Methylene blue as treatment for vasoplegic shock in severe metformin overdose: A case report.

Introduction: Severe metformin overdose can result in life-threatening conditions such as metabolic acidosis with hyperlactatemia and vasoplegic shock. Current treatment guidelines recommend hemodialysis and supportive care. However, this case report presents the use of methylene blue as an additional treatment for severe metformin overdose-induced vasoplegic shock, which is not commonly described in the literature or guidelines. Case report: A 55-year-old woman presented to the emergency department after ingesting 82.5 g of metformin, resulting in severe metabolic acidosis with hyperlactatemia and refractory vasoplegic shock. Despite continuous hemodialysis and high levels of noradrenalin and vasopressin, the shock persisted. Methylene blue was administered, leading to an immediate and persistent reduction in the noradrenalin dose and rapid shock resolution. Discussion: This case illustrates the potential use of methylene blue in the treatment of severe metformin overdose. The mechanism for metformin-induced vasoplegia is likely mediated by nitric oxide (NO). Methylene blue has been used to treat NO-mediated vasoplegia in other conditions, such as sepsis and poisoning with beta-blockers and calcium channel blockers, but it is rarely described in metformin toxicity. Methylene blue has a rapid onset of action, with only a few mild side effects. This case report emphasizes the need for clinicians to consider methylene blue as a potential treatment option in cases of refractory vasoplegic shock due to severe metformin overdose.

Treatment implications of augmented renal clearance in a critically ill COVID-19 patient: A case report.

Augmented renal clearance (ARC) is a pathophysiological phenomenon that can occur in critically ill patients, leading to enhanced renal function. It is defined as a creatinine clearance of >130 mL/min/1.73 m2 . ARC can lead to subtherapeutic levels of renally cleared drugs and subsequent treatment failure. In COVID-19, it has only been described in the literature in a few cases. We present the case of a 38-year-old critically ill patient with COVID-19 who developed ARC with an initial clearance of 226 mL/min/1.73 m2 , persisting for 30 days. He required high doses of sedatives and neuromuscular blocking agents, as well as increased doses of vancomycin and dalteparin, to reach adequate serum levels. This case emphasizes the importance for clinicians to consider ARC in the dosing of all renally cleared drugs, including antibiotics, low molecular weight heparins, and sedatives, to prevent subtherapeutic drug levels and treatment failure.

The association between obesity and pressure ulcer development in critically ill patients: A prospective cohort study.

BACKGROUND: Pressure ulcers (PUs) are one of the leading potentially preventable adverse events in the hospital. Critically ill patients are at risk for the development of PUs. The primary aim of the study was to investigate the relation of PUs and obesity in critically ill ICU patients. METHODS: A single center prospective cohort study was conducted on adult patients with obesity (defined as a body mass index BMI ≥ 30 kg/m2) and patients without obesity (BMI 18-25 kg/m2) admitted to the intensive care unit between May 2013 and July 2017 with an ICU length of stay of at least 3 days without pre-existing PUs at admission. RESULTS: 851 of 1205 patients (70.6%) had a normal BMI and 354 (29.4%) had a BMI ≥ 30 kg/m2 and were considered obese. Overall, 157 patients (13.0%) developed PUs; 112/851 (13.2%) of patients without obesity and 45/354 (12.7%) of patients with obesity (p = 0.907). There was no difference in the severity (p = 0.609) and PU location (p = 0.261). Mean days to PU development was 11.1; 11.7 days for patients without obesity and 9.5 days for patients with obesity (p = 0.270). Mean days to PU recovery was 13.2, which was 14.1 days for patients without obesity and 10.8 days for patients with obesity (p = 0.215). A multivariate logistic regression model showed no significant correlation between the occurrence of PUs in the ICU and obesity (OR 0.875 with 95% CI 0.528-1.448, p = 0.594). Subgroup analysis showed that patients with morbid obesity (BMI ≥ 40 kg/m2) developed PUs earlier during ICU admission when compared to patients without obesity (p = 0.004). CONCLUSION: Our study demonstrates that obesity is not an independent risk factor for the development of PUs in the ICU. However, patients with morbid obesity might develop PUs earlier compared to patients without obesity.

[Medication during severe infections]. / Medicatiegebruik bij patiënten met ernstige infecties.

