.06-85.77, p=0.044) for mortality. A decrease >35% of NT proBNP had a HR 0.13 (95%CI 0.02-1.19, p=0.071) for mortality, 0.38 (95%CI 0.14-1.00, p=0.049) for rehospitalization, and 0.42 (95%CI 0.12-0.76, p=0.010) for both. NT proBNP on admission >17.860 pg/dL together with EF <20 %, BMI >30 kg/m2 with edema and NYHA class IV were the most accurate predictor with AUC =0,94 (p=0.0001). Conclusion. Non decreased NT proBNP > 35 % during hospitalization was the predictor of mortality and rehospitalization. NT proBNP > 17,860 pg/mL at entry, NT proBNP > 8,499 pg/mL at discharged, NYHA class IV, BMI >30 kg/m2 with edema, EF <20%, acute pulmonary edema, Hb <12 g/dL, Na <130 mmol/ dL and not using beta-blocker were found as predictors for mortality of heart failure.


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Multiple Shotgun Pellet Embolization to the Pulmonary Artery

Pellet embolization to the pulmonary artery from a shotgun injury is a rare event. Our current experience with this entity is described. We reviewed the literature of Bullet Embolization with emphasis on management. We believe that shotgun pellet pulmonary artery embolism should be regarded as a separate entity from bullet embolism. The mechanism of injury and its sequelae, leading to complication is very much subtle compared to bullet embolism per se. After entry into the venous system, smaller sized pellets can easily lodge into the distal segments of pulmonary artery but tend to have less deleterious effect as compared to bigger sized bullet. We therefore recommend non-surgical management of pellet pulmonary embolism with clinical follow up to determine emergence of complications.


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Hypothyroidism Induced Cardiac Tamponade in Intensive Care Unit—A Rare Presentation

Hypothyroidism is common disease with multisystem involvement. Pericardial tamponade secondary to hypothyroidism is extremely rare. In current paper we describe a case of middle age Hispanic man presenting with pericardial tamponade due to severe hypothyroidism, and discuss the relevant literature.


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