A prospective emergency department-based study of pattern and outcome of neurologic and neurosurgical diseases in Haiti.

OBJECTIVE: To perform the first prospective survey of neurologic and neurosurgical emergency department (ED) admissions in Haiti. METHODS: Data of all ED admissions at 3 Haitian hospitals for 90 consecutive days per site were collected prospectively. Patients who were given a diagnosis of a neurologic or neurosurgical disorder by the ED physician were entered in a deidentified database including demographics, presenting symptoms, brain imaging (when available), requests for neurosurgical consultation, and outcome. RESULTS: Of the 7628 patients admitted to the ED during this study, 1243 patients had a neurologic disorder, yielding an ED-based neurologic disease prevalence of 16%. The 3 most common neurologic diseases were cerebrovascular disease (31%), neurotrauma (28%), and altered mental status (12%). Neurosurgical pathologies represented 19% of all neurologic admissions with a combined ED-based disease prevalence of 3%. Mortality rate was 9%. The most common neurosurgical disease was neurotrauma (87%), caused by motor vehicle accidents (59%), falls (20%), and assault (17%). Neurosurgical procedures were performed in 14 of 208 patients with a mortality rate of 33%. CONCLUSIONS: This prospective survey represents the first study of neurosurgical or neurologic disease patterns in Haiti. The results suggest specific disease priorities for this population that can guide efforts to improve Haitian health care and conduct more comprehensive epidemiologic studies in Haiti.

Pulmonary hypertension in pregnancy: critical care management.

Pulmonary hypertension is common in critical care settings and in presence of right ventricular failure is challenging to manage. Pulmonary hypertension in pregnant patients carries a high mortality rates between 30-56%. In the past decade, new treatments for pulmonary hypertension have emerged. Their application in pregnant women with pulmonary hypertension may hold promise in reducing morbidity and mortality. Signs and symptoms of pulmonary hypertension are nonspecific in pregnant women. Imaging workup may have undesirable radiation exposure. Pulmonary artery catheter remains the gold standard for diagnosing pulmonary hypertension, although its use in the intensive care unit for other conditions has slowly fallen out of favor. Goal-directed bedside echocardiogram and lung ultrasonography provide attractive alternatives. Basic principles of managing pulmonary hypertension with right ventricular failure are maintaining right ventricular function and reducing pulmonary vascular resistance. Fluid resuscitation and various vasopressors are used with caution. Pulmonary-hypertension-targeted therapies have been utilized in pregnant women with understanding of their safety profile. Mainstay therapy for pulmonary embolism is anticoagulation, and the treatment for amniotic fluid embolism remains supportive care. Multidisciplinary team approach is crucial to achieving successful outcomes in these difficult cases.

Principles and practice of disaster relief: lessons from Haiti.

Disaster relief is an interdisciplinary field dealing with the organizational processes that help prepare for and carry out all emergency functions necessary to prevent, prepare for, respond to, and recover from emergencies and disasters caused by all hazards, whether natural, technological, or human-made. Although it is an important function of local and national governing in the developed countries, it is often wanting in resource-poor, developing countries where, increasingly, catastrophic disasters tend to occur and have the greatest adverse consequences. The devastating January 12, 2010, Haiti earthquake is a case study of the impact of an extreme cataclysm in one of the poorest and most unprepared settings imaginable. As such, it offers useful lessons that are applicable elsewhere in the developing world. Emergency preparedness includes 4 phases: mitigation or prevention, preparedness, response, and recovery. Periods of normalcy are the best times to develop disaster preparedness plans. In resource-poor countries, where dealing with the expenses of daily living is already a burden, such planning is often neglected; and, when disasters strike, it is often with great delay that the assistance from international community can be deployed. In this increasingly interconnected world, the Haiti earthquake and the important international response to it make a strong case for a more proactive intervention of the international community in all phases of emergency management in developing countries, including in mitigation and preparedness, and not just in response and recovery. Predisaster planning can maximize the results of the international assistance and decrease the human and material tolls of inevitable disasters. There should be a minimum standard of preparedness that every country has to maintain and the international assistance to achieve that. International academic medical centers interested in global health could strengthen their programs by prospectively including in them contingency planning for international relief operations. Healthcare professionals of these institutions who travel to disaster zones should rigorously prepare themselves and make provisions for collecting and reporting data, which will enrich the knowledge of this growing activity.

Adult parenteral nutrition utilization at a tertiary care hospital.

