The hallmark of acute liver failure is hepatic encephalopathy, which often presents with the devastating complication of cerebral edema. Given the extremely high mortality rate associated with the development of cerebral edema, it is prudent to aggressively manage this pathology. One tool that is used to guide treatment of cerebral edema is an intracranial pressure monitor. This article will review the literature regarding the use of intracranial pressure monitors in acute liver failure in an effort to elucidate their utility in this setting.
A 30 year old male with a history of recurrent pulmonary emboli presented with hemoptysis 6 weeks after discontinuing anticoagulation therapy. He was found to have submassive pulmonary embolism with elevated pulmonary artery pressures and underwent bilateral catheter-directed pharmacomechanical thrombolysis. On day 3 of admission he developed massive hemoptysis and bronchoscopy revealed a Dieulafoy lesion on the left upper lobe bronchial mucosa to which electrocautery and cryotherapy was applied. Bronchial arteriogram revealed dilated bronchial arteries and left bronchial artery embolization was performed after which he was started on sildenafil. His hemoptysis resolved and he was discharged home on warfarin.
Pulmonary herniation is a protrusion of the lung beyond the usual boundaries of the thoracic cavity, which is caused by increased intrathoracic pressures coupled with defects in the thoracic wall. Most lung herniations due to surgical intervention described in the literature occurred weeks to months in the post-operative period. We describe 3 cases of lung herniation occurring years after surgery, all apparently caused by acute increase in intrathoracic pressure.
A 35-year-old man presented with a two day history of epigastric pain and was diagnosed with acute pancreatitis. During his workup, he was found to have a left-sided bilious pleural effusion. Further studies were unrevealing for an anatomic source. A bilious pleural effusion, almost always seen on the right side, is a rarity in clinical medicine and is usually secondary to traumatic injury. We report a case of an even more rare spontaneous, left-sided bilious pleural effusion.
Some patients with severe acute respiratory distress syndrome (ARDS) experience hypoxemia during lung-protective ventilation, refractory to a fraction of inspired oxygen of 1.0 and high levels of positive end-expiratory pressure. Management options for refractory ARDS are discussed, including neuromuscular blocking agents (NMBA), prone positioning, inhaled pulmonary vasodilators, high-frequency oscillatory ventilation (HFOV), and extracorporeal membrane oxygenation (ECMO).
Impairments in function after resolution of critical illness are common and may be under-recognized. Cognitive dysfunction, mood disorders, respiratory impairment, physical debility and reduced quality of life, occur at high rates among survivors of critical illness, with important clinical and public health implications. The elderly, patients with preexisting comorbidities, and those experiencing delirium during hospitalization are at elevated risk for impairment after critical illness resolves. Predicting impairment after critical illness and developing interventions to prevent impairment are areas of ongoing research.
In North America, imported malaria is the principal cause of febrile illness and life threatening infection in travelers and immigrants arriving from endemic areas. Severe malaria due to Plasmodium vivax is an emerging infectious disease that requires prompt identification and appropriate management. Malaria symptoms may present in a gradual or fulminant fashion. With treatment, severe malaria has a case fatality of 10 to 20%; if left untreated or with a significant treatment delay, severe malaria is usually fatal with death due to multiorgan dysfunction including adult respiratory distress syndrome. Consultation with an infectious diseases or tropical medicine specialist is strongly recommended in the management of malaria, as timely diagnosis and treatment are essential. Parenteral artesunate or quinine is recommended for treatment of severe malaria. Speciation of plasmodium is required, as P. vivax and P. ovale require additional treatment to eliminate dormant parasites (radical cure).
Gabapentin is an anticonvulsant most often prescribed for off-label indications, such as neuropathic pain. Rarely, an adrenergic toxidrome may occur after discontinuation of gabapentin. We describe a case of gabapentin withdrawal precipitating an autonomic hyperactive state which resolved with administration of gabapentin. Gabapentin withdrawal should be considered in patients presenting with unexplained autonomic hyperactivity after abrupt discontinuation of chronic gabapentin, especially at higher doses.
Esophageal injuries in adults are most often iatrogenic, occurring after dilation of esophageal strictures. In this case, a 72 year-old female underwent esophageal dilations for a stricture resulting from radiation for breast and esophageal cancer. She then developed symptoms of pneumonia, followed by seizures and quadraparesis. Imaging revealed esophageal rupture with osteomyelitis, ventriculitis, intraventricular abscess and hydrocephalus from infectious dissemination. Iatrogenic esophageal rupture after dilation has a high mortality; the recommended initial evaluation is with a barium esophogram. Recent experience supports consideration of nonsurgical treatment, which can be as successful as surgical options.
Intravenous fluid administration is a cornerstone of intensive care resuscitation. When considering fluid therapy, clinicians must attempt to answer two fundamental questions: (1) Is an increase in cardiac output likely to reverse or improve a hypoperfusion state? and (2) Is a fluid bolus likely to increase the cardiac output? Recent data on the potentially harmful effect of fluid overload in ICU patients have led intensivists to reconsider the sacrosanct practice of the “fluid challenge”. As such, various predictors of fluid responsiveness have been proposed as potential alternatives to inform clinicians on the best course of action. A better understanding of the largely ignored basic physiologic mechanisms that determine fluid responsiveness can inform the choice of available bedside maneuvers, interpretation of data, and use of available technologies in hypoperfused patients.