Hemodialysis For Acute Renal Failure Research Articles

A RARE CASE OF LUMBOSACRAL PLEXOPATHY SECONDARY TO SEVERE RHABDOMYOLYSIS FOLLOWING KRATOM, COCAINE, AND HEROIN USE

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Lumbosacral (LS) plexopathy can be difficult to diagnose as it is not commonly encountered in clinical practice. Disease severity is related to the underlying etiology however, progressive neurological deterioration is often seen if proper intervention is not executed promptly. LS plexopathy secondary to severe rhabdomyolysis has been reported in a small number of case reports. We present a rare case of LS plexopathy caused by severe rhabdomyolysis following concurrent use of kratom, cocaine, and heroin. CASE PRESENTATION: A 25 year old male with a history of schizophrenia presented to the emergency department (ED) after experiencing numbness and tingling in his lower extremities following cocaine, heroin and kratom use the day prior. On presentation, the patient became increasingly lethargic and sustained a cardiac arrest while in the ED. CPR was performed for 9 minutes before ROSC was achieved. Labs were remarkable for potassium of 8, BUN 35, creatinine 4.03, and creatine kinase of >100,000 consistent with rhabdomyolysis. The patient was also found to have compartment syndrome of his left lower extremity requiring emergent fasciotomy. He was admitted to the medical intensive care unit where he remained intubated and underwent hemodialysis for acute renal failure. On day 4 of admission, the patient was successfully liberated from the ventilator. At this point, flaccid paralysis and loss of sensation of his bilateral lower extremities were noted on exam. Work up including CT and MRI of the spine were significant for severe paraspinal edema and myonecrosis consistent with rhabdomyolysis. EMG of the lower extremities revealed mild chronic partial denervation with abnormal spontaneous activity in the proximal and distal right leg muscles. Oral Prednisone was initiated with improvement in the patient's lower extremity paralysis after five days of therapy. The patient completed a three week steroid taper with continued improvement in his exam. He was discharged to rehab. At one month follow-up, he showed near complete resolution of his neurologic deficits. DISCUSSION: The LS plexus includes a network of nerves that are formed by the anterior rami of the lumbar and sacral spinal cord which supply the lower back, pelvis and legs. LS plexopathy often presents with lower back and lower extremity weakness, pain, paresthesias, numbness and tingling. LS plexopathy is typically caused by trauma, diabetes, neoplasms and pregnancy. Complications of LS plexopathy may include progressive neurological deterioration, intractable pain, recurrent infections, joint contracture and bedsores. CONCLUSIONS: LS plexopathy secondary to severe rhabdomyolysis is rare, described in only a few case reports. Treatment often relies on addressing the underlying etiology and should be geared towards preventing further nerve damage as LS plexopathy can cause significant detriment to the quality of life of a patient. REFERENCE #1: Dydyk, A. (2021, February 07). Lumbosacral plexopathy. Retrieved April 29, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK556030/ REFERENCE #2: Jeon, H., Cho, B., Oh, S., & Park, S. (2007, December). Lumbosacral Plexopathy, COMPLICATING rhabdomyolysis in a 57-YEAR-OLD man, presented with sudden weakness in both legs. Retrieved April 29, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2588181/#:~:text=A%20diagnosis%20of%20lumbosacral%20plexopathy%2C%20complicating%20rhabdomyolysis%20was%20made.&text=Pelvic%20MRI%20is%20a%20helpful, with%20sudden%20weakness%20of%20legs. DISCLOSURES: No relevant relationships by Utku Ekin, source=Web Response No relevant relationships by Christopher Millet, source=Web Response No relevant relationships by Natalie Millet, source=Web Response No relevant relationships by Justin Thorson, source=Web Response

S2905 Prolonged Cholestasis After COVID-19

Introduction: The coronavirus SARS-CoV-2 (COVID-19) is known to cause both pulmonary and hepatic injury. Cholangiocytes have an abundance of angiotensin-converting enzyme 2 receptors, which are the main mode of entry for the virus. Whether the liver injury is caused directly by the virus or as a result of the cytokine storm remains unknown. We present a case of prolonged cholestatic liver injury secondary to COVID-19. Case Description/Methods: A 55-year-old woman presented to our institution with sudden onset of right leg pain and swelling. She had hypertension, diabetes, obesity, and hypothyroidism. She denied any history of liver disease, toxic habits and was not taking any hepatotoxic medications or supplements. Two months prior to presentation, she was admitted to another hospital with severe COVID-19 pneumonia requiring mechanical ventilation. She had received Remdesivir, Convalescent Plasma, Extra Corporeal Membrane Oxygenation (ECMO), and hemodialysis for acute renal failure, before being discharged. During this admission, she was found to have a right lower extremity thrombus and was started on Enoxaparin. Her liver function tests were significant for a markedly elevated alkaline phosphatase level. An ultrasound abdomen was significant only for a fatty liver. CT scan of the abdomen with contrast and an MRCP did not reveal any hepatobiliary abnormalities. Viral hepatitis serology and autoimmune workup were negative. She underwent a liver biopsy which demonstrated cholestasis, mild lobular necroinflammation, and macrovesicular steatosis. There was no PCR evidence of SARS-CoV-2. Her hospital course was complicated by MRSA and pseudomonas pneumonia. She suffered a cardiac arrest and ultimately succumbed to her infection 2 months later. Her Alkaline phosphatase remained elevated throughout her hospital stay. Discussion: Although our patient’s liver biopsy did not demonstrate PCR evidence of SARS-COV-2, it was consistent with histological features of COVID-19 related hepatic injury. Macrovesicular steatosis is the most common histological finding, followed by lobular necroinflammation, according to a case series of 40 patients who died of COVID-19. PCR for SARS-COV-2 in liver biopsy was positive in only 55% of patients. Recent reports have identified ECMO as a cause of secondary sclerosing cholangitis in critically ill patients, which remains a possibility in our case. However, a normal bilirubin level and MRCP did not support this diagnosis in our patient.Figure 1.: (A) 4 x magnification, (B) 10 x magnification, and (C) 40 x magnification of a liver biopsy specimen demonstrating hepatocellular cholestasis with feathery degeneration of hepatocytes, mild lobular neuroinflammation, and mild macrovesicular steatosis. There is sinusoidal dilatation and glycogenated nuclei. Portal tracts show mild to moderate mixed cellular infiltration, including eosinophils, endothelilitis, ductular reaction, and focal mild bile duct damage. There is no pericellular fibrosis to indicate non-alcoholic chronic steatohepatitis, although rare perivenular ballooned hepatocytes are noted on the H&E slide. CK7 immunostain shows moderate to marked ductular reaction, rare cholestatic hepatocytes, and damaged bile ducts. Findings are those of subacute cholestatic hepatitis.Table 1.: Laboratory values from the previous hospitalization, on admission day of this hospitalization, at 1-month of hospitalization, and prior to death.

