Portal venous gas entrapment secondary to mesenteric ischemia after withdrawal of intra-aortic balloon pump: A case report with a rare ultrasound image

Abstract

After coronary artery bypass graft (CABG), mesenteric ischemia is a rare but dreadful complication with high mortality rates. Prophylactic use of intra-aortic balloon pump (IABP) is a common practice in patients with severe coronary artery disease awaiting CABG. During withdrawal of the IABP, there is a risk of dislodging atheromatous debris, thus causing peripheral and mesenteric emboli, which can cause mesenteric ischemia. Here we are reporting on a case where a patient had an IABP installed after a ST-elevation myocardial infarction (STEMI) while awaiting CABG surgery. After surgery, the IABP was eventually removed, but rising lactates led to further investigation. The abdominal computerized tomography (CT) scan showed extensive bowel pneumatosis and portal venous gas entrapment. The patient died despite aggressive non-surgical management. This case shows a fatal complication of IABP use in a high-risk patient undergoing CABG surgery and highlights the need for careful aorta and peripheral vascular assessment prior to IABP device insertion to avoid intestinal compromise.


Authors:

A fatal case of cerebral oedema and myocarditis associated with secondary dengue infection

Abstract

Background: Secondary dengue infection (SDI), in the form of two sequential infections by different serotypes, will lead to severe dengue. Concomitant organ failure in particular cardiovascular (CVS) and central nervous system (CNS) carries further rise in the mortality rate.

Case report: We report a confirmed SDI in a 27-year-old man who presented with hypovolemic shock due to persistent vomiting and diarrhoea. He was stabilized after fluid resuscitation. However, he developed sudden onset of seizure and myocarditis with unstable haemodynamic thereafter. After stabilization, his gag and cough reflexes were absent with dilated pupils. Imaging of the brain showed extensive cerebral oedema with poor flow beyond the internal carotid arteries and its branches above circle of Willis. He remained comatose with subsequent complications of diabetes insipidus, secondary bacterial infection, and acute kidney injury. He passed away after 19 days of admission.

Discussion: There is a higher risk of severe dengue with SDI as it is associated with antibodydependent enhancement (ADE) mechanism. The pre-existing dengue antibodies enhance virus replication by activating memory T-cells causing surges in inflammatory cytokines. The increased capillary permeability with massive vascular leak most likely led to the extensive cerebral oedema in this patient. The concomitant cardiovascular failure also led to his irreversible outcome.

Conclusion: Severe cardiovascular and neurological manifestations can occur in SDI with resultant in the fatality. Therefore, early recognition of risk factors in the early phase of severe dengue is important to prevent the irreversible outcome.


Authors:

“Complete” loss of brain stem reflexes - not always brain death! Beware of amitriptyline overdose

Abstract

We present a case of “complete” loss of brain stem reflexes following amitriptyline overdose, which mimicked brain death. This case highlights the complexities associated with clinical brain death determination and calls for close attention to details.

Based on previously published case reports, we analyse the relationship with the amitriptyline dose, blood level and timing of neurological recovery. Ours is the fourth case report in literature demonstrating “complete” loss of brain stem reflexes following amitriptyline overdose.

The amount of amitriptyline ingested in these cases (including our case report) ranged from 500 mg to 9 g; the blood concentrations ranged from 1.35 microgram/ml to 3.43 microgram/ml. The neurological recovery seems to start by day two to four with complete neurological recovery by day five to seven.


Authors:

Levamisole tainted cocaine induced vasculitis

Abstract

Levamisole has been implicated in the vasculitis and aganulocytosis. It has been pulled from the United States market for human use. Due to its euphoric and bulking properties, it has been used as a bulking agent in cocaine.
We hereby present a case of a 56-year-old Hispanic male, who developed vasculitis due to cocaine use adulterated with levamisole.


Authors:

Is my patient really brain dead?

Abstract
The diagnosis of brain death can be fraught with multiple challenges ranging from the presence of complex motor movements to inappropriate patient screening, e.g. patient’s not meeting preconditions.
We describe two cases where complex motor movements persisted following clinical death by standard brain death criteria and caused uncertainty with regards to diagnosis of brain death.
We wish to highlight that complex motor movements are common and do not always preclude the diagnosis of brain death.


Authors:

MRSA pneumonia mucus plug burden and the difficult airway

An 80-year-old female with a past medical history of chronic obstructive pulmonary disease (COPD), diabetes, and hypertension was initially admitted to the hospital for surgical repair of an incarcerated inguinal hernia. She underwent successful herniorrhaphy with mesh placement. Her post-operative course was complicated by a pelvic hematoma requiring evacuation during an exploratory laparotomy. The patient subsequently developed worsening hypoxia and increased work of breathing. She was placed on supplemental oxygen and as part of her work-up, underwent chest-computed tomography (CT) (Figures A and B). Subsequently, she was admitted to the Intensive Care Unit (ICU).

MRSA pneumonia mucus plug burden and the difficult airway


Authors:

Levetiracetam use during extracorporeal membrane oxygenation in an adolescent patient

Abstract
Extracoporeal membrane oxygenation (ECMO) is a form of advanced life support which is reserved for respiratory or cardiac failure. Drug properties are affected and there are limited studies of medication use in this form of life support. We describe the case of a 16-year-old male deployed on ECMO for refractory respiratory failure who was receiving levetiracetam for seizures. A pharmacokinetic study was performed to determine drug levels through different points in the ECMO circuit and in the patient. Pharmacokinetic parameters were similar in healthy pediatric patients suggesting that ECMO does not affect the pharmacokinetic parameters of levetiracetam. To the authors’ knowledge, this is the first report of levetiracetam use during ECMO in a pediatric patient.


Authors:

Unusual presentation of clozapine-induced abdominal compartment syndrome

Abstract
Clozapine-induced gastrointestinal hypomotility is common side effect of this drug. It can lead to various degrees of colon obstruction. In rare cases, it can be life-threatening since severe colon obstruction can lead to colon perforation, colon necrosis and ischemia and septic shock. In all these cases, there had been some complaints of constipation or abdominal symptoms prior fatal event. Here, we are reporting a case that had rapidly progressed to cardiac arrest in which the initial symptom was dyspnea instead of abdominal complaint.

Unusual presentation of clozapine-induced abdominal compartment syndrome


Authors:

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.


Authors:

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.


Authors:

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.


Authors:

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


Authors:

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


Authors:

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


Authors:

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


Authors: