case of near fatal asthma: the role of ECMO as rescue therapy

We report a case of an adolescent with near fatal asthma [NFA]. He presented with severe hypoxemia and lifethreatening acidemia, who failed to respond to conventional therapy. His hospital course was complicated by barotrauma and hemodynamic instability. Early introduction of extracorporeal membrane oxygenation [ECMO] led to dramatic improvement in gas exchange and lung mechanics. This case illustrates the important role of ECMO as salvage therapy in NFA

Severe pneumonia requiring ICU admission: revisited

To describe the aetiology, outcome and management approach for patients with community acquired pneumonia [CAP] and hospital-acquired pneumonia [HAP] who required ICU admission and to determine the predictors of mortality. A prospective observational study of 119 consecutive patients who were admitted to the ICU with diagnoses of CAP [n = 89] or HAP [n = 30] from May 2011 until December 2012. The overall ICU and hospital mortality rates for CAP and HAP were 24.4% and 30.3%, respectively. There were no significant differences between the patients with CAP and HAP in terms of ICU mortality or the average length of hospital stay. The most commonly isolated pathogens were H1N1 [23%] and Streptococcus pneumonia [17%] in the patients with CAP and Acinetobacter baumannii [37%] in the patients with HAP. Multidrug resistant [MDR] organisms were detected in 32 [38.6%] isolates. The median time for receiving antibiotics was 2 h. Most of the patients [82%] received double antibiotic coverage. Multiple regression analysis identified septic shock [beta = 0.43, p < 0.001], acute respiratory distress syndrome [ARDS] [beta = 0.34, p = 0.003], and the pneumonia severity index [PSI] [beta = -0.36, p < 0.024] as significant predictors of mortality. The outcomes of patients with severe pneumonia who were admitted to the ICU were better than those of previous reports. Early administration of combination antibiotics was practiced with vigilance. MDR organisms and respiratory viruses were the commonly isolated pathogens. The presence of septic shock, ARDS and high PSI were independent predictors of mortality

Descending necrotizing mediastinitis

Descending necrotizing mediastinitis [DNM] is a rare but severe life threatening complication of oropharyngeal infections. We report a young lady who had severe pharyngitis complicated by anterior neck infection that descended to the mediastinum causing necrotizing mediastinitis. The course of her illness was complicated with septic shock, acute kidney injury, tracheo-esophageal fistula, and critical illness polyneuropathy. There was considerable delay in her diagnosis; however, she survived after aggressive surgical intervention, wide spectrum antibiotics, and appropriate intensive care management. Early and repeated chest imaging using computed tomography was vital for the detection and follow up of this case. There is a need to increase physicians' awareness of this condition that can complicate odontogentic or pharyngeal infection, procedures, or trauma

Sweat chloride concentration in patients with heat stroke

The effect of hyperpyrexia on sweat gland function in heat stroke [HS] has been poorly studied. The aim of this study was to assess changes in sweat chloride concentration before and after recovery from heat stroke. Sweat chloride concentration in response to pilocarpine stimulation was measured in 10 HS patients on admission and after 12 h and was compared with that of 7 heat exhaustion [HE] and 10 heat stress patients. The mean age of HS patients was 51.1 +/- 8.9 years. Their mean rectal temperature was 42.9 +/- 0.6 [degree]C, cooling time was 96 +/- 12 min, APACHE II score was 23.5 +/- 6.9, and serum lactate concentration was 5.2 +/- 2.1 mmol/L. The mean sweat chloride concentration was significantly lower among HS patients [5.3 +/- 0.6 mmol/L] compared with HE [20.0 +/- 1.5 mmol/L, p< 0.0001] and heat stress patients [27 +/- 3.2 mmol/L, p< 0.0001]. The mean sweat chloride concentration at 12 h among 8 HS patients who survived increased to 17.9 +/- 6.6 mmol/L, whereas in 2 HS patients who died, the sweat chloride concentration remained unchanged [p<0.0001]. Sweat chloride concentration in HS was markedly reduced compared to HE and heat stress. However, in HS patients who survived, sweat chloride concentration recovered 12 h after treatment.

Protocolized eye care prevents corneal complications in ventilated patients in a medical intensive care unit

Eye care is an essential component in the management of critically ill patients. Standardized eye care can prevent corneal complications in ventilated patients. This study was designed to compare old and new practices of corneal care for reduction in corneal complications in ventilated patients. This study was done in three phases each of six month duration. Phase 1 was the ongoing practice of eye care in the unit. Before the start of phase 2, a new protocol was made for eye care. Corneal complications were observed in terms of haziness, dryness, and ulceration. All nursing staffs were educated and made compliant with the new protocol. In phase 2, a follow-up audit was done to check the effectiveness and compliance to protocol. In phase 3, a follow-up audit was started 3 months after phase 2. In phase 1, total ventilated patients were 40 with 240 ventilator days. The corneal dryness rate was 40 per 1000 ventilator days while the haziness and ulceration rate was 16 per 1000 ventilator days each. In the second phase 2, total ventilated patients were 53 making 561 ventilator days. The rate of corneal haziness and dryness was 3.52 and 1.78 per 1000 ventilator days, respectively, with no case of corneal ulceration. In phase 3, the number of ventilated patients was 91 with 1114 ventilator days. The corneal dryness rate was 2.69 while the haziness and ulceration rate was 1.79 each. Protocolized eye care can reduce the risk of corneal complications in ventilated patients

Venous thromboembolism in a medical intensive care unit. The effect of implementing clinical practice guidelines

To determine the incidence of VTE in medical patients admitted to the intensive care unit [ICU] following the implementation of a standard deep venous thrombosis [DVT] prophylaxis protocol using unfractionated heparin [UFH], and to identify risk factors for DVT in these patients. We prospectively studied 123 consecutive patients admitted to the Medical ICU of King Khalid University Hospital, Riyadh, Saudi Arabia. We excluded patients on anticoagulation or with contraindications for heparin. Patients who were negative for DVT by screening Doppler Ultrasound [U/S] were started on UFH twice a day. The Doppler U/S was repeated twice weekly for 6 weeks. One hundred and four critically ill medical patients were included. A DVT was diagnosed in 10 patients while receiving UFH, an incidence rate of 9.8%. The compliance rate was 98%. Sepsis [p=0.0167], limited mobility [p<0.0001], previous DVT [p=0.024], and nephrotic syndrome [p=0.008] were significantly more common in patients who developed DVT compared with others. However, by backward logistic regression, previous DVT was the only significant factor for the development of DVT [B=-0.439, AOR=5.01, p<0.0001]. The implementation of clinical practice guidelines for VTE prophylaxis in critically ill medical patients using UFH twice daily resulted in a high compliance rate and low incidence of VTE. Previous DVT was a significant risk factor for development of VTE

Respiratory tract infection during Hajj

Respiratory tract infection during Hajj [pilgrimage to Mecca] is a common illness, and it is responsible for most of the hospital admissions. Influenza virus is the leading cause of upper respiratory tract infection during Hajj, and pneumonia can be serious. Taking into account the close contacts among the pilgrims, as well as the crowding, the potential for transmission of M. tuberculosis is expected to be high. These pilgrims can be a source for spreading infection on their return home. Although vaccination program for influenza is implemented, its efficacy is uncertain in this religious season. Future studies should concentrate on prevention and mitigation of these infections

Yield and complications of flexible fiberoptic bronchoscopy in a teaching hospital

To assess the diagnostic yield and safety of flexible fiberoptic bronchoscopy [FFB]. A retrospective review of bronchoscopy reports and corresponding patients charts over 3 years from January 2004 - December 2006 in King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia. Indication for procedure, suspected diagnosis, final diagnosis, and complications were reported. Out of 720 patients, 707 [98.2%] patients had a full follow up. Five hundred and ninety-two [83.7%] underwent FFB for diagnostic purposes and 115 [16.3%] for therapeutic purposes. The mean age was 42 -/+ 18 years. Infection, including mycobacterium tuberculosis, and malignancy were the 2 main indications for FFB [35.9% and 25.9%]. The overall diagnostic yield was 58%. Tuberculosis was diagnosed in 67% of suspected cases, whereas bacterial pneumonia was diagnosed in 40.5%. Malignancy was confirmed in 61.2% of suspected cases. Bronchoscopy diagnosed 37 [43%] of 86 patients with interstitial lung disease. The diagnostic yield was 57% for sarcoidosis, 40% for usual interstitial pneumonia and 88% for bronchiolitis obliterans organizing pneumonia. The overall complication rate was 5%; pneumothorax occurred in 0.56% and was associated exclusively with transbronchial biopsy. No mortality was observed. Flexible fiberoptic bronchoscopy is a useful diagnostic tool with a low rate of complications. The diagnostic yield in our institution is similar to that reported in Western series

HRCT score in bronchiectasis: Correlation with pulmonary function tests and pulmonary artery pressure

High resolution CT scan [HRCT] and its score have an important role in delineating pathological changes and pulmonary functional impairment in patients with bronchiectasis. To assess pulmonary function tests [PFTs] in patients with cystic and cylindrical bronchiectasis. To correlate HRCT score with PFTs and systolic pulmonary artery pressure [SPAP] in both radiological types. A cross-sectional study of patients with bronchiectasis diagnosed by HRCT was conducted at King Khalid University Hospital, Riyadh, Saudi Arabia. PFTs, HRCT score and SPAP were measured in both types. We studied 94 patients with bronchiectasis: 62 were cystic and 32 were cylindrical. Their mean age was 53.4 +/- 17.5 SD years. Forced vital capacity [FVC%] and forced expiratory volume in 1 second [FEV1%] were significantly lower in cystic patients [P < .0001] compared with cylindrical and Diffusion capacity [DLCO%] was also significantly lower [p < 0.01]. In cystic group PaO[2] was significantly lower and PaCO[2] higher [P < 0.0001]. HRCT score was correlated with FEV1% [r= -0.51]. HRCT score was significantly lower in the cystic group [P =0.002]and correlated with SPAP [r =0.23]. Global HTCT score of 10.3 +/- 2.5 was associated with SPAP >/= 40 mmHg[P =0.011]. Patients with cystic bronchiectasis have significant impairment of pulmonary physiology compared with cylindrical bronchiectasis patients. HRCT score correlated with PFTs and SPAP

Pneumothorax, pneumomediastinum, pneumoperitoneum and surgical emphysema in mechanically ventilated patients

A 29 year old male patient of Indian ancestry was admitted to an outside hospital with rapid deterioration of his level of consciousness. The patient required mechanical ventilation and transfer to MICU at Hamad Medical Corporation. The patient remained hypoxic. Chest X-ray, CT of chest, abdomen, pelvis and proximal areas of both lower limbs were performed. Pneumomediastinum, pneumoperitoneum, and extensive surgical emphysema were the diagnoses