Perioperative support of a patient with fat embolism syndrome with extracorporeal membraneoxygenation.

Fat embolism syndrome (FES) is a serious complication of trauma that can result in multiorgan failure, including the acute respiratory distress syndrome. Occasionally, the severity of respiratory failure associated with FES warrants support with venovenous extracorporeal membrane oxygenation (VV-ECMO), a therapy with widespread use but inconclusive evidence. Early definitive fracture fixation is the mainstay of preventing further fat embolism and ongoing organ dysfunction, but poses significant risks to the maintenance of the extracorporeal circuit. We describe a rare case of a patient who required VV-ECMO for respiratory support prior to fracture fixation. The risks of intraoperative fat embolisation causing sudden circuit failure were managed by having a spare circuit available outside the operating room with readiness for an emergency circuit change. Postoperative fat deposition in the oxygenator was managed by a circuit change. Our case is the first to describe preoperative initiation of VV-ECMO for FES and highlights why this therapy should not delay definitive fracture fixation and how it can be safely managed in this setting.

Leptospirosis presenting to an intensive care unit in provincial New Zealand: a case series and review.

BACKGROUND: Leptospirosis is a disease associated with meat and agricultural workers which is endemic in New Zealand and Australia. During 2003-2005, it resulted in 207 hospitalisations in New Zealand. Hawke's Bay had the highest regional incidence in 2004 and 2005. While admission to intensive care units with leptospirosis is not infrequent, no such cases have been described in the literature from New Zealand, and only five from Australia. METHODS: A chart review of all patients admitted to the intensive care/high dependency unit of a regional hospital in New Zealand with a diagnosis of leptospirosis from June 1999 to May 2005. Admission features, progress and diagnostic tests were collated, and APACHE II score on admission and daily Sequential Organ Failure Assessment (SOFA) score were calculated. RESULTS: 15 cases were identified; median age was 44 years (range, 27-62), and 13 were men. Myalgia, headache, nausea and vomiting were common; nine had conjunctival suffusion. Ten had hypotension and 14 had renal failure before ICU admission. Eleven received vasoactive support, and three received renal replacement therapy. Median length of ICU stay was 4 days (range, 2- 11; mean, 4 days). Median hospital stay was 6 days (range, 2-13; mean, 7.6 days). All patients survived and were discharged free of dialysis. CONCLUSION: Leptospirosis presents to the ICU with a variety of signs and symptoms. Renal failure is the most common organ dysfunction requiring intensive care, and its severity is disproportionate to other signs of severe sepsis. Leptospirosis has a good prognosis with early management in an ICU.