Case Reports in Critical Care The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Combined Negative- and Positive-Pressure Ventilation for the Treatment of ARDS Tue, 28 Jul 2015 08:27:41 +0000 Objective. Tracheal intubation and positive-pressure ventilation as the current standard of care for the adult respiratory distress syndrome (ARDS) seem to have reached their limit in terms of a further relevant reduction of the still very high mortality. Case Presentation. A 75-year-old male patient developed ARDS after abscess drainage with deteriorating oxygenation, despite positive end-expiratory pressure (PEEP) values above 15 cm H2O. We applied external negative-pressure ventilation with a chamber respirator using −33 cm H2O at inspiration and −15 cm H2O at expiration, combined with conventional pressure support using a PEEP of about 8 cm H2O and a pressure support of 4–12 cm H2O. Alveolar infiltrates disappeared rapidly and PaO2/FiO2 values surpassed 300 mmHg after the first application and 500 mmHg after the second. Negative-pressure ventilation was used for 6–18 hours/day over five days. Now, 13 years later, the patient is still alive and has a good quality of life. Conclusion. Using this or similar concepts, not only in intubated patients but also as a noninvasive approach in patients with ARDS, offers new options that may genuinely differ from the present therapeutic approaches and may, therefore, have the potential to decrease the present high mortality from ARDS. Konstantinos Raymondos, Jörg Ahrens, and Ulrich Molitoris Copyright © 2015 Konstantinos Raymondos et al. All rights reserved. Traumatic Cervical Spondyloptosis in a Neurologically Stable Patient: A Therapeutic Challenge Thu, 16 Jul 2015 05:54:00 +0000 This is a case report of a neurologically intact patient following posttraumatic cervical spondyloptosis. We discuss the disease, management protocol and some surgical nuances to prevent any damage to the cord during different stages of its treatment. Sunil Munakomi, Binod Bhattarai, and Iype Cherian Copyright © 2015 Sunil Munakomi et al. All rights reserved. Rare Strain of Vibrio cholerae Septicemia in a Patient with Multiple Myeloma Wed, 15 Jul 2015 09:10:58 +0000 Introduction. Non-O1/non-O139 is a rare strain of Vibrio cholera that has been documented to cause significant morbidity and mortality in the immunosuppressed population. Case Presentation. A patient with multiple myeloma develops non-O1/non-O139 Vibrio cholera septicemia, leading to multiorgan failure and ultimately death. Discussion. An exceedingly rare strain of Vibrio cholera, non-O1/non-O139, may be an important factor of morbidity and mortality in certain immunosuppressed populations, such as patients with multiple myeloma and malignancies. Conclusion. Bacteremia involving generally noninvasive microbes, such as non-O1/non-O139 Vibrio cholerae, can have significant deleterious effects in the immunosuppressed patients as shown by this case report. Physicians need to be more diligent when treating these patients. Deepu Daniel and Sunil Kumar Copyright © 2015 Deepu Daniel and Sunil Kumar. All rights reserved. Flucytosine Pharmacokinetics in a Critically Ill Patient Receiving Continuous Renal Replacement Therapy Sun, 12 Jul 2015 10:25:03 +0000 Purpose. A case report evaluating flucytosine dosing in a critically ill patient receiving continuous renal replacement therapy. Summary. This case report outlines an 81-year-old male who was receiving continuous venovenous hemofiltration (CVVH) for acute renal failure and was being treated with flucytosine for the treatment of disseminated Cryptococcus neoformans infection. Due to patient specific factors, flucytosine was empirically dose adjusted approximately 50% lower than intermittent hemodialysis (iHD) recommendations and approximately 33% lower than CRRT recommendations. Peak and trough levels were obtained, which were supratherapeutic, and pharmacokinetic parameters were calculated. The patient experienced thrombocytopenia, likely due to elevated flucytosine levels, and flucytosine was ultimately discontinued. Conclusion. Despite conservative flucytosine dosing for a patient receiving CVVH, peak and trough serum flucytosine levels were supratherapeutic (120 μg/mL at 2 hours and 81 μg/mL at 11.5 hours), which increased drug-related adverse effects. The results