[Intermediate-high risk pulmonary embolism: identification and treatment]. / Longembolie met intermediair-hoog risico op overlijden.

Patients with intermediate-high risk pulmonary embolism have a different mix of clinical symptoms. Optimal treatment of patients with intermediate high-risk pulmonary embolism is necessary to prevent short-term mortality. According to the current guidelines, the use of standard coagulation is the treatment of choice in hemodynamic stable patients with intermediate-high risk pulmonary embolism. Systemic thrombolytic therapy is recommended in patients with intermediate-high risk pulmonary embolism who circulatory deteriorate or who did not respond appropriately to standard anticoagulation. Catheter-guided thrombolysis is reserved for patients with intermediate-high risk pulmonary embolism who have a contraindication for systemic thrombolysis or did not respond to systemic thrombolysis. The timing and choice for the right treatment are significant treatment dilemmas. The development of pulmonary embolism response teams helps in the decision-making in patients with intermediate high-risk pulmonary embolism.

Successful treatment of fulminant postoperative bleeding due to acquired haemophilia.

Acquired haemophilia is a rare but life-threatening phenomenon in patients who have undergone surgical treatment. We describe a patient with a history of pancreatic cancer and a conventional pancreaticoduodenectomy, who underwent elective resection of an enterocutaneous fistula, complicated by fulminant haemorrhagic shock, caused by acquired haemophilia A. Eventually, the bleeding was controlled by a combination of aggressive haemostatic and immunosuppressive therapy. Prompt diagnosis of acquired haemophilia is crucial to allow early and appropriate haemostatic treatment and reduce the period of increased bleeding risk by eradicating the inhibitor with immunosuppressive therapy.

Use of synthetic colloids in sepsis: a critical review on efficacy, safety and patient benefits.

In this narrative review, the studies and analyses are discussed that pertain to benefits and detriments of synthetic colloids versus natural colloids or crystalloids used for fluid resuscitation in sepsis and septic shock. The relative amount of fluid infusions used to reach clinical or hemodynamic end-points are reviewed, as well as potential toxicity of starch solutions on the kidney. Hence, it cannot be excluded that adverse effects partly offset beneficial hemodynamic effects that are similar to that of natural colloids, so that in most analyses a mortality benefit of synthetic colloid fluid resuscitation in sepsis and septic shock cannot be demonstrated.

Acute refractory hyperkalaemia and fatal cardiac arrest related to administration of liposomal amphotericin B.

A 36-year-old male with acute myeloid leukaemia was treated with liposomal amphotericin B for a breakthrough fungal infection with Absidia corymbifera during voriconazole and caspofungin therapy for invasive pulmonary aspergillosis. Four episodes of hyperkalaemia developed with a highly probable relation to infusion of liposomal amphotericin B, of which the last episode was characterised by severe, refractory hyperkalaemia and fatal cardiac arrest. The available literature on severe hyperkalaemia and cardiac arrest during administration of both conventional and liposomal amphotericin B is reviewed here and revealed only four similar cases. The most likely mechanism of toxicity is the release of potassium from a variety of mammal cells including erythrocytes and endothelial cells. Whether prevention of toxicity can be established by decreasing the infusion rate is unclear but conceivable.

Management of invasive pulmonary aspergillosis in non-neutropenic critically ill patients.

During recent years, a rising incidence of invasive pulmonary aspergillosis (IPA) in non-neutropenic critically ill patients has been reported. Critically ill patients are prone to develop disturbances in immunoregulation during their stay in the ICU, which render them more vulnerable for fungal infections. Risk factors such as chronic obstructive pulmonary disease (COPD), prolonged use of steroids, advanced liver disease, chronic renal replacement therapy, near-drowning and diabetes mellitus have been described. Diagnosis of IPA may be difficult and obtaining histo- or cytopathological demonstration of the fungus in order to meet the gold standard for IPA is not always feasible in these patients. Laboratory markers used as a non-invasive diagnostic tool, such as the galactomannan antigen test (GM), 1,3-beta-glucan, and Aspergillus PCR, show varying results. Antifungal therapy might be considered in patients with persistent pulmonary infection who exhibit risk factors together with positive cultures or sequentially positive GM and Aspergillus PCR in serum, in whom voriconazole is the drug of choice. The benefit of combination antifungal therapy lacks sufficient evidence so far, but this treatment might be considered in patients with breakthrough infections or refractory disease.

Spontaneous remission of acute myeloid leukaemia after recovery from sepsis.

Spontaneous remission of acute myeloid leukaemia (AML) is extremely rare and usually of short duration. We report two patients with documented AML who developed spontaneous remission of their leukaemia shortly after an episode of severe sepsis and respiratory failure requiring mechanical ventilation. The underlying mechanisms of spontaneous remission remain unclear but an association with preceding blood transfusions and severe systemic infections has been reported. An overwhelming immune response due to sepsis and leading to raised levels of TNF-alpha, INF-gamma, IL -2 and an increased activity of NK cells, cytotoxic T-cells and macrophages are thought to play an important role. Better insights into the mechanisms of spontaneous remission of AML after recovery from sepsis could help in developing new therapies for AML.

[Life threatening hyperkalemia: the value of the electrocardiogram]. / Levensbedreigende hyperkaliëmie: de waarde van het elektrocardiogram.

In two men, aged 19 and 64, with chronic renal insufficiency and subacute symptoms of malaise and weakness of the leg muscles, broad QRS complexes were seen in the ECG. The younger patient developed an asystole and resuscitation was unsuccessful. His blood potassium level was found to be 8.3 mmol/l. The older patient recovered after administration of calcium gluconate. His blood potassium level was found to be 8.5 mmol/l. An 80-year-old woman who was taking various drugs because of heart failure also complained of muscle weakness. Her blood potassium level was 7.2 mmol/l and her ECG showed narrow complexes. She recovered without calcium gluconate after a change in medication. Hyperkalemia is a potentially life-threatening electrolyte disorder that may require immediate treatment. The changes in the ECG, especially widening of the QRS complexes, are the most important clues to the severity of the hyperkalemia. A treatment protocol based on ECG changes may reduce the mortality in these patients.