Case Reports in Critical Care https://www.hindawi.com The latest articles from Hindawi © 2017 , Hindawi Limited . All rights reserved. Heat Stroke: A Medical Emergency Appearing in New Regions Wed, 13 Sep 2017 00:00:00 +0000 http://www.hindawi.com/journals/cricc/2017/6219236/ Heat stroke is an acute, life-threatening emergency characterized clinically by elevated body temperature and central nervous system dysfunction. Early recognition and treatment including aggressive cooling and management of life-threatening systemic complications are essential to reduce morbidity and mortality. This case report describes two Danish patients diagnosed with heat stroke syndrome during a heat wave in the summer of 2014. Both patients were morbidly obese and had several predisposing illnesses. However since heat stroke is a rare condition in areas with temperate climate, they were not diagnosed until several days after admittance; hence treatment with cooling was delayed. Both patients were admitted to the intensive care unit, where they were treated with an external cooling device and received treatment for complications. Both cases ended fatally. As global warming continues, more heat waves will occur in previously cooler regions. Therefore it is important to raise awareness of heat stroke since outcome depends on early recognition and rapid cooling. Sofie Søndergaard Mørch, Johnny Dohn Holmgren Andersen, and Morten Heiberg Bestle Copyright © 2017 Sofie Søndergaard Mørch et al. All rights reserved. Spontaneous Tumor Lysis Syndrome due to Uterine Leiomyosarcoma with Lung Metastases Mon, 11 Sep 2017 00:00:00 +0000 http://www.hindawi.com/journals/cricc/2017/4141287/ Tumor lysis syndrome (TLS) is an oncologic emergency characterized by a combination of metabolic derangements (hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia) caused by rapid turnover from cell destruction in certain cancers. These metabolic derangements can lead to seizures, cardiac arrhythmias, renal failure, and death. TLS is usually seen after the initiation of chemotherapy for hematologic malignancies. TLS occurring spontaneously, without initiation of chemotherapy, is rare and its occurrence in solid tumors is rarer still. We report a case of spontaneous TLS in a patient with leiomyosarcoma of the uterus, with metastasis to lung. Such a case has never been reported before. Vivek Alaigh and Debapriya Datta Copyright © 2017 Vivek Alaigh and Debapriya Datta. All rights reserved. Significant Bradycardia in Critically Ill Patients Receiving Dexmedetomidine and Fentanyl Wed, 06 Sep 2017 09:44:31 +0000 http://www.hindawi.com/journals/cricc/2017/4504207/ Purpose. To report a case series of three patients who developed significant bradycardia while receiving the combination of dexmedetomidine and fentanyl for sedation and analgesia. Materials and Methods. This is a case series of patients obtained from a mixed medical, surgical, and cardiac ICU in a community teaching hospital. Three intubated patients receiving fentanyl and dexmedetomidine infusion developed sudden bradycardia requiring intervention. In all three cases, adjustments to therapy were required. Results. All three patients experienced significant bradycardia, with a heart rate less than 50 bpm, and one patient briefly developed asystole. In Case  1, the fentanyl infusion rate was reduced by 67% and the dexmedetomidine infusion rate was reduced by 25%. In Case  2, the sedation was changed to midazolam, and in Case  3, both fentanyl and dexmedetomidine were discontinued. In all three cases, there were no further incidences of significant bradycardia following intervention. Conclusions. Fentanyl used in combination with dexmedetomidine can result in clinically significant bradycardia. Further study is warranted to identify risk factors and elucidate the mechanisms that result in life-threatening bradycardia. Channing Hui, Maria Cardinale, and Balaji Yegneswaran Copyright © 2017 Channing Hui et al. All rights reserved. Stress Cardiomyopathy Managed with Extracorporeal Support after Self-Injection of Epinephrine Sun, 27 Aug 2017 00:00:00 +0000 http://www.hindawi.com/journals/cricc/2017/3731069/ A 28-year-old man was admitted to the ICU for self-injection of Epinephrine. This injection resulted in the rapid development of a catecholamine-induced cardiomyopathy (inverted Takotsubo) with a severe cardiogenic shock. The importance of ventricular dysfunction required the implementation of a temporary arteriovenous circulatory support until the recovery of myocardial stunning. This case allows redefining the role of circulatory assistance during cardiotropic agents intoxication. Bourenne Jeremy, Fresco Raphaëlle, Kerbaul François, Michelet