Severe Rhabdomyolysis Associated with Staphylococcus aureus Acute Endocarditis Requiring Surgery.

BACKGROUND: Rhabdomyolysis has multiple etiologies with unclear mechanisms; however, rhabdomyolysis caused by Staphylococcus aureus infection is rare. CASE REPORT: A case report of severe rhabdomyolysis in a patient who presented with endocarditis caused by methicillin-susceptible S. aureus and review of relevant literature. RESULTS: The patient had a history of cardiac surgery for tetralogy of Fallot. He was admitted to the hospital because of fever and digestive symptoms. Respiratory and hemodynamic status deteriorated rapidly, leading to admission to the intensive care unit (ICU) for mechanical ventilation and vasopressor support. Laboratory tests disclosed severe rhabdomyolysis with a serum concentration of creatine kinase that peaked at 49,068 IU/L; all blood cultures grew methicillin-susceptible S. aureus. Antibiotic therapy was amoxicillin-clavulanic acid, ciprofloxacin, and gentamicin initially and was changed subsequently to oxacillin, clindamycin, and gentamicin. Transesophageal echocardiography showed vegetation on the pulmonary valve, thus confirming the diagnosis of acute endocarditis. Viral testing and computed tomography (CT) scan ruled out any obvious alternative etiology for rhabdomyolysis. Bacterial analysis did not reveal any specificity of the staphylococcal strain. The patient improved with antibiotics and was discharged from the ICU on day 26. He underwent redux surgery for valve replacement on day 53. CONCLUSIONS: Staphylococcal endocarditis should be suspected in cases of severe unexplained rhabdomyolysis with acute infectious symptoms.

Hemodynamic assessment of ventilated ICU patients with cardiorespiratory failure using a miniaturized multiplane transesophageal echocardiography probe.

PURPOSE: To assess the feasibility, image quality, diagnostic accuracy, therapeutic impact and tolerance of diagnostic and hemodynamic assessment using a novel miniaturized multiplane transesophageal echocardiography (TEE) probe in ventilated ICU patients with cardiopulmonary compromise. STUDY DESIGN: Prospective, descriptive, single-center study. METHODS: Fifty-seven ventilated patients with acute circulatory or respiratory failure were assessed, using a miniaturized multiplane TEE probe and a standard TEE probe used as reference, randomly by two independent experienced operators. Measurements of hemodynamic parameters were independently performed off-line by a third expert. Diagnostic groups of acute circulatory failure (n = 5) and of acute respiratory failure (n = 3) were distinguished. Hemodynamic monitoring was performed in 9 patients using the miniaturized TEE probe. TEE tolerance and therapeutic impact were reported. RESULTS: The miniaturized TEE probe was easier to insert than the standard TEE probe. Despite lower imaging quality of the miniaturized TEE probe, the two probes had excellent diagnostic agreement in patients with acute circulatory failure (Kappa: 0.95; 95% CI: 0.85-1) and with acute respiratory failure (Kappa: 1; 95% CI: 1.0-1.0). Accordingly, therapeutic strategies derived from both TEE examinations were concordant (Kappa: 0.82; 95% CI: 0.66-0.97). The concordance between quantitative hemodynamic parameters obtained with both TEE probes was also excellent. No relevant complication secondary to TEE probes insertion occurred. CONCLUSIONS: Hemodynamic assessment of ventilated ICU patients with cardiopulmonary compromise using a miniaturized multiplane TEE probe appears feasible, well-tolerated, and relevant in terms of diagnostic information and potential therapeutic impact. Further larger-scale studies are needed to confirm these preliminary results.

Efficacy of and tolerance to mild induced hypothermia after out-of-hospital cardiac arrest using an endovascular cooling system.

INTRODUCTION: We evaluated the efficacy of and tolerance to mild therapeutic hypothermia achieved using an endovascular cooling system, and its ability to reach and maintain a target temperature of 33 degrees C after cardiac arrest. METHODS: This study was conducted in the medical-surgical intensive care unit of an urban university hospital. Forty patients admitted to the intensive care unit following out-of-hospital cardiac arrest underwent mild induced hypothermia (MIH). Core temperature was monitored continuously for five days using a Foley catheter equipped with a temperature sensor. Any equipment malfunction was noted and all adverse events attributable to MIH were recorded. Neurological status was evaluated daily using the Pittsburgh Cerebral Performance Category (CPC). We also recorded the mechanism of cardiac arrest, the Simplified Acute Physiologic Score II on admission, standard biological variables, and the estimated time of anoxia. Nosocomial infections during and after MIH until day 28 were recorded. RESULTS: Six patients (15%) died during hypothermia. Among the 34 patients who completed the period of MIH, hypothermia was steadily maintained in 31 patients (91%). Post-rewarming 'rebound hyperthermia', defined as a temperature of 38.5 degrees C or greater, was observed in 25 patients (74%) during the first 24 hours after cessation of MIH. Infectious complications were observed in 18 patients (45%), but no patient developed severe sepsis or septic shock. The biological changes that occurred during MIH manifested principally as hypokalaemia (< 3.5 mmol/l; in 75% of patients). CONCLUSION: The intravascular cooling system is effective, safe and allows a target temperature to be reached fairly rapidly and steadily over a period of 36 hours.