BACKGROUND: Guidelines from the American Society for Parenteral and Enteral Nutrition promote appropriate use of parenteral nutrition (PN). In addition, involvement of multidisciplinary nutrition support teams (NSTs) has led to a reduction of inappropriate PN administration. This study evaluated the effect of introducing hospital-wide PN guidelines and a PN review committee on PN prescription behavior of NSTs in the authors' hospital. METHODS: A PN guidelines form with established indications was developed and made available to the NSTs. A PN review committee was formed to assess the appropriateness of PN prescriptions and educate the NSTs if an inappropriate PN prescription was noted. The initial-phase PN prescriptions were compared with those in a later (established) phase. RESULTS: Of a total of 614 PN prescriptions, 8.1% did not meet the established indications. The initial phase recorded 312 PN prescriptions, and the established phase had 302 prescriptions. The number of inappropriate PN prescriptions decreased significantly from 11.9% in the initial phase to 4.3% in the established phase (P = .001). CONCLUSION: The incidence of inappropriate PN prescription was low when NSTs were closely involved in patient care. Availability of written guidelines and continuous oversight of NSTs promoted appropriate PN usage.

Sinus bradycardia associated with daclizumab in liver transplant recipients: report of 3 cases.

Daclizumab is a commonly used immunosuppressive agent for prophylaxis of solid organ rejection. Although rare, the cardiovascular adverse effects of daclizumab include sinus tachycardia, hypotension, and hypertension. Here, we report 3 patients who developed significant and prolonged sinus bradycardia after receiving daclizumab following orthotopic liver transplant. Daclizumab should be considered a possible cause of bradycardia following its administration in orthotopic liver transplant.

Effect of lower limb compression devices on thermodilution cardiac output measurement.

OBJECTIVE: The aim of this study was to determine whether lower limb (calf) sequential compression devices (SCDs) have a significant effect on thermodilution cardiac output measurements using a pulmonary artery catheter. DESIGN: Prospective clinical investigation. SETTING: Surgical and neurosurgical intensive care units in a university hospital. PATIENTS: A total of 43 patients with pulmonary artery catheters and bilateral lower limb SCDs. MEASUREMENTS AND MAIN RESULTS: Cardiac output was measured (average of three) when the SCDs were off (T1), during the first 2-4 secs of the inflation cycle (T2), during seconds 4-8 of the inflation cycle (T3), and when the SCDs were off again (T4). Cardiac output measurements were consistently lower when measured during the SCD inflation cycle. The decrease in cardiac output ranged from 7.58% to 49.5%, with a mean reduction of 24.51% in the first 2-4 seconds and 20.61% during seconds 4-8 (p < .001). Two patients displayed an increase in cardiac output during the inflation cycle; one patient had an increase of 2.78% and the other an increase of 13.5%. In 11 patients, measurements were also made using a pulse contour-analysis cardiac output device, but no changes in pulse contour-analysis cardiac output were observed during the same time period. CONCLUSIONS: Thermodilution cardiac output measurements via a pulmonary artery catheter should not be done during the inflation cycle of lower limb SCDs because they produce a falsely low cardiac output.

Feasibility and potential clinical utility of goal-directed transthoracic echocardiography performed by noncardiologist intensivists using a small hand-carried device (SonoHeart) in critically ill patients.

OBJECTIVE: This study was designed to assess the clinical applicability of a small, handheld, portable transthoracic echocardiography device by noncardiologist intensivists. DESIGN: Prospective, observational study. After 10 one-hour tutorials, intensivists performed a limited transthoracic echocardiography (TTE) (2-4 views, without Doppler or M-mode) examination with the 5.6-lb SonoHeart Echo System (SonoSite, Bethell, WA) on critically ill patients admitted to the surgical intensive care unit. After initial cardiac clinical assessment in 90 patients, a limited TTE was performed by an intensivist to assess left ventricular (LV) function and LV volume status. Each study was immediately reviewed and repeated by an echocardiographer to determine the technical quality of the TTE and the accuracy of the intensivist's interpretation. Data were analyzed and presented in proportions using descriptive statistics. SETTING: Surgical intensive care unit of an academic medical center. PARTICIPANTS: Ninety critically ill adult patients. INTERVENTIONS: After initial cardiac clinical assessment, a limited TTE was performed by an intensivist to assess LV size and function, to rule out significant pericardial effusions, and to estimate circulatory volume. RESULTS: Intensivists successfully performed a diagnostic limited TTE in 94% of patients and interpreted their studies correctly in 84%. Limited TTE provided new cardiac information and changed management in 37% of patients. TTE added useful information in an additional 47% of patients but did not alter immediate management. The mean "goal-directed TTE" acquisition time was 10.5 +/- 4.2 minutes. CONCLUSION: After a brief formal training in using this handheld echocardiographic system in intensive care unit patients, surgical intensivists successfully performed and correctly interpreted a limited TTE in critically ill patients. Limited TTE provided new information and altered management in a significant number of patients. This study supports incorporating bedside goal-directed, limited TTE into intensivists' training programs.