Pierre, and Gainnier Marc Copyright © 2017 Bourenne Jeremy et al. All rights reserved. Anoxic Brain Injury Presenting as Pseudosubarachnoid Hemorrhage in the Medical Intensive Care Unit Wed, 23 Aug 2017 07:16:11 +0000 http://www.hindawi.com/journals/cricc/2017/9071482/ Anoxic encephalopathy is frequently encountered in the medical intensive care unit (ICU). Cerebral edema as a result of anoxic brain injury can result in increased attenuation in the basal cisterns and subarachnoid spaces on computerized tomography (CT) scans of the head. These findings can mimic those seen in acute subarachnoid hemorrhage (SAH) and are referred to as pseudosubarachnoid hemorrhage (pseudo-SAH). Pseudo-SAH is a diagnosis critical care physicians should be aware of as they treat and evaluate their patients with presumed SAH, which is a medical emergency. This lack of awareness could have important clinical implications on outcomes and impact management decisions if patients with anoxic brain injury are inappropriately treated for SAH. We describe three patients who presented to the hospital with anoxic brain injury. Subsequent CT head suggested SAH, which was subsequently proven to be pseudo-SAH. O’Dene Lewis, Samina Afreen, Supo Folaranmi, Marie Fidelia-Lambert, Vishal Poddar, and Alicia Thomas Copyright © 2017 O’Dene Lewis et al. All rights reserved. Efficacy of Prompt Initiation of Antiretroviral Therapy in the Treatment of Hemophagocytic Lymphohistiocytosis Triggered by Uncontrolled Human Immunodeficiency Virus Thu, 10 Aug 2017 00:00:00 +0000 http://www.hindawi.com/journals/cricc/2017/8630609/ Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening, rapidly progressive hematologic disorder involving uncontrolled immune system activation. HLH has been associated with viral infections, including human immunodeficiency virus (HIV) infections. We report a case of a critically ill 30-year-old female who was hospitalized with HIV-associated HLH, with a CD4 count of 4 cells/mL and HIV viral load of 1,842,730 copies/mL. After ruling out other potential infectious causes of HLH, antiretroviral therapy (ART) was initiated with darunavir, ritonavir, tenofovir, and emtricitabine. Within one week of initiation of ART, the patient began to improve clinically and hematologically and was stable enough for discharge from the hospital three weeks after starting therapy. This case suggests that treatment with ART in patients with HIV-associated HLH should be considered even in critically ill patients with low CD4 counts. Bryan P. Fitzgerald, Amy L. Wojciechowski, and Rajinder P. S. Bajwa Copyright © 2017 Bryan P. Fitzgerald et al. All rights reserved. An Unexpected Case of Black Mamba (Dendroaspis polylepis) Bite in Switzerland Mon, 31 Jul 2017 08:37:35 +0000 http://www.hindawi.com/journals/cricc/2017/5021924/ Mambas (genus Dendroaspis) are among the most feared venomous African snakes. Without medical treatment, mamba bites are frequently fatal. First-aid treatment includes lymphatic retardation with the pressure immobilization technique. Medical management comprises continuous monitoring, securing patency of the airway, ensuring adequate ventilation, symptomatic measures, and administration of specific antivenin. We report an unusual case of a snake breeder bitten by a black mamba in Switzerland, report the clinical course, and review the lifesaving emergency management of mamba bites. This case highlights the importance of early antivenin administration and suggests that emergency and critical care physicians as well as first responders all around the world should be familiar with clinical toxinology of exotic snake bites as well as with the logistics to most rapidly make the specific antivenin available. Verena Quarch, Lukas Brander, and Luca Cioccari Copyright © 2017 Verena Quarch et al. All rights reserved. Zinc Chloride Smoke Inhalation Induced Severe Acute Respiratory Distress Syndrome: First Survival in the United States with Extended Duration (Five Weeks) Therapy with High Dose Corticosteroids in Combination with Lung Protective Ventilation Wed, 26 Jul 2017 09:07:39 +0000 http://www.hindawi.com/journals/cricc/2017/7952782/ Zinc chloride smoke bomb exposure is frequently seen in military drills, combat exercises, metal industry works, and disaster simulations. Smoke exposure presents with variety of pulmonary damage based on the intensity of the exposure. Smoke induced severe acute respiratory distress syndrome (ARDS) is often fatal and there are no standard treatment guidelines. We report the first survival of smoke induced severe ARDS in the United States (US) with prolonged use of high dose steroids (five weeks) and lung protective ventilation