ABSTRACT
RATIONALE: High-dose insulin (HDI) therapy has been used as inotropic support for toxin-induced cardiogenic shock, but literature suggests that it can also be used in non-toxin-induced cardiogenic shock states. Its use has not been reported in veno-arterial extracorporeal membrane oxygenation (VA-ECMO) decannulation. PATIENT CONCERNS: A 56-year-old male presented with progressive dyspnea and lower extremity edema without any reported toxic ingestion. DIAGNOSIS: After left heart catheterization, he was diagnosed with acute biventricular nonischemic cardiac failure that ultimately required VA-ECMO support for 8 days, after which decannulation was planned. INTERVENTIONS: During decannulation, he was initiated on HDI therapy via a 1 U/kg regular insulin bolus with 25 g of dextrose and a 1 U/kg/hr insulin infusion. OUTCOMES: During the decannulation, he was monitored with transesophageal echocardiography. Initially, left ventricular (LV) ejection fraction (EF) was estimated at 10% to 15%. Transesophageal echocardiography after HDI but prior to decannulation showed LVEF 30% to 40%. Transthoracic echocardiography 3.5 hours after HDI bolus and decannulation revealed normal LV systolic function; LVEF 50% to 55%. LESSONS: While multiple interventions occurred during decannulation, HDI therapy may have assisted in transitioning off ECMO support, and HDI should be investigated as an adjunctive option in future decannulations and other non-toxin-induced cardiogenic shock states.
Subject(s)
Extracorporeal Membrane Oxygenation , Heart Failure , Hyperinsulinism , Insulin/therapeutic use , Humans , Male , Middle Aged , Retrospective Studies , Shock, Cardiogenic/chemically induced , Shock, Cardiogenic/therapy , Stroke Volume , Ventricular Function, LeftABSTRACT
Acute respiratory distress syndrome (ARDS) is defined by acute diffuse inflammatory lung injury invoked by a variety of systemic or pulmonary insults. Despite medical progress in management, mortality remains 27% to 45%. Patients with ARDS should be managed with low tidal volume ventilation. Permissive hypercapnea is well tolerated. Conservative fluid strategy can reduce ventilator and hospital days in patients without shock. Prone positioning and neuromuscular blockers reduce mortality in some patients. Early management of ARDS is relevant to emergency medicine. Identifying ARDS patients who should be transferred to an extracorporeal membrane oxygenation center is an important task for emergency providers.
Subject(s)
Airway Management/methods , Emergency Treatment/methods , Respiratory Distress Syndrome/therapy , Extracorporeal Membrane Oxygenation , Fluid Therapy/methods , Humans , Hypoxia/etiology , Hypoxia/therapy , Neuromuscular Blockade/methods , Respiration, Artificial/methods , Respiratory Distress Syndrome/diagnosis , Respiratory Distress Syndrome/physiopathologyABSTRACT
The transplantation of malignant cells during allogeneic transplant is a rare occurrence. 27 months after donating progenitor cells, a diagnosis of multiple myeloma was made in a 6/6 HLA-phenotypically matched unrelated donor. The 42-year-old recipient transplanted for chronic phase chronic myeloid leukemia developed IgA myeloma 40 months after transplantation. Serum electrophoresis and bone marrow investigations established the diagnosis of IgA K multiple myeloma in both. This case illustrates the natural history and biology of multiple myeloma.