A descriptive study of seasonal influenza cases in a single season in a tertiary center in Kathmandu

Introduction: This is a clinic-epidemiological study of the total cases of polymerase chain reaction (PCR) confirmed influenza cases. We aim to characterize the disease, its morbidities and mortality. Materials and Methods: The details of all PCR confirmed influenza (H1N1) cases were obtained from the hospital records and descriptive statistical analysis tools were used to report the findings. Results: A total of 35 cases were confirmed as influenza from January to March 2019. The most common presenting complaints were fever (91%), cough (85%) and shortness of breath (65%). The most frequent diagnosis made was pneumonia (88%). Septic shock was present in 29% while 14% had acute kidney injury (AKI). Oxygen therapy was required in 71% with 17% requiring mechanical ventilation and another 11% requiring non-invasive ventilation. Fourteen percent had developed severe acute respiratory distress syndrome (ARDS) requiring proning. A total of 77% patients were successfully discharged home, 8% were transferred to other centers on request for various reasons and 11% were withdrawn from all active treatment leading to death. One patient was taken home against advice whose outcome could not be traced. During treatment, two patients had developed ischemic stroke, two required haemodialysis for acute renal failure and other two had scrub typhus co-infection. Conclusions: A total of 85% of the patient survived while the rest lost their lives. The most important factor recognized was the financial burden associated with the treatment. Diagnostic delays and limited supply of Oseltamivir might be the other barriers in the treatment of the disease.

The Contribution of Scientists of the Kirov Military Medical Academy to the Development of Military Transfusiology, in Commemoration of the 100th Anniversary of the Birth of Professor S.V. Ryzhkov

June 23, 2019 marks the 100th anniversary of the birth of prominent Russian transfusiologist, professor, student of academic V.N. Shamov, participant of the Stalingrad Battle Semyon Vavilovich Ryzhkov (1919-2004). He was the one who established the Russian Ministry of Defense Blood Service. In 1961, he founded the Research Laboratory of Fibrinolysis Blood and Tissue Preservation, which since 1964 bears the name of the Blood and Tissue Center. He had been the head of the Center for20 years. His academic interests covered such issues as the use of hemodialysis in acute renal failure, the cryopreservation of red blood cells and bone marrow, which brought him the Union of Soviet Socialist Republics State Prize in 1978, the substantiation of the safety of a 400 ml blood donation, and the use of donor hardware plasmacytopheresis. The article presents data on the contribution of the scientists of the Military Medical Academy to the development of the national blood transfusion service from the 2nd half of the XIX century till the establishment of the Ministry of Defense Blood Service in 1965. June 21, 1919V.N. Shamov, N.N. Elansky, and I.R. Petrov carried out the first donor and recipient matching blood transfusion in Russia. They contributed a lot to teaching medical practitioners to do blood type tests. In 1926, N.N.Yelansky was the first in Russia to publish the study Blood Transfusion. In 1944, V.N.Shamov was the first in Russia to publish The Blood Transfusion Manual for Military Doctors. On the battlefields of Lake Hassan, the Khalkhin Gol River, and in Spain, the surgeons of the Military Medical Academy proved the universal type 0 blood transfusion to be a successful technique. The opinions of scientists on blood donation and preservation, indications and contraindications to blood transfusion in peacetime and wartime are presented.

2494 Rare Case of Concomitant Acute Hepatic Failure and Renal Failure Induced by Intravenous Amiodarone

INTRODUCTION: Hepatotoxicity caused by chronic oral amiodarone is well documented with around 15–20%. However, acute liver failure due to intravenous Amiodarone is rare clinical presentation with 3% incidence rate. Incidence of concomitant renal failure is even more rare. There is no full explanation for the underlying mechanism. CASE DESCRIPTION/METHODS: 67-year-old male with PMH of CAD s/p coronary artery bypass graft, CKD, presented with chest pain for one week. In the ED, he was found to have atrial flutter. Due to unresponsiveness to IV beta blocker and Diltiazem, patient was loaded with IV Amiodarone and continued IV Amiodarone drip. 16 hours later patient developed acute hepatic failure with AST 4250 (10-42 IU/L), ALT 2422 (10-60 IU/L), INR 2.28 (2-3 conventional anticoagulation), acute renal failure with creatinine of 3.2 mg/dl (0.44-1.0 mg/dl), BUN of 44 mg/d (5-25 mg/dl). Patient was intubated due to acute hepatic encephalopathy. IV Amiodarone was stopped immediately. All workup for other causes of acute hepatic failure came back negative. He was started on intravenous N-Acetyl cysteine and required hemodialysis for acute renal