Negative pressure pulmonary edema: an uncommon life-threatening postoperative complication

Negative pressure pulmonary edema [NPPE] is an uncommon but potentially life-threatening postoperative complication which occurs following sudden upper airway obstruction. Hypoxemia and acute respiratory failure are often severe. Therefore, early recognition and initiation of appropriate treatment are warranted. We present a case of a twenty-one-year-old male who presented with NPPE due to upper airway obstruction following adenoidectomy. The patient was intubated and sedated to initiate mechanical ventilation. Fluid balance was optimized and weaning off mechanical ventilation was successful under dexmedetomidine infusion. The patient was discharged with favourable outcome

Lemierre syndrome: an unusual complication of tongue cancer

An eighty-year-old female was admitted to the intensive care unit for hemorrhagic shock due to bleeding tongue malignancy. Clinical assessment revealed infected neoplastic lesion. Blood cultures on admission revealed Streptococcus spp. The diagnosis of Lemierre syndrome was suspected. Therefore, an ultrasound Doppler was performed and revealed thrombosed right internal jugular vein. The patient had a favorable outcome and improved with appropriate antimicrobial treatment

[Epidemiological features of stress hyperglycemia in elderly at emergency department]

Background: Stress hyperglycemia among patients having an acute pathology is frequently described in recent studies

Aims: The objectives of this work were to describe epidemiologic features of elderly patients hospitalized in the emergency department and having a hyperglycemia due to stress

Methods: A retrospective chart review identified patients older than 65 years with obtained serum glucose levels. Patients with diabetes were excluded. Two levels of serum glucose were considered [>6,9 mmol/l and

Results: We included 165. There were 94 patients with high level of serum glucose level [56,9%]. Multivariate analysis found that only cardio-vascular pathologies were more predictive of having stress hyperglycemia [p=0,014, odds-ratio=2,8, IC=1,2-6,4]. There were no correlation between serum glucose levels and mortality

Conclusion: Stress hyperglycemia is a fairly common disorder but underestimated in emergency department. Its impact on the prognosis of elderly patients remains to be studied

[Pulmonary thromboembolism: incidence, physiopthology, diagnosis and treatment]

The objective of this work was to review current data about the pathophysiology, clinical features, and treatment of pulmonary thromboembolism. Venous thromboembolism [VTE] remains a major challenge in hospitalised especially the care of critically ill patients. Pulmonary embolism [PE] is the major complication of VTE. By occluding the pulmonary arterial bed it may lead to acute life-threatening but potentially reversible right ventricular failure. The outcome of patients with PE is quite variable depending primarily on the cardio-respiratory status and the embolus size. PE is a difficult diagnosis that may be missed because of non-specific clinical presentation. Clinical signs include hypoxia, tachypnea, and tachycardia. Severe cases of untreated PE can lead to circulatory instability, and sudden death. However, in ICU, most of patients require sedation and mechanical ventilation. The clinical manifestations usually observed in this condition [PE] cannot be exhibited by these patients and clinical presentation is usually atypical. For these reasons, the diagnosis of PE is usually suspected when un-explicated hypoxemia and/or shock and arterial hypotension were observed. Positive diagnosis is based on these clinical findings in combination with laboratory tests and imaging studies. D-dimer testing is of clinical use when there is a suspicion of DVT or pulmonary embolism PE. In Emergency department, a negative D-dimer test will virtually rule out thromboembolism with a negative predictive value at 95 to 98%. In massive and submassive PE, dysfunction of the right side of the heart can be seen on echocardiography. While the gold standard for diagnosis is the finding of a clot on pulmonary angiography, CT pulmonary angiography is the most commonly used imaging modality today. When the diagnosis is confirmed, anticoagulant therapy is the mainstay of treatment. Acutely, supportive treatments a pivotal role in the management of patients with PE. Severe cases may require thrombolysis with drugs such as tissue plasminogen activator [tPA] or may require surgical intervention via pulmonary thrombectomy. Prevention is highly warranted

[Use of catecholamine and shocks. continuous debate!]