Laryngotracheal reconstruction in congenital laryngeal webs and atresias.

OBJECTIVE: To review the role of open laryngotracheal reconstruction (LTR) in congenital laryngeal webs and atresias. STUDY DESIGN AND SETTING: A retrospective chart review was undertaken in a specialist otorhinolaryngology unit in an academic tertiary referral paediatric hospital. Twenty-one patients with congenital laryngeal subglottic stenosis (SGS) underwent LTR between 1993 and 2003. Two groups were identified; one group had SGS alone (n = 6) and the other group had SGS associated with a laryngeal web (n = 15). Information recorded included presenting features, classification of lesion, surgery performed, and whether decannulation was achieved. RESULTS: All grades of stenosis (Myer-Cotton classification) and webs of type 2, 3, and 4 (Cohen's classification) were recorded. Fifteen patients had a staged reconstruction and 6 patients had a single-stage LTR. Complications included 2 revision procedures, 3 tracheocutaneous fistulas, and 1 death (cause unrelated). All appropriate patients were successfully decannulated at between 3 and 18 months post-LTR (median, 5 months). CONCLUSION: This series illustrates the effective role of open LTR in both congenital SGS alone and that in association with glottic webbing.

Bronchiolitis obliterans organizing pneumonia after orthotopic liver transplantation.

Bronchiolitis obliterans organizing pneumonia (BOOP) has been described after bone marrow, lung, heart-lung, and renal transplantation, but rarely after orthotopic liver transplantation (OLT). We report a case of BOOP after OLT to emphasize BOOP as an under diagnosed and treatable cause of nonresolving pneumonia, which may not be preventable by maintenance low-dose prednisone. A 48-year-old man was hospitalized for dyspnea and cough one month after OLT. Among his medications were tacrolimus and prednisone. Physical examination was significant for lung crepitations and bilateral leg edema. Chest x-ray revealed bilateral infiltrates. Computed tomography (CT) of the chest demonstrated bilateral diffuse infiltrates with areas of sparing and nodularities. Bronchoscopy was normal and bronchoalveolar lavage was negative. Lung biopsy was performed and demonstrated serpiginous plugs of fibroblastic tissue filling the alveolar spaces, focal fibrosis of some alveolar septa, and reactive pneumocytic hyperplasia consistent with BOOP. Methylprednisolone was continued with clinical improvement and weaning from the ventilator, but subsequent sepsis and multisystem organ failure finally led to the patient's death.

Multicenter evaluation of a human monoclonal antibody to Enterobacteriaceae common antigen in patients with Gram-negative sepsis.

OBJECTIVE: To evaluate in Gram-negative sepsis patients the human monoclonal immunoglobulin M antibody (MAB-T88) directed at the enterobacterial common antigen which is a specific surface antigen closely linked to lipopolysaccharide and shared by all members of the Enterobacteriaceae family of Gram-negative bacteria. DESIGN: Prospective, randomized, double-blinded, placebo-controlled, multicenter trial. SETTING: Thirty-three academic medical centers in the United States. PATIENTS: Patients were entered with a clinical diagnosis of sepsis, the presence of either shock or multiple organ dysfunction, and presumptive evidence for Gram-negative infection. INTERVENTIONS: Patients received a single intravenous infusion, over 30 mins, of either 300 mg of MAB-T88 formulated in albumin, or placebo (albumin). MEASUREMENTS AND MAIN RESULTS: The primary analysis group was prospectively identified as those patients with documented evidence of an infection with bacteria of the family Enterobacteriaceae at any site. The primary end point was survival within the first 28 days. A total of 826 patients were enrolled with 55% (n = 455) in the primary analysis group. There were no significant differences between the intervention and control primary analysis group study groups for sites of infection, severity of illness, underlying medical conditions, adequacy of antibiotic or surgical treatment, or other baseline variables except for a higher frequency of chronic renal failure in the MAB-T88 group (4.4% vs. 1.3%, p=.051). The average Acute Physiology and Chronic Health Evaluation II scores were 26.8 +/- 8.6 (mean +/- sd) in the MAB-T88-treated group and 26.5 +/- 8.3 in the placebo-treated group (p =.72). There was no significant difference between MAB-T88- and placebo-treated groups during the first 28-day all-cause mortality in the primary analysis group (34.2% vs. 30.8%, p=.44) or in all 826 patients enrolled (37.0% vs. 34.0%, p=.36). On subset analysis, the use of MAB-T88 was not associated with significant mortality trends. More adverse events were seen with the use of MAB-T88 in the bacteremic enterobacterial common antigen group (p <.05). CONCLUSIONS: Use of the human monoclonal antibody, MAB-T88, did not improve the mortality in patients with presumed Gram-negative sepsis or in those patients with proven enterobacterial common antigen infections. No subset trends were identified that would support further investigation of this agent in sepsis.