alone. Previously reported surviving patients in China and Taiwan required extracorporeal membrane oxygenation (ECMO) and other invasive modalities. We suggest that an extended course of high dose corticosteroids should be considered for the treatment of smoke inhalation related ARDS and should be introduced as early as possible to minimize the morbidity and mortality. We further suggest that patients with smoke inhalation should be observed in the hospital for at least 48 to 72 hours before discharge, as ARDS can have a delayed onset. Being vigilant for infectious complications is important due to prolonged steroid treatment regimen. Patients must also be monitored for critical illness polyneuromyopathy. Additionally, upper airway injury should be suspected and early evaluation by otorhinolaryngology may be beneficial. Hafiz Mahboob, Robert Richeson III, and Robert McCain Copyright © 2017 Hafiz Mahboob et al. All rights reserved. Use of Hemadsorption in a Case of Pediatric Toxic Shock Syndrome Sun, 16 Jul 2017 07:49:14 +0000 http://www.hindawi.com/journals/cricc/2017/3818407/ Background. Toxic shock syndrome is a potentially fatal toxin-mediated disease. The role of toxins in this clinical entity made us hypothesize that extracorporeal blood purification with CytoSorb® could play a beneficial role in the clinical management of toxic shock syndrome. This case report describes the successful treatment of toxic shock syndrome using a combination of renal replacement therapy and hemadsorption in a pediatric patient. Case Presentation. A 5-year-old girl with Down’s syndrome presented with an inflamed area surrounding an insect bite, signs of systemic inflammation, and multiple organ failure. As previous attempts of immune modulation therapy were unsuccessful, renal replacement therapy was supplemented by the cytokine absorber CytoSorb. Treatment using this combination was associated with a rapid and significant stabilization in the hemodynamic situation and a decrease in inflammatory mediators within hours after the initiation of therapy. The application of CytoSorb therapy was simple and safe. Conclusion. The use of extracorporeal blood purification with CytoSorb proved potentially beneficial by removing toxins and inflammatory mediators in this case and could therefore play a role in the clinical management of toxic shock syndrome. Whether CytoSorb has the potential to even positively influence mortality in patients with toxic shock syndrome still needs to be confirmed. Andrea Berkes, Edit Szikszay, János Kappelmayer, Adrienne Kerényi, Tamás Szabó, László Ujhelyi, Krisztina Bari, György Balla, and József Balla Copyright © 2017 Andrea Berkes et al. All rights reserved. Anasarca, Fever, Thrombocytopenia, Organomegaly, and Multiorgan Failure in a 24-Year-Old Pregnant Woman Thu, 22 Jun 2017 09:33:41 +0000 http://www.hindawi.com/journals/cricc/2017/3871593/ TAFRO syndrome is a distinct idiopathic multicentric Castleman disease characterized by the association of thrombocytopenia, anasarca, fever, reticulin fibrosis, and organomegaly. We report the first case occurring in a Caucasian pregnant woman. At 34 weeks of gestation, our patient presented with all clinical and biological symptoms compatible with a TAFRO syndrome. Tough quick cesarean section was performed as symptoms got worse with onset of multiorgan failure requiring mechanical ventilation for acute respiratory distress, continuous renal replacement, and vasopressors. Nine days after ICU admission, steroid boluses were started and allowed spectacular clinical and biological improvement. As systemic inflammatory manifestations are important, TAFRO syndrome can be mistaken with severe autoimmune diseases, systemic infections, hematological malignancies, or hemophagocytic lymphohistiocytosis. Guillaume Morel, Joy Mootien, Philippe Guiot, and Khaldoun Kuteifan Copyright © 2017 Guillaume Morel et al. All rights reserved. A Rare Case of Septic Shock Secondary to Emphysematous Hepatitis Tue, 30 May 2017 09:20:50 +0000 http://www.hindawi.com/journals/cricc/2017/3020845/ Objective. To describe a case of emphysematous hepatitis which is a rare clinical entity, characterized by a fatal, rapidly progressive infection of the liver with a radiological appearance simulating emphysematous pyelonephritis and to help provide more data about the causative organisms and precipitating factors of this pathology. Data Sources and Synthesis. Relevant literature was reviewed and, to the best of our knowledge, there is limited data regarding the pathogenesis, causative organisms, and management of this condition. Conclusion. Emphysematous hepatitis is a rapidly progressive infection that can be fatal in the absence of