Epidemiology and outcomes of elderly patients requiring renal replacement therapy in the intensive care unit: an observational study.

BACKGROUND: Renal replacement therapy (RRT) in critically ill patients is associated with high morbidity and mortality. The appropriateness of RRT initiation is sometimes questioned in elderly patients. Therefore, we sought to evaluate the long-term mortality, dialysis dependence and quality of life (QOL) of elderly patients who survived critical illness requiring RRT. METHODS: This is a monocentric observational study including all patients > 55 yo who received RRT for acute kidney injury in our intensive care unit (ICU) between January 2015 and April 2018. At the time of the study (May 2019), we assessed if they were still alive by cross referencing our hospital database and the Swiss national death registry. We sent survivors written information and, subsequently, contacted them over the phone. We obtained their consent for participation, asked about their dialytic status and performed an EQ-5D survey with visual analog scale (VAS). Results were stratified according to their age at the time of ICU admission (G1: "55-65 yo"; G2: "> 65-75 yo" and G3: "> 75 yo"). QOL in G3 patients were compared to G1 and G2 and to predicted values. RESULTS: Among the 352 eligible patients, 171 died during the index hospital admission. After a median follow-up time of 32.7 months (IQR 19.8), a further 62 had died (median time to death for ICU survivors 5.0 (IQR 15.0) months. Hence, 119 (33.6%) patients were still alive at the time of the study. We successfully contacted 96 (80.7%) of them and 83 (69.7%) were included in the study (G1: 24, G2: 44 and G3: 15). Only 6 (7.2%) were RRT dependent. Patients in G3 had lower EQ-5D and VAS scores than those in G1 and G2 (p < 0.01). These scores were also significantly lower than predicted values (p < 0.05). CONCLUSIONS: RRT patients have a very high in-hospital and post discharge mortality. Among survivors, RRT dependency was low. Irrespective of baseline values, patients > 75 yo who survived ICU had a lower QOL than younger patients. It was lower than predicted according to age and sex. The appropriateness of RRT initiation in elderly patients should be discussed according to their pre-existing QOL and frailty.

Intrarachidial Misplacement of a Venous Stent for Iliofemoral Deep Vein Thrombosis.

INTRODUCTION: Complications due to venous thrombectomy and iliofemoral stenting in a patient with May-Thurner syndrome are reported. REPORT: The patient presented with a third episode of deep vein thrombosis (DVT). A computed tomography (CT) scan confirmed the clinical suspicion of left iliofemoral vein thrombosis. After thrombectomy and stenting, the patient complained of left foot paralysis. CT showed the misplaced stent to be in the intrarachidial space. Surgical removal of the stent and new endovascular stenting resulted in complete recovery. DISCUSSION: This is the first description of this kind of complication after stenting of the left iliofemoral vein. Peri-operative Xray appeared to confirm correct placement of the stent via bilateral femoral venous access. Is a profile control image necessary in patients with an important collateral venous network including large veins?

SIADH and water intoxication related to ecstasy.

Recreational drug use is a significant societal issue and remains a clinical challenge in emergency and critical care departments. We report on a 19-year-old woman admitted to hospital semiconscious and with severe hyponatraemia. Urinalysis was positive for methamphetamine and supported a diagnosis of hyponatraemia related to ecstasy use together with a syndrome of inappropriate antidiuretic hormone secretion (SIADH). The woman was transferred to an intensive care unit, where a hypertonic saline infusion was started. Three hours postadmission she developed polyuria. Follow-up urinalysis at this point was consistent with water intoxication. This case is a reminder that hyponatraemia is a potentially fatal complication after the ingestion of 3,4-methylenedioxymethamphetamine, illustrates the sequential nature of an SIADH and water intoxication and highlights the importance of considering the sequence of onset of hyponatraemia, as the patient may be admitted at any stage.

[Exertional heatstroke]. / Le coup de chaleur d'exercice.

Exertional heatstroke is defined by an increase of core body temperature above 40 degrees C and neurological symptoms in association with exercise. It is related to excessive heat production, which overwhelms the endogenous mechanisms of thermoregulation. It is observed during intense physical activity in a hot and humid environment, most commonly in untrained subjects poorly adapted to such conditions. Clinical manifestations of exertional heatstroke are related to the induction of a systemic inflammatory response and a disseminated intravascular coagulation triggered by heat stress, which may lead to multiorgan dysfunction and death. Early management through rapid cooling is mandatory to prevent the devastating consequences of exertional heatstroke.