Hypotension and shocks are frequently observed in patients requiring admission in ICU. However, the optimal adrenergic support in shock is controversial. To perform a descriptive approach of the current use of catecholamine in a medico-surgical ICU in patients with schoks. Our study is prospective over 3 month period. Were included all patients admitted in our ICU during the study period's. We compared the populations with and without catecholamine, we analysed the catecholamine selected in various clinical settings and we studied the impact of the use of catecholamine on the patient outcomes. During the study's period, 226 patients were hospitalized in our service and were the subject of this study. The median age [ +/- SD] was of 47 +/- 24 years. During their hospitalization in the ICU, 132 patients [58.4%] presented a shock. The cardiogenic shock and the hypovolemic shock were the most observed [37.8% and 35.6% respectively]. Hundred thirty patients [57.5%] received catecholamines during their stay in ICU. Eighty four patients [64.6% of the patients having received catecholamines] had received dopamine. Sixty two patients [47.7% of the patients having received catecholamines] had received dobutamine, 63 patients [48.5%] had received epinephrine and 22 patients [16.9%] had received norepinephrine. The mean's period of catecholamines use was 5 +/- 4 days. Among drugs proposed in order to manage patients with cardiogenic shock, dobutamine was chosen as the first choice agent in 62% of the cases. Among drugs proposed in order to manage patients with septic shock, Dopamine was chosen as the first choice agent in 85.7% of the cases. In our study the patients of the class C or D in the Knauss classification are significantly predisposed to receive catecholamines during their ICU stay [OR: 5.3 ; IC 95%: 1.7 - 5.7].Moreover, the needing of catecholamine use is strongly associated with high mortality [OR: 16,8; IC 95%: 16.4 - 49.2]. The choice of catecholamines is a matter of debate for critically ill patients. The use of catecholamines is a clinical marker of severity and provider of mortality

Pulmonary embolism in intensive care unit: predictive factors, clinical manifestations and outcome

To determine predictive factors, clinical and demographic characteristics of patients with pulmonary embolism [PE] in ICU, and to identify factors associated with poor outcome in the hospital and in the ICU. During a four-year prospective study, a medical committee of six ICU physicians prospectively examined all available data for each patient in order to classify patients according to the level of clinical suspicion of pulmonary thromboembolism. During the study periods, all patients admitted to our ICU were classified into four groups. The first group includes all patients with confirmed PE; the second group includes some patients without clinical manifestations of PE; the third group includes patients with suspected and not confirmed PE and the fourth group includes all patients with only deep vein thromboses [DVTs] without suspicion of PE. The diagnosis of PE was confirmed either by a high-probability ventilation/perfusion [V/Q] scan or by a spiral computed tomography [CT] scan showing one or more filling defects in the pulmonary artery or in tits branches. The diagnosis was also confirmed by echocardiography when a thrombus in the pulmonary artery was observed. During the study periods, 4408 patients were admitted in our ICU. The diagnosis of PE was confirmed in 87 patients [1.9%]. The man delay of development of PE was 7.8 +/- 9.5 days. On the day of PE diagnosis, clinical examination showed that 50 patients [57.5%] were hypotensive, 63 [72.4%] have SIRS, 15 [17.2%] have clinical manifestations of DVT and 71 [81.6%] have respiratory distress requiring mechanical ventilation. In our study, intravenous unfractionated heparin was used in 81 cases [93.1%] and low molecular weight heparins were used in 4 cases [4.6%]. The mean ICU stay was 20.2 +/- 25.3 days and the mean hospital stay was 25.5 +/- 25 days. The mortality rate in ICU was 47.1% and the in-hospital mortality rate was 52.9%. Multivariate analysis showed that factors associated with a poor prognosis in ICU are the use of norepinephrine and epinephrine. Furthermore, factors associated with in-hospital poor outcome in multivariate analysis were a number of organ failure associated with PE >/= 3. Moreover, comparison between patients with and without pe showed that predictive factors of pe are: acute medical illness, the presence of meningeal hemorrhage, the presence of spine fracture, hypoxemia with PaO[2]/FiO[2] ration < 300 and the absence of pharmacological prevention of venous thromboembolis, Despite the high frequency of DVT in critically ill patients, symptomatic PE remains not frequently observed, because systematic screening is not performed. Pulmonary embolism is associated with a high ICU and in-hospital mortality rate. Predictive factors of PE are acute medical illness, the presence of meningeal hemorrhage, the presence of spine fracture, hypoxemia with PaO[2]/FiO[2] < 300 and absence of pharmacological prevention of venous thromboembolism

Contribution of the liver biopsy in intensive care unit

Our aim was to evaluate the indications and contribution of liver biopsy [LB] in intensive care [ICU] and to compare them to those of LB in gastroenterology. We included retrospectively 37 successive LB achieved in ICU and 38 successive LB achieved in gastroenterology. All data were reviewed by three intensivists and three gastroenterologists to determine the contribution of the LB. The indications of LB were different in the two units. The most frequent indications were cirrhosis [36.8%], isolated biological hepatic disruptions [26.3%] and histological classification of viral hepatitis [18.4%] in gastroenterology and isolated biological hepatic disruptions [48.6%], hepatopathy during pregnancy [27%] and fever of unknown origin [10.8%] in intensive care unit. According to the six reviewers, LB was enough contributive in the two units, [78.4% in ICU and 71.1% in gastroenterology -p=0.46-]. It allowed to eliminate, to confirm, or to change a diagnosis in more than 70% of cases and allowed to modify the course of therapy in 21.6% of cases in ICU and in 26.3% of cases in gastroenterology [p=0.6]. The LB is a feasible technique in ICU and can be as contributive as it is in gastroenterology