indicate that this conservative dosing regimen utilizing the patient’s actual body weight was too aggressive. This case report provides insight into flucytosine dosing in CVVH, a topic that has not been investigated previously. Further pharmacokinetic studies of flucytosine dosing in critically ill patients receiving CVVH are needed in order to optimize pharmacokinetic and pharmacodynamic parameters while avoiding toxic flucytosine exposure. Megan E. Kunka, Elizabeth A. Cady, Heejung C. Woo, and Melissa L. Thompson Bastin Copyright © 2015 Megan E. Kunka et al. All rights reserved. Normalization of Activated Partial Thromboplastin Time Correlates with Low Levels of Dabigatran in a Patient with Severe Sepsis Mon, 29 Jun 2015 06:12:47 +0000 The oral anticoagulant dabigatran etexilate can be a challenge when patients need acute surgery. Sepsis and acute renal failure exacerbate the anticoagulant effect. There is no specific reversal agent for dabigatran etexilate, but it can be removed by hemodialysis. We present a case where a patient treated with dabigatran etexilate was admitted to intensive care unit with severe sepsis and acute renal failure and in need of bilateral lower limp amputation due to ischemia. The patient had severe coagulopathy and was treated with continuous venovenous hemofiltration in attempt to remove dabigatran etexilate before surgery. Rikke Ebenhard Højland, Stine Borch Thorup, and Bodil Steen Rasmussen Copyright © 2015 Rikke Ebenhard Højland et al. All rights reserved. Spontaneous Dissection of the Renal Artery in Vascular Ehlers-Danlos Syndrome Mon, 15 Jun 2015 12:45:42 +0000 Ehlers-Danlos syndrome (EDS) is a rare heterogeneous group of connective tissue disorders. The vascular type (vEDS) is an autosomal dominant disorder caused by heterozygous mutations in the COL3A1 gene predisposing to premature arterial, intestinal, or uterine rupture. We report a case of a 38-year-old woman with a recent diagnosis of vEDS admitted in the Emergency Department with a suspicion of a pyelonephritis that evolved to a cardiopulmonary arrest. A fatal retroperitoneal hematoma related with a haemorrhagic dissection of the right renal artery was found after emergency surgery. This case highlights the need to be aware of the particular characteristics of vEDS, such as a severe vascular complication that can lead to a fatal outcome. Filipa Pereira, Teresa Cardoso, and Paula Sá Copyright © 2015 Filipa Pereira et al. All rights reserved. Severe Dextran-Induced Anaphylactic Shock during Induction of Hypertension-Hypervolemia-Hemodilution Therapy following Subarachnoid Hemorrhage Thu, 11 Jun 2015 05:59:20 +0000 Dextran is a colloid effective for volume expansion; however, a possible side effect of its use is anaphylaxis. Dextran-induced anaphylactoid reaction (DIAR) is a rare but severe complication, with a small dose of dextran solution sufficient to induce anaphylaxis. An 86-year-old female who underwent clipping for a ruptured cerebral aneurysm was admitted to the intensive care unit. Prophylactic hypertension-hypervolemia-hemodilution therapy was induced for cerebral vasospasm following a subarachnoid hemorrhage. The patient went into severe shock after administration of dextran for volume expansion, and dextran administration was immediately discontinued. The volume administered at that time was only 0.8 mL at the most. After fluid resuscitation with a crystalloid solution, circulatory status began to recover. However, cerebral vasospasm occurred and the patient’s neurological condition deteriorated. Five weeks after the shock, she was diagnosed with hypersensitivity to dextran by a skin test. When severe hypotension occurs after dextran administration, appropriate treatments for shock should be performed immediately with discontinuation of dextran solution. Although colloid administration is recommended in some guidelines and researches, it is necessary to consider concerning the indication for volume expansion as well as the risk of colloid administration. Tohru Shiratori, Atsushi Sato, Masao Fukuzawa, Naoko Kondo, and Shogo Tanno Copyright © 2015 Tohru Shiratori et al. All rights reserved. Severe Uncompensated Metabolic Alkalosis due to Plasma Exchange in a Patient with Pulmonary-Renal Syndrome: A Clinician’s Challenge Mon, 08 Jun 2015 12:46:53 +0000 Metabolic alkalosis