appropriate therapeutic intervention. Initial clinical manifestations are usually subtle and thus high clinical suspicion is required for early diagnosis and management of this condition to help decrease the mortality rates. Khaled M. Nada, Ibrahim El Husseini, Mohammad E. Abu Hishmeh, Neerav S. Shah, Nadezhda Ibragimova, and Riyad Basir Copyright © 2017 Khaled M. Nada et al. All rights reserved. Central Venous Line Insertion Revealing Partial Anomalous Pulmonary Venous Return: Diagnosis and Management Mon, 29 May 2017 07:57:27 +0000 http://www.hindawi.com/journals/cricc/2017/3218063/ Central venous line malposition is a well-known complication of line insertion. Rarely, it can be mal-positioned in an anomalous pulmonary vein. We present an unusual case of a 56-year-old woman that was found to have partial anomalous pulmonary venous return on central venous line insertion. In this report, we describe a systematic approach to diagnosis and management of this unusual situation. Bashar Alzghoul, Ayoub Innabi, Aditya Chada, Ahmad R. Tarawneh, Krishna Kakkera, and Khaled Khasawneh Copyright © 2017 Bashar Alzghoul et al. All rights reserved. Severe Rhabdomyolysis due to Presumed Drug Interactions between Atorvastatin with Amlodipine and Ticagrelor Thu, 25 May 2017 00:00:00 +0000 http://www.hindawi.com/journals/cricc/2017/3801819/ Atorvastatin and ticagrelor combination is a widely accepted therapy for secondary prevention of ischaemic heart disease. However, rhabdomyolysis is a well-known rare side effect of statins which should be considered when treatments are combined with cytochrome P450 3A4 enzyme inhibitors. We report a case of atorvastatin and ticagrelor associated severe rhabdomyolysis that progressed to multiorgan failure requiring renal replacement therapy, inotropes, intubation, and mechanical ventilation. Despite withdrawal of the precipitating cause and the supportive measures including renal replacement therapy, creatinine kinase increased due to ongoing rhabdomyolysis rapidly progressing to upper and lower limbs weakness. A muscle biopsy was performed to exclude myositis which confirmed extensive myonecrosis, consistent with statin associated rhabdomyolysis. After a prolonged ventilatory course in the intensive care unit, patient’s condition improved with recovery from renal and liver dysfunction. The patient slowly regained her upper and lower limb function; she was successfully weaned off the ventilator and was discharged for rehabilitation. To our knowledge, this is a second case of statin associated rhabdomyolysis due to interaction between atorvastatin and ticagrelor. However, our case differed in that the patient was also on amlodipine, which is considered to be a weak cytochrome P450 3A4 inhibitor and may have further potentiated myotoxicity. Iouri Banakh, Kavi Haji, Ross Kung, Sachin Gupta, and Ravindranath Tiruvoipati Copyright © 2017 Iouri Banakh et al. All rights reserved. Refractory Lactic Acidosis in Small Cell Carcinoma of the Lung Tue, 23 May 2017 07:33:55 +0000 http://www.hindawi.com/journals/cricc/2017/6148350/ Background. Elevated lactate levels in critically ill patients are most often thought to be indicative of relative tissue hypoxia or type A lactic acidosis. Shock, severe anemia, and thromboembolic events can all cause elevated lactate due to tissue hypoperfusion, as well as the mitochondrial dysfunction thought to occur in sepsis and other critically ill states. Malignancy can also lead to elevation in lactate, a phenomenon described as type B lactic acidosis, which is much less commonly encountered in the critically ill. Case Presentation. We present the case of a 73-year-old Caucasian woman with type 2 diabetes and hypertension who presented with abdominal pain, nausea, vomiting, nonbloody diarrhea, and weight loss over five weeks and was found to have unexplained refractory lactic acidosis despite fluids and antibiotics. She was later diagnosed with small cell carcinoma of the lung. Conclusions. In this case report, we describe a critically ill patient whose elevated lactate was incorrectly attributed to her acute illness, when in truth it was an indicator of an underlying, as yet undiagnosed, malignancy. We believe this case is instructive to the critical care clinician as a reminder of the importance of considering malignancy on the differential diagnosis of a patient presenting with elevated lactate out of proportion to their critical illness. Daniel J. Oh, Ellen Dinerman, Andrew H. Matthews, Abraham W. Aron, and Katherine M. Berg Copyright © 2017 Daniel J. Oh et al. All rights reserved. Successful Use of Extracorporeal Membrane Oxygenation for the Treatment of Cardiogenic Shock due to Scorpion Envenomation Thu, 27 Apr 2017 06:57:24 +0000 http://www.hindawi.com/journals/cricc/2017/8073989/ Introduction. The occurrence of a cardiogenic shock is a rare presentation after scorpion envenomation. The treatment includes classically the use of inotropes and specific vasodilators. Case Presentation. We report a case of an 11-year-old boy presenting with cardiogenic shock and pulmonary edema after a scorpion sting. Despite adequate management at the emergency department and intensive care unit, the patient’s hemodynamic status worsened rapidly, justifying his transfer to our department for ventricular mechanical assistance by venoarterial extracorporeal membrane oxygenation. The following outcomes were favorable and the boy was discharged home on day 29 without aftereffects. Conclusion. This is the first report of successful use of extracorporeal membrane oxygenation for the treatment of cardiogenic shock after scorpion envenomation. Amine Tarmiz, Imene Mgarrech, Chokri Kortas, and Sofiane Jerbi Copyright © 2017 Amine Tarmiz et al. All rights reserved. Disseminated Necrotizing Leukoencephalopathy Complicating Septic Shock in an Immunocompetent Patient Mon, 24 Apr 2017 00:00:00 +0000 http://www.hindawi.com/journals/cricc/2017/1092537/ Disseminated necrotizing leukoencephalopathy (DNL) is characterized by multiple microscopic foci of white matter necrosis. DNL was initially thought to be exclusively associated with immunosuppression conditions but it has been recently described in immunocompetent patients in septic shock. A 90-year-old immunocompetent woman with no previous neurological impairment presented with septic shock and drowsiness that responded well to therapy with clinical improvement and a full neurological recovery. Unexpectedly deterioration with progression to coma occurred. Investigation excluded other causes and Magnetic Resonance Imaging (MRI) was consistent with the diagnosis of DNL showing bilateral multifocal white matter lesions with a nonvascular pattern with restricted diffusion. Neurological impairment persisted with progression to death. DNL is an unexpected diagnosis in an immunocompetent patient. We compared the present case to those found in the literature of DNL complicating septic shock and discuss the antemortem diagnosis based on MRI findings. Pedro Gaspar-da-Costa, Sofia Reimão, Sandra Braz, João Meneses Santos, and Rui M. M. Victorino Copyright © 2017 Pedro Gaspar-da-Costa et al. All rights reserved. Optic Nerve Sheath Diameter as a Bedside Assessment for Elevated Intracranial Pressure Wed, 05 Apr 2017 09:48:02 +0000 http://www.hindawi.com/journals/cricc/2017/3978934/ A previously fit and healthy 26-year-old lady with no significant medical history presented with a two-month history of headaches. The headaches were prolonged, generalised, and unusually severe for the patient. Examination revealed papilloedema. The patient’s optic nerve sheath diameter was measured 3 mm posterior to the globe and found to be 7.5 mm. The patient subsequently had computed tomography scan of her brain that showed an optic nerve sheath diameter of 7.56 mm as measured 3 mm posterior to the globe. After an obstructive lesion was ruled out on the computed tomography scan, a lumbar puncture was then performed and cerebrospinal fluid was drained. An ultrasound of the optic nerve sheath diameter was repeated showing a reduced diameter of 5.6 mm. The patient was admitted to the neurology unit and ultimately diagnosed with idiopathic intracranial hypertension. This case report highlights the potential of rapidly identifying elevated intracranial pressure using a noninvasive method. Peter Williams Copyright © 2017 Peter Williams. All rights reserved. DKA-Induced Takotsubo Cardiomyopathy in Patient with Known HOCM Mon, 03 Apr 2017 06:11:33 +0000 http://www.hindawi.com/journals/cricc/2017/4287125/ The first published case of Diabetic Ketoacidosis-induced Takotsubo cardiomyopathy was in 2009. Our patient is the 1st reported case of Diabetic Ketoacidosis- (DKA-) induced Takotsubo cardiomyopathy (TC) in a patient with known hypertrophic cardiomyopathy (HOCM) in the United States. In the literature, there are only two examples linking DKA to TC; however, this report focuses on the biochemical and physiological causes of TC in a patient with known HOCM and new-onset DKA. TC in previously diagnosed HOCM poses particular complications. With the above patient’s baseline outflow tract obstruction due to septal hypertrophy, the acute reduction in EF due to TC resulted in transient drop in brain perfusion and, therefore, syncope. Ayla Gordon, Gina LaCapra, and Roberto Roberti Copyright © 2017 Ayla Gordon et al. All rights reserved. Hypercapnea and Acidemia despite Hyperventilation following Endotracheal Intubation in a Case of Unknown Severe Salicylate Poisoning Wed, 29 Mar 2017 07:36:52 +0000 http://www.hindawi.com/journals/cricc/2017/6835471/ Salicylates are common substances for deliberate self-harm. Acute salicylate toxicity is classically associated with an initial respiratory alkalosis, followed by an anion gap metabolic acidosis. The respiratory alkalosis is achieved through hyperventilation, driven by direct stimulation on the respiratory centers in the medulla and considered as a compensatory mechanism to avoid acidemia. However, in later stages of severe salicylate toxicity, patients become increasingly obtunded, with subsequent loss of airway reflexes, and therefore intubation may be necessary. Mechanical ventilation has been recommended against in acute salicylate poisoning, as it is believed to take away the compensatory hyperpnea and tachypnea. Despite the intuitive physiological basis for this recommendation, there is a paucity of evidence to support it. We describe a case of a 59-year-old male presenting with decreased level of consciousness and no known history of ingestion. He was intubated and experienced profound hypercarbia and acidemia despite mechanical ventilation with high minute ventilation and tidal volumes. This case illustrates the deleterious effects of intubation in severe salicylate toxicity. Shannon M. Fernando, Valérie Charbonneau, and Hans Rosenberg Copyright © 2017 Shannon M. Fernando et al. All rights reserved. Iatrogenic Right-Sided Pneumothorax Presenting as ST-Segment Elevation: A Rare Case Report and Review of Literature Sun, 26 Mar 2017 07:09:59 +0000 http://www.hindawi.com/journals/cricc/2017/3291751/ Pneumothorax is a well-recognized complication of central venous line insertion (CVL). Rarely, pneumothorax can lead to electrocardiogram (ECG) findings mimicking ST-segment elevation myocardial infarction. We present a 63-year-old man with iatrogenic right-sided pneumothorax who developed ST-segment elevation on a 12-lead ECG suggestive of myocardial infarction. The ECG findings completely resolved after needle decompression and chest tube placement. This case points up this rare electrocardiographic finding with discussion of possible mechanisms and differential diagnosis. Bashar Alzghoul, Ayoub Innabi, Anusha Shanbhag, Kshitij Chatterjee, Farah Amer, and Nikihil Meena Copyright © 2017 Bashar Alzghoul et al. All rights reserved. Increased Intracranial Pressure during Hemodialysis in a Patient with Anoxic Brain Injury Mon, 20 Mar 2017 00:00:00 +0000 http://www.hindawi.com/journals/cricc/2017/5378928/ Dialysis disequilibrium syndrome (DDS) is a serious neurological complication of hemodialysis, and patients with acute brain injury are at increased risk. We report a case of DDS leading to intracranial hypertension in a patient with anoxic brain injury and discuss the subsequent dialysis strategy. A 13-year-old girl was admitted after prolonged resuscitation from cardiac arrest. Computed tomography (CT) revealed an inferior vena cava aneurysm and multiple pulmonary emboli as the likely cause. An intracranial pressure (ICP) monitor was inserted, and, on day 3, continuous renal replacement therapy (CRRT) was initiated due to acute kidney injury, during which the patient developed severe intracranial hypertension. CT of the brain showed diffuse cerebral edema. CRRT was discontinued, sedation was increased, and hypertonic saline was administered, upon which ICP normalized. Due to persistent hyperkalemia and overhydration, ultrafiltration and intermittent hemodialysis were performed separately on day 4 with a small dialyzer, low blood and dialysate flow, and high dialysate sodium content. During subsequent treatments, isolated ultrafiltration was well tolerated, whereas hemodialysis was associated with increased ICP necessitating frequent pauses or early cessation of dialysis. In patients at risk of DDS, hemodialysis should be performed with utmost care and continuous monitoring of ICP should be considered. Anton Lund, Mette B. Damholt, Ditte G. Strange, Jesper Kelsen, Hasse Møller-Sørensen, and Kirsten Møller Copyright © 2017 Anton Lund et al. All rights reserved. The Use of Coupled Plasma Filtration Adsorption in Traumatic Rhabdomyolysis Sun, 19 Mar 2017 06:58:21 +0000 http://www.hindawi.com/journals/cricc/2017/5764961/ Severe musculoskeletal injuries induce the release of sarcoplasmic elements such as muscle enzymes, potassium, and myoglobin in the systemic circulation. The circulating myoglobin damages the glomerulus and renal tubules. Conventional haemodialysis is not able to remove myoglobin, due to its high molecular weight (17,8 kilodaltons [kDa]). We treated four traumatic rhabdomyolysis patients with Coupled Plasma Filtration Adsorption (CPFA) in order to remove myoglobin followed by 14 hours of Continuous Veno-Venous Hemofiltration (CVVH). During the treatment, all patients showed clinical improvement with a decrease in muscular (creatine kinase [CK] and myoglobin) and renal (creatinine and potassium) damage indices. One patient, in spite of full renal recovery, died of cerebral haemorrhage on the 26th day of hospital stay. Mario Pezzi, Silvia Renda, Anna Maria Giglio, Anna Maria Scozzafava, Simona Paola Tiburzi, Patrizia Casella, Fabrizio Iannelli, and Mario Verre Copyright © 2017 Mario Pezzi et al. All rights reserved. Nuclear Imaging to Detect Diaphragmatic Perforation as a Rare Complication of Microwave Ablation Tue, 14 Mar 2017 00:00:00 +0000 http://www.hindawi.com/journals/cricc/2017/6541054/ Acquired diaphragmatic perforation leading to massive hepatic hydrothorax and respiratory failure is a rare complication of microwave ablation (MWA) of hepatocellular carcinoma (HCC). Imaging modalities to detect pleuroperitoneal communication remain poorly described. We report a nuclear imaging technique used to efficiently diagnose and locate diaphragmatic defects. A 57-year-old male with cirrhosis and HCC presented with respiratory distress after undergoing MWA of a HCC lesion. He was admitted to the intensive care unit for noninvasive positive pressure ventilator support. Chest radiography revealed a new large right pleural effusion. Large-volume thoracentesis was consistent with hepatic hydrothorax. The fluid reaccumulated within 24 hours; therefore an acquired diaphragmatic perforation induced by the ablation procedure was suspected. To investigate, Technetium-labeled albumin was injected into the peritoneal cavity. The tracer accumulated in the right hemi thorax almost immediately. The patient then underwent transjugular intrahepatic portosystemic shunting in efforts to relieve portal hypertension and decrease ascites volume. Unfortunately, the patient deteriorated and expired after few days. Although diaphragmatic defects develop in cirrhotic patients, such small fenestrations do not normally lead to rapid development of life-threatening pleural effusion. MWA procedures can cause large diaphragmatic defects. Immediate detection of this complication is essential for initiating early intervention. Stephanie Cull, Gebran Khneizer, Abhishek Krishna, Razi Muzaffar, Sameer Gadani, and Zafar Jamkhana Copyright © 2017 Stephanie Cull et al. All rights reserved. Acute Gastric Volvulus and Atrial Fibrillation with RVR: A Coincidence or Association Wed, 08 Mar 2017 09:09:14 +0000 http://www.hindawi.com/journals/cricc/2017/9403601/ Gastric volvulus is a rare and life-threatening condition that involves the abnormal rotation of the stomach around its axis by more than 180°. The association between acute gastric volvulus and atrial fibrillation with rapid ventricular response is rare with only few cases that have been reported. Our patient was an 86-year-old female who presented with upper abdominal pain, distension, nausea, and shortness of breath. Clinical and laboratory workup revealed acute gastric volvulus with diaphragmatic hernia. On presentation, she was also in atrial fibrillation with rapid ventricular response. She was successfully treated by laparotomy with reduction of the gastric volvulus and repair of the diaphragmatic hernia, with significant improvement. Omar Nadhem, Omar Salh, and Faisal Khasawneh Copyright © 2017 Omar Nadhem et al. All rights reserved. Bronchopleural Fistula Resolution with Endobronchial Valve Placement and Liberation from Mechanical Ventilation in Acute Respiratory Distress Syndrome: A Case Series Tue, 07 Mar 2017 00:00:00 +0000 http://www.hindawi.com/journals/cricc/2017/3092457/ Patients who have acute respiratory distress syndrome (ARDS) with persistent air leaks have worse outcomes. Endobronchial valves (EBV) are frequently deployed after pulmonary resection in noncritically ill patients to reduce and eliminate bronchopleural fistulas (BPFs) with persistent air leak (PAL). Information regarding EBV placement in mechanically ventilated patients with ARDS and high volume persistent air leaks is rare and limited to case reports. We describe three cases where EBV placement facilitated endotracheal extubation in patients with severe respiratory failure on prolonged mechanical ventilation with BPFs. In each case, EBV placement led to immediate resolution of PAL. We believe endobronchial valve placement is a safe method treating persistent air leak with severe respiratory failure and may reduce days on mechanical ventilation. Haris Kalatoudis, Meena Nikhil, Fuad Zeid, and Yousef Shweihat Copyright © 2017 Haris Kalatoudis et al. All rights reserved. Abnormal Breathing Patterns Predict Extubation Failure in Neurocritically Ill Patients Tue, 28 Feb 2017 00:00:00 +0000 http://www.hindawi.com/journals/cricc/2017/9109054/ In neurologically injured patients, predictors for extubation success are not well defined. Abnormal breathing patterns may result from the underlying neurological injury. We present three patients with abnormal breathing patterns highlighting failure of successful extubation as a result of these neurologically driven breathing patterns. Recognizing abnormal breathing patterns may be predictive of extubation failure and thus need to be considered as part of extubation readiness. Pragya Punj, Premkumar Nattanmai, Pravin George, and Christopher R. Newey Copyright © 2017 Pragya Punj et al. All rights reserved. Effective and Safe Use of Glucocorticosteroids for Rescue of Late ARDS Sun, 26 Feb 2017 06:27:32 +0000 http://www.hindawi.com/journals/cricc/2017/6740532/ We describe a case of severe refractory hypoxemia requiring prolonged extra corporeal membrane oxygenation (ECMO) support in a case of postpartum acute respiratory distress syndrome (ARDS). The clinical course was marked by persistently poor lung compliance and several complications of ECMO, that is, significant hemolysis, hemothorax, and intracranial bleeding. We report marked improvement of lung mechanics and respiratory function, leading to accelerated separation from ECMO, following rescue administration of low dose methylprednisolone 24 days after the onset of ARDS. Corticosteroid treatment was safe and well tolerated. In contrast with the conclusions of the 2006 ARDS Network trial, our report establishes a case in support of the use of low dose methylprednisolone as a safe and effective rescue treatment option in selected subsets of patients with nonresolving ARDS. Paolo Diana, Dustin T. Money, Michael G. Gelvin, and Nadia Lunardi Copyright © 2017 Paolo Diana et al. All rights reserved. Venovenous Extracorporeal Membrane Oxygenation as a Treatment for Obesity Hypoventilation Syndrome Thu, 23 Feb 2017 08:18:27 +0000 http://www.hindawi.com/journals/cricc/2017/9437452/ The mortality rate for respiratory failure resulting from obesity hypoventilation syndrome is high if it requires ventilator management. We describe a case of severe acute respiratory failure resulting from obesity hypoventilation syndrome (BMI, 60.2 kg/m2) successfully treated with venovenous extracorporeal membrane oxygenation (VV-ECMO). During ECMO management, a mucus plug was removed by bronchoscopy daily and 18 L of water was removed using diuretics, resulting in weight loss of 24 kg. The patient was weaned from ECMO on day 5, extubated on day 16, and discharged on day 21. The fundamental treatment for obesity hypoventilation syndrome in morbidly obese patients is weight loss. VV-ECMO can be used for respiratory support until weight loss has been achieved. Nao Umei and Shingo Ichiba Copyright © 2017 Nao Umei and Shingo Ichiba. All rights reserved. Spinal Cord Infarction in the Course of a Septic Shock: About One Case and Review of the Literature Mon, 20 Feb 2017 00:00:00 +0000 http://www.hindawi.com/journals/cricc/2017/1571048/ We report the case of a patient admitted to our intensive care unit in the course of a septic shock, secondary to cholangitis. After rapid hemodynamic stabilization, antibiotherapy, and endoscopic extraction of bile ducts stones, she appeared to have developed flaccid paraplegia. The suspected diagnosis of medullar ischemia was confirmed by typical MRI findings. This case stresses the potential pathogenic role of hypotension in medullar ischemia and the place of magnetic resonance imaging (MRI) as a reliable diagnostic tool. P. Henin, A. Molderez, V. Huberlant, and H. Trine Copyright © 2017 P. Henin et al. All rights reserved. Primitive Tumour of the Pulmonary Valve: Discussion of the Differential Diagnosis Sun, 19 Feb 2017 00:00:00 +0000 http://www.hindawi.com/journals/cricc/2017/6263578/ There is a paucity of information concerning cardiac tumours of the pulmonary valve due to their rarity at this location. We report a case of a 47-year-old patient suffering from haemoptysis, asthenia, and acute kidney injury (AKI). A transthoracic echocardiography (TTE) revealed a mass on the pulmonary valve. Further diagnostic investigation was completed until he exhibited worsening hemodynamic instability. This case emphasizes the lack of information regarding the management of a pulmonary valve tumour. A. Hannecart, D. Ndjekembo-Shango, F. Vallot, O. Simonet, and M. De Kock Copyright © 2017 A. Hannecart et al. All rights reserved.