Severe infectious diseases result in an increased volume of distribution. Renal function is usually impaired, but can in fact be increased early in the course of the disease. In renally cleared drugs with a small therapeutic index a dose reduction should take place or these medications should be temporarily discontinued. Renally cleared antibiotics may be subject to subtherapeutic levels of antibiotics, especially early in the course of the disease. Diuretics and RAAS inhibitors should usually be interrupted during acute illness; bèta-blockers should be continued. Statins can usually be continued. Paracetamol can usually be prescribed. NSAIDs, however, are almost always contra-indicated. Patients with chronic use of corticosteroids should receive a stress dose. There is no evidence to support discontinuing immunosuppressants. Platelet aggregation inhibitors and directly acting oral anticoagulants are continued, whereas coumarins should be monitored vigorously or substituted for low molecular weight heparins.

Considerations in Neuromuscular Blockade in the ICU: A Case Report and Review of the Literature.

Neuromuscular blocking agents are regularly used in the intensive care unit (ICU) to facilitate mechanical ventilation in patients with acute respiratory distress syndrome and patient-ventilator dyssynchronies. However, prolonged neuromuscular blockade is associated with adverse effects like ICU-acquired weakness. Residual neuromuscular blockade is, however, not routinely monitored in the intensive care unit, and as such, this phenomenon might be unrecognized and underreported. We report a case in which an unusual prolonged effect of neuromuscular blockade was seen after cessation of the drug, which illustrates the complexity of neuromuscular blockade in the ICU. We advocate for the use of train-of-four measurements in the ICU, recommend to choose cisatracurium over rocuronium in critically ill patients due to their pharmacokinetics when continuous neuromuscular blockade is considered, and propose a subsequent strategy once the choice has been made to start neuromuscular blockade.

[Autointoxication with 'suicide powder']. / Auto-intoxicatie met 'zelfmoordpoeder'.

We present two patients who were treated for an intentional overdose of sodium nitrite. When ingested sodium nitrite leads to severe methaemoglobinaemia, resulting in severe hypoxia (as methaemoglobin does not transport oxygen), vasodilation and hypotension. Symptoms include cyanosis, headache, nausea, convulsions, coma and death. When measured by pulse oximetry, patients with a sodium nitrite intoxication and severe methaemoglobinaemia generally have an oxygen saturation of around 85%. This value is unreliable as the oxygen content of the blood is often extremely low - this can be confirmed by arterial blood gas analysis. Treatment of sodium nitrite intoxication consists of intravenous administration of methylthioninium chloride 1-2 mg/kg. Methylthioninium chloride converts the methaemoglobin back to haemoglobin. Due to the pharmacokinetics of methylthioninium chloride and sodium nitrite, a rebound effect is not to be expected. The only contra-indication for methylthioninium chloride is glucose-6-phosphate dehydrogenase deficiency, which is extremely rare in the Netherlands.

Microbiological and immunological characteristics of a lethal pulmonary Aspergillus niger infection in a non-neutropenic patient.

Invasive pulmonary aspergillosis is increasingly described in non-neutropenic patients, such as patients with COPD receiving corticosteroids and the critically ill. Here, we present a case of a lethal pulmonary Aspergillus niger infection in a COPD patient. Immunological tests showed an impaired innate and adaptive immune response to Aspergillus. A history of COPD, unresponsiveness to antibiotics and especially a suggestive CT-scan should trigger the clinician to consider diseases caused by Aspergillus.

Effect of preadmission sunlight exposure on intensive care unit-acquired delirium: a multicenter study.

PURPOSE: It is assumed that there is a relation between light exposure and delirium incidence. The aim of our study was to determine the effect of prehospital light exposure on the incidence of intensive care unit (ICU)-acquired delirium. MATERIALS AND METHODS: Data from 3 ICUs in the Netherlands were analyzed retrospectively. Delirium was assessed with the Confusion Assessment Method for the ICU. Daily light intensity data were obtained from meteorological stations in the vicinity of the 3 hospitals. The association between light intensity and delirium incidence was analyzed using logistic regression analysis adjusting for known covariates for delirium. RESULTS: Data of 3198 patients, aged (mean ± SD) 61.9 ± 15.3 years with Acute Physiology and Chronic Health Evaluation II score 16.4 ± 6.6 were analyzed. Delirium incidence was 31.2% and did not vary significantly throughout the year. Twenty-eight-day preadmission photoperiod was highest in spring and lowest in winter; however, no association between light exposure and delirium incidence was found (odds ratio, 1.00; 95% confidence interval, 0.99-1.00; P = 0.72). Furthermore, delirium was significantly associated with age, infection, use of sedatives, Acute Physiology and Chronic Health Evaluation II score, and diagnosis of neurological disease or trauma. CONCLUSIONS: The incidence of delirium does not differ per season and prior sunlight exposure does not play a role of importance in the development of ICU-acquired delirium.