secondary to citrate toxicity from plasma exchange is very uncommon in patients with normal renal function. In patients with advanced renal disease this can be a fatal event. We describe a case of middle-aged woman with Goodpasture’s syndrome treated with plasma exchange who developed severe metabolic alkalosis. High citrate load in plasma exchange fluid is the underlying etiology. Citrate metabolism generates bicarbonate and once its level exceeds the excretory capacity of kidneys, the severe metabolic alkalosis ensues. Our patient presented with generalized weakness, fever, and oliguria and developed rapidly progressive renal failure. Patient had positive serology for antineutrophilic cytoplasmic antibodies myeloperoxidase (ANCA-MPO) and anti-glomerular basement membrane antibodies (anti-GBM). Renal biopsy showed diffuse necrotizing and crescentic glomerulonephritis with linear glomerular basement membrane staining. Patient did not respond to intravenous steroids. Plasma exchange was started with fresh frozen plasma but patient developed severe metabolic alkalosis. This metabolic alkalosis normalized with cessation of plasma exchange and initiation of low bicarbonate hemodialysis. ANCA-MPO and anti-GBM antibodies levels normalized within 2 weeks and remained undetectable at 3 months. Patient still required maintenance hemodialysis. Mohsin Ijaz, Naeem Abbas, and Dmitry Lvovsky Copyright © 2015 Mohsin Ijaz et al. All rights reserved. Clinical Brain Death with False Positive Radionuclide Cerebral Perfusion Scans Mon, 08 Jun 2015 07:53:18 +0000 Practice guidelines from the American Academy of Neurology for the determination of brain death in adults define brain death as “the irreversible loss of function of the brain, including the brainstem.” Neurological determination of brain death is primarily based on clinical examination; if clinical criteria are met, a definitive confirmatory test is indicated. The apnea test remains the gold standard for confirmation. In patients with factors that confound the clinical determination or when apnea tests cannot safely be performed, an ancillary test is required to confirm brain death. Confirmatory ancillary tests for brain death include (a) tests of electrical activity (electroencephalography (EEG) and somatosensory evoked potentials) and (b) radiologic examinations of blood flow (contrast angiography, transcranial Doppler ultrasound (TCD), and radionuclide methods). Of these, however, radionuclide studies are used most commonly. Here we present data from two patients with a false positive Radionuclide Cerebral Perfusion Scan (RCPS). Sindhaghatta Venkatram, Sara Bughio, and Gilda Diaz-Fuentes Copyright © 2015 Sindhaghatta Venkatram et al. All rights reserved. Liver Trauma in the Kitchen: Preparing Whipped Cream with a Siphon Is Not without Risk Sun, 07 Jun 2015 08:19:09 +0000 We report the case of a 36-year-old woman suffering from liver injury caused by the malfunction of a whipped cream siphon. When this patient handled the whipped cream siphon, the screwed metallic upper part of the siphon was suddenly dissociated from its base and came violently striking her right hypochondrium. At first, the severity of injury was underestimated. Subsequently, due to the persistence of pain experienced by the patient, an abdominal CT scan was performed. It highlighted a severe liver injury with rupture of a branch of the hepatic artery. The evolution was favorable after completion of an embolization and a secondary capsular rupture. Jeremy Bourenne, Béatrice Eon, Fouad Bouzana, Dominique Lambert, Estelle Jean, Pierre Michelet, and Marc Gainnier Copyright © 2015 Jeremy Bourenne et al. All rights reserved. Diagnostic Challenge in a Patient with Severe Anion Gap Metabolic Acidosis Sun, 31 May 2015 14:05:27 +0000 The approach to the patient with acute renal failure and elevated anion and osmolal gap is difficult. Differential diagnoses include toxic alcohol ingestion, diabetic or starvation ketoacidosis, or 5-oxoproline acidosis. We present a 76-year-old female with type 2 diabetes mellitus, who was found at home in a confused state. Laboratory analysis revealed serum pH 6.84, bicarbonate 5.8 mmol/L, pCO2 29 mmHg, anion gap 22.2 mmol/L, osmolal gap 17.4 mOsm/kg, elevated beta-hydroxybutyrate (4.2 mmol/L), random blood sugar 213 mg/dL, creatinine 2.1 mg/dL, and