Intravenous iloprost increases mesenteric blood flow in experimental acute nonocclusive mesenteric ischemia.

OBJECTIVE: To evaluate the effect of an intravenously administered synthetic epoprostenol analog, iloprost, in nonocclusive acute mesenteric ischemia induced by cardiac tamponade. DESIGN: Prospective, randomized, controlled experimental study. SETTING: Animal research laboratory at a university medical center. SUBJECTS: Ten Yorkshire pigs (weight range, 20-25 kg). INTERVENTIONS: Nonocclusive acute mesenteric ischemia was induced by pericardial tamponade. Pigs were randomized to receive either a low-dose, continuous intravenous infusion of iloprost (0.075 microg/kg/min) or an equivalent volume of normal saline to serve as the control. Infusion of iloprost or saline was continued after pericardial tamponade was reversed. METHODS: Ten anesthetized and ventilated pigs underwent laparotomy and thoracotomy. A pulmonary artery catheter was inserted, a magnetic flow probe was positioned around the superior mesenteric artery (SMA), and cannulation of the pericardial space was performed. Pericardial tamponade was induced by injecting 5% dextrose in water into the pericardial space until blood flow in the superior mesenteric artery decreased to half of baseline. After 60 mins, animals received either a continuous intravenous infusion of iloprost at 0.075 microg/kg/min (n = 6) or an equal volume of normal saline (n = 4) for 60 mins. Pericardial fluid was then removed, and iloprost or normal saline infusion was continued for another 60 mins. MEASUREMENTS: Heart rate, blood pressure, cardiac output, oxygen delivery, oxygen consumption, SMA blood flow, ileal Pco2, ileal intramucosal pH, and serum lactate levels of mixed venous blood and mesenteric venous blood were recorded at baseline, after pericardial tamponade was induced, during the iloprost or normal saline infusion with pericardial tamponade, and after removal of pericardial fluid (reperfusion period). RESULTS: Iloprost infusion increased SMA blood flow by 60% in this model of nonocclusive mesenteric ischemia (from 168 +/- 41 to 269 +/- 76 mL/min; p <.05). The effect of iloprost infusion was more prominent after the tamponade (422 +/- 87 mL/min in the iloprost group vs. 232 +/- 111 mL/min in the control group; p <.05). Increased mesenteric perfusion decreased intestinal mucosal hypercarbia, leading to improvement of intramucosal pH.

Multicenter Experience Using a New Prototype Transnasal Transesophageal Echocardiography Probe.

Transesophageal echocardiography (TEE) is an invaluable diagnostic tool, particularly in patients with inadequate transthoracic echocardiographic examinations. In addition, continuous TEE has been used to monitor ventricular and valvular performance in the intensive care unit and the operating room. However, current generation transesophageal probes have limitations in the critical care setting due to their size. Recently, a prototype miniaturized transesophageal probe was developed to overcome these limitations. This probe was used by five medical centers for 194 examinations. A large proportion of these patients were in the intensive care unit (43%), as well as mechanically ventilated (39%). Seventy percent (70%) of the subjects in this study were intubated nasally with the prototype probe, with a success rate of 88.5%. Oral intubation was successful in every case. Subject tolerance was good, and 25% of the patients were intubated for > 1 h. Nasal intubation with the probe was more likely in intensive care patients, ventilated subjects, and patients who were intubated for > 1 hour. TEE with this miniaturized probe is feasible and safe even in multi-instrumented critical care patients. This probe provides adequate diagnostic imaging capabilities and may allow imaging over prolonged periods of time, making it suitable for the serial monitoring of ventricular performance.