potassium 7.5 mmol/L with no electrocardiogram (EKG) changes. Fomepizole and hemodialysis were initiated for presumed ethylene glycol or methanol ingestion. Drug screens returned negative for ethylene glycol, alcohols, and acetaminophen, but there were elevated urine levels of acetone (11 mg/dL). The acetaminophen level was negative, and 5-oxoproline was not analyzed. After 5 days in the intensive care unit (ICU), her mental status improved with supportive care. She was discharged to a nursing facility. Though a diagnosis was not established, our patient’s presentation was likely due to starvation ketosis combined with chronic acetaminophen ingestion. Acetone ingestion is less likely. Overall, our case illustrates the importance of systematically approaching an elevated osmolal and anion gap metabolic acidosis. Eugene M. Tan, Ejaaz Kalimullah, M. Rizwan Sohail, and Kannan Ramar Copyright © 2015 Eugene M. Tan et al. All rights reserved. Pulmonary Hemorrhage Secondary to Disseminated Strongyloidiasis in a Patient with Systemic Lupus Erythematosus Tue, 26 May 2015 10:11:19 +0000 Introduction. Pulmonary hemorrhage secondary to disseminated strongyloidiasis is an unusual, well-recognized entity in immunocompromised patients with autoimmune disease, which is associated with the hyperinfection syndrome, sepsis, and a high mortality rate. Case Presentation. We present a case of a 44-year-old Mexican woman with systemic lupus erythematosus and acute bacterial meningitis who developed pulmonary hemorrhage with acute respiratory failure requiring mechanical ventilation, treated with broad spectrum systemic antibiotics and high dose methylprednisolone, who subsequently developed a characteristic purpuric skin eruption and septic shock and died two days later of refractory hypoxemia caused by massive pulmonary bleeding. The postmortem examination reports filariform larvae of S. stercolaris in lung, skin, and other organs. Conclusion. This case highlights the importance of considering disseminated strongyloidiasis in the differential diagnosis of diffuse alveolar hemorrhage in systemic lupus erythematosus, and screening for S. stercolaris infection before initiation of immunosuppressive therapy should be considered, especially in endemic areas. Disseminated strongyloidiasis has a high mortality rate, explained in part by absence of clinical suspicion. Erika P. Plata-Menchaca, V. M. De la Puente-Diaz de Leon, Adriana G. Peña-Romero, and Eduardo Rivero-Sigarroa Copyright © 2015 Erika P. Plata-Menchaca et al. All rights reserved. Gas-Forming Pyogenic Liver Abscess with Septic Shock Sun, 24 May 2015 14:23:12 +0000 The pyogenic liver abscess caused by Clostridium perfringens (C. perfringens) is a rare but rapidly fatal infection. The main virulence factor of this pathogen is its α-toxin (lecithinase), which decomposes the phospholipid in cell membranes leading to cell lysis. Once the bacteria are in blood stream, massive intravascular hemolysis occurs. This can present as anemia on admission with evidence of hemolysis as indicated by low serum haptoglobin, high serum lactate dehydrogenase (LDH), elevated indirect bilirubin, and spherocytosis. The clinical course of C. perfringens septicemia is marked by rapidly deteriorating course with a mortality rate ranging from 70 to 100%. The very rapid clinical course makes it difficult to diagnose on time, and most cases are diagnosed at autopsy. Therefore it is important to consider C. perfringens infection in any severely ill patient with fever and evidence of hemolysis. We present a case of seventy-seven-year-old male with septic shock secondary to pyogenic liver abscess with a brief review of existing literature on C. perfringens. Muhammad S. Khan, Muhammad K. Ishaq, and Kellie R. Jones Copyright © 2015 Muhammad S. Khan et al. All rights reserved. Anaphylactoid Reaction from IV Contrast Dye Causing Ischemic Colitis with Portal Venous Gas Thu, 23 Apr 2015 06:51:56 +0000 Portal venous gas is a radiographic finding with numerous causes. The most common etiologies include bowel ischemia or other intra-abdominal catastrophes. The finding of portal venous gas carries a high mortality rate. We report the first case of portal venous gas associated with anaphylactoid reaction to intravenous contrast dye in a middle-aged woman. This was likely secondary to anaphylactoid-induced ischemic colitis. This patient was managed conservatively and had a good outcome. Adeleke Adesina, Adam Colombo, and Rebecca Jeanmonod Copyright © 2015 Adeleke Adesina et al. All rights reserved. Always Consider the Possibility of Opioid Induced Respiratory Depression in Patients Presenting with Hypercapnic Respiratory Failure Who Fail to Improve as Expected with Appropriate Therapy Sun, 29 Mar 2015 12:31:25 +0000 Hypercapnic respiratory failure is a frequently encountered medical emergency. Two common causes are acute exacerbations of chronic obstructive pulmonary disease (COPD) and as a side effect of opioids. The two causes may coexist leading to diagnostic confusion and consequent delay in optimal management. We report a case of what was initially thought to be an exacerbation of COPD. The patient failed to improve with treatment as expected which led to the empirical administration of naloxone resulting in a dramatic reversal of her respiratory failure. The patient was subsequently discovered to be taking regular dihydrocodeine for chronic back pain. Martin Steynor and Andrew MacDuff Copyright © 2015 Martin Steynor and Andrew MacDuff. All rights reserved. Recurrent Febrile Neutropenia and Thrombocytopenia in a Chronic Cocaine User: A Case of Levamisole Induced Complications Sun, 22 Mar 2015 10:43:36 +0000 Cocaine is used by approximately 1.5 million Americans each month and up to 69% of the cocaine seized contains levamisole. The real incidence of cocaine-levamisole induced neutropenia is unclear but probably underestimated. Associated complications include fever, thrombocytopenia, skin-vasculitis disorders, and rarely kidney injury. We present a young male, with chronic active cocaine use presenting with recurrent episodes of febrile neutropenia and thrombocytopenia. He underwent extensive work-up and was treated with many antibiotics and we suspect that his neutropenia and thrombocytopenia were caused by recurrent cocaine-levamisole use. Eduardo Martinez, Raza Alvi, Sindhaghatta Venkatram, and Gilda Diaz-Fuentes Copyright © 2015 Eduardo Martinez et al. All rights reserved. Nitric Oxide-Sensitive Pulmonary Hypertension in Congenital Rubella Syndrome Mon, 16 Feb 2015 13:02:43 +0000 Persistent pulmonary hypertension is a very rare presentation of congenital virus infection. We discuss the case of complete congenital rubella syndrome presenting at echocardiography with pulmonary hypertension that worsened after ductus ligation. Cardiac catheterization showed a normal pulmonary valve and vascular tree but a  mmHg. The infant promptly responded to inhaled nitric oxide while on mechanical ventilation and was later shifted to oral sildenafil. It is not clear whether our observation may be due to direct viral damage to the endothelium or to the rubella virus increasing the vascular tone via a metabolic derangement. Francesco Raimondi, Fiorella Migliaro, Elisa Di Pietro, Francesco Borgia, Antonio Rapacciuolo, and Letizia Capasso Copyright © 2015 Francesco Raimondi et al. All rights reserved. Staphylococcal Toxic Shock Syndrome Caused by Tampon Use Mon, 26 Jan 2015 07:37:14 +0000 The authors report a case of near-fatal sepsis with multiorgan failure resulting from a Staphylococcal tampon-associated toxic shock syndrome, requiring a lengthy critical care admission. Successful treatment of this condition focuses on early identification, source control, and administration of antimicrobial agents. Intravenous immunoglobulin therapy used early may prevent widespread tissue necrosis. Cian McDermott and Michael Sheridan Copyright © 2015 Cian McDermott and Michael Sheridan. All rights reserved. Management of Cerebellar Tonsillar Herniation following Lumbar Puncture in Idiopathic Intracranial Hypertension Sun, 18 Jan 2015 13:57:39 +0000 Lumbar puncture is performed routinely for diagnostic and therapeutic purposes in idiopathic intracranial hypertension, despite lumbar puncture being classically contraindicated in the setting of raised intracranial pressure. We report the case of a 30-year-old female with known idiopathic intracranial hypertension who had cerebellar tonsillar herniation following therapeutic lumbar puncture. Management followed guidelines regarding treatment of traumatic intracranial hypertension, including rescue decompressive craniectomy. We hypothesize that the changes in brain compliance that are thought to occur in the setting of idiopathic intracranial hypertension are protective against further neuronal injury due to axonal stretch following decompressive craniectomy. Kenneth R. Hoffman, Sean W. Chan, Andrew R. Hughes, and Stephen J. Halcrow Copyright © 2015 Kenneth R. Hoffman et al. All rights reserved. Systemic Capillary Leak Syndrome: Is Methylene Blue the Silver Bullet? Sun, 07 Dec 2014 00:10:26 +0000 Background. Systemic capillary leak syndrome (SCLS) is a rare disorder characterized by unexplained, recurrent episodes of transient, abrupt increase in endothelial permeability, leading to severe hypotension, generalized edema, and hemoconcentration. Case Report. We report the case of a patient suffering from systemic capillary leak syndrome and present a possible interpretation of the pathophysiology of this condition. Besides the classical triad of hypotension, edema, and hemoconcentration, we recorded increased levels of methemoglobin, an index of NO overproduction. We present a possible interpretation of the pathophysiology of this condition based on the fast and complete reversal of symptoms after methylene blue administration (which opposes NO-induced effects) and speculate that increased NO levels could be implicated in the pathophysiology of the capillary leak phase. Why should an emergency physician be aware of this? The safety of this treatment and its fluid- and cathecolamine-sparing effect deserve consideration and further research. Michele Umbrello, Marco Gardinali, Davide Ottolina, Giancarlo Zanforlin, and Gaetano Iapichino Copyright © 2014 Michele Umbrello et al. All rights reserved. Early Implementation of THAM for ICP Control: Therapeutic Hypothermia Avoidance and Reduction in Hypertonics/Hyperosmotics Thu, 04 Dec 2014 09:01:31 +0000 Background. Tromethamine (THAM) has been demonstrated to reduce intracranial pressure (ICP). Early consideration for THAM may reduce the need for other measures for ICP control. Objective. To describe 4 cases of early THAM therapy for ICP control and highlight the potential to avoid TH and paralytics and achieve reduction in sedation and hypertonic/hyperosmotic agent requirements. Methods. We reviewed the charts of 4 patients treated with early THAM for ICP control. Results. We identified 2 patients with aneurysmal subarachnoid hemorrhage (SAH) and 2 with traumatic brain injury (TBI) receiving early THAM for ICP control. The mean time to initiation of THAM therapy was 1.8 days, with a mean duration of 5.3 days. In all patients, after 6 to 12 hours of THAM administration, ICP stability was achieved, with reduction in requirements for hypertonic saline and hyperosmotic agents. There was a relative reduction in mean hourly hypertonic saline requirements of 89.1%, 96.1%, 82.4%, and 97.0% for cases 1, 2, 3, and 4, respectively, comparing pre- to post-THAM administration. Mannitol, therapeutic hypothermia, and paralytics were avoided in all patients. Conclusions. Early administration of THAM for ICP control could potentially lead to the avoidance of other ICP directed therapies. Prospective studies of early THAM administration are warranted. F. A. Zeiler, L. M. Gillman, J. Teitelbaum, and M. West Copyright © 2014 F. A. Zeiler et al. All rights reserved. Hypertriglyceridemia Induced Pancreatitis (Chylomicronemia Syndrome) Treated with Supportive Care Sun, 23 Nov 2014 08:25:48 +0000 Hypertriglyceridemia is a rare cause of pancreatitis. In treatment pancreatic rest, lifestyle changes, medications (fibrates, n-3 polyunsaturated fatty acids, and nicotinic acid) are essential. Many experimental treatment modalities have been reported as insulin and heparin infusion and plasmapheresis. In this study we present the hypertriglyceridemia-induced pancreatitis treated with supportive care. Emin Uysal, Yahya Ayhan Acar, Emel Gökmen, Ahmet Kutur, and Hatice Doğan Copyright © 2014 Emin Uysal et al. All rights reserved. Air Embolism after Endoscopic Retrograde Cholangiopancreatography in a Patient with Budd Chiari Syndrome Tue, 18 Nov 2014 06:57:33 +0000 Endoscopic retrograde cholangiopancreatography is a procedure commonly used for the diagnosis and treatment of various pancreatic and biliary diseases. Air embolism is a rare complication, which may be associated with this procedure. This condition can be manifested as cardiopulmonary instability and/or neurological symptoms. Known risk factors include: sphincterotomy; application of air with high intramural pressure; anatomic abnormalities; and chronic hepatobiliary inflammation. It is important for the health-care staff, including anesthesiologists, interventional gastroenterologists, and critical care specialists, amongst others, to promptly recognize air embolism and to initiate therapy in a timely fashion, thus preventing potentially fatal outcomes. We submit a brief review of the literature and a case report of air embolism which occurred in the immediate postoperative stage of an endoscopic retrograde cholangiopancreatography, performed in a woman with a history of liver transplantation due to Budd Chiari syndrome and biliary stricture. Beatriz Wills-Sanin, Yenny R. Cárdenas, Lucas Polanco, Oscar Rivero, Sebastian Suarez, and Andrés F. Buitrago Copyright © 2014 Beatriz Wills-Sanin et al. All rights reserved. Maintaining Oxygenation Successfully with High Flow Nasal Cannula during Diagnostic Bronchoscopy on a Postoperative Lung Transplant Patient in the Intensive Care Thu, 13 Nov 2014 07:46:11 +0000 Bronchoscopy is an important diagnostic and therapeutic intervention for a variety of patients displaying pulmonary pathology. The heterogeneity of the patients undergoing bronchoscopy affords a challenge for providing minimal and safe respiratory support during anesthesia. Currently, options are intubation and general anesthesia versus frequently inadequate sedation or local anaesthesia with low flow oxygen through nasal prongs or mouthpiece. The advent of high flow nasal cannula allows the clinician to have a “middle man” that allows high flow oxygen delivery as well as a degree of respiratory support, which in some cases has been noted to be between 3 and 4 cm of continuous positive airway pressure-like effect. There are minimal data analyzing the use of high flow nasal cannula during anesthesia for bronchoscopy. We present a case report of orthotropic lung transplant recipient undergoing diagnostic bronchoscopy whilst being supported with high flow nasal oxygen in the intensive care unit. Sara Diab and John F. Fraser Copyright © 2014 Sara Diab and John F. Fraser. All rights reserved. Fatal Pulmonary Tumor Embolic Microangiopathy in Young Lady without Known Primary Malignancy Thu, 13 Nov 2014 06:57:49 +0000 Pulmonary embolism (PE) is a common cause of morbidity and mortality in hospitalized patients. Malignancy, prolonged recumbence, and chemotherapy are renowned risk factors for development of clinically significant PE. Cancer exerts a multitude of pathophysiological processes, for example, hypercoagulability and abnormal vessels with sluggish circulation that can lead to PE. One of the peculiar characteristics of tumor cells is their ability to reach the circulation and behave as blood clot—not a metastasis-occluding the pulmonary circulation. We present a case of fatal pulmonary embolism diagnosed histologically to be due to tumor cell embolism. Adel Hammodi, M. Ali Al-Azem, Ahmed Hanafy, and Talal Nakkar Copyright © 2014 Adel Hammodi et al. All rights reserved. Norepinephrine as a Potential Aggravator of Symptomatic Cerebral Vasospasm: Two Cases and Argument for Milrinone Therapy Sun, 09 Nov 2014 11:37:02 +0000 Background. During hypertensive therapy for post-subarachnoid hemorrhage (SAH) symptomatic vasospasm, norepinephrine is commonly used to reach target blood pressures. Concerns over aggravation of vasospasm with norepinephrine exist. Objective. To describe norepinephrine temporally related deterioration in neurological examination of two post-SAH patients in vasospasm. Methods. We retrospectively reviewed two charts of patients with delayed cerebral ischemia (DCI) post-SAH who deteriorated with norepinephrine infusions. Results. We identified two patients with DCI post-SAH who deteriorated during hypertensive therapy with norepinephrine. The first, a 43-year-old male presented to hospital with DCI, failed MABP directed therapy with rapid deterioration in exam with high dose norepinephrine and MABP of 140–150 mm Hg. His exam improved on continuous milrinone and discontinuation of norepinephrine. The second, a 39-year-old female who developed DCI on postbleed day 8 responded to milrinone therapy upfront. During further deterioration and after angioplasty, norepinephrine was utilized to drive MABP to 130–140 mm Hg. Progressive deterioration in examination occurred after angioplasty as norepinephrine doses escalated. After discontinuation of norepinephrine and continuation of milrinone, function dramatically returned but not to baseline. Conclusions. The potential exists for worsening of DCI post-SAH with hypertensive therapy directed by norepinephrine. A potential role exists for vasodilation and inotropic directed therapy with milrinone in the setting of DCI post-SAH. F. A. Zeiler, J. Silvaggio, A. M. Kaufmann, L. M. Gillman, and M. West Copyright © 2014 F. A. Zeiler et al. All rights reserved. Complete Heart Block and Persistent Lactic Acidosis as an Initial Presentation of Non-Hodgkin Lymphoma in a Critically Ill Newly Diagnosed AIDS Patient Thu, 06 Nov 2014 11:42:20 +0000 A 66-year-old male with newly diagnosed untreated acquired immunodeficiency syndrome (AIDS) presented with chronic nonspecific complaints of weakness, fatigue, myalgia, and weight loss. His initial EKG showed complete heart block necessitating temporary pacemaker placement. He had no previous history of cardiac disease. He was also found to have a persistent lactic acidosis and imaging studies showed abdominal lymphadenopathy. The patient underwent biopsy of these lymph nodes and was found to have diffuse large B-cell lymphoma. The hospital course was complicated by respiratory failure requiring mechanical ventilator support and cardiac arrest. Patient remained critically ill; he was not a candidate for chemotherapy and, after a month of hospitalization, he died. Lactic acidosis and heart block as an initial presentation of non-Hodgkin lymphoma in an AIDS patient are an unusual and unique presentation. Mohsin Ijaz, Hassan Tariq, Masooma Niazi, and Dmitry Lvovsky Copyright © 2014 Mohsin Ijaz et al. All rights reserved. Prolonged QT Syndrome in a 27-Year-Old Female Presenting as a Cardiac Arrest after Elective Surgery Thu, 06 Nov 2014 09:12:04 +0000 Cardiac arrest is a true medical emergency and clinicians should base the management on American Heart Association advanced cardiac life support algorithm. The potential triggers of cardiac arrest should be sought. We present a case of a 27-year-old female who developed cardiac arrest and was later found to have congenital long QT syndrome. The patient’s outcome was favorable. Discussion of the key management options will be discussed in the text. Aibek E. Mirrakhimov, Prakruthi Voore, and Alaa M. Ali Copyright © 2014 Aibek E. Mirrakhimov et al. All rights reserved. Intravenous Lormetazepam during Sedation Weaning in a 26-Year-Old Critically Ill Woman Wed, 08 Oct 2014 09:49:41 +0000 Recent evidence revealed that sedation is related to adverse outcomes including a higher mortality. Despite this fact, patients sometimes require deep sedation for a limited period of time to control, for example, intracranial hypertension. In particular in these cases, weaning from sedation is often challenging due to emerging agitation, stress, and delirium. The submitted research letter reports a rare case of severe and persisting agitation that was unresponsive to all available treatments. Ultimately, lormetazepam which has recently become available for intravenous use in Germany resolved the problem by stress-reduction and anxiolysis without leading to measurable sedation. Alawi Luetz, Bjoern Weiss, and Claudia D. Spies Copyright © 2014 Alawi Luetz et al. All rights reserved. Anterior Ischemic Optic Neuropathy as a Manifestation of HELLP Syndrome Mon, 29 Sep 2014 06:20:36 +0000 Thrombotic microangiopathies (TMAs) are a group of disorders characterized by occurrence of thrombi of fibrin and/or platelets with microvascular occlusion and organ ischemia especially the kidney and brain. Hemolysis with a microangiopathic blood smear, elevated liver enzymes, and low platelet count (HELLP syndrome) is a type of TMA peculiar to pregnancy and may be associated with neurological complications. Visual complications in HELLP are usually related to cortical blindness. We present the first case of HELLP associated with bilateral anterior ischemic optic neuropathy (AION) and blindness which resolved with plasma exchange. Boby Varkey Maramattom Copyright © 2014 Boby Varkey Maramattom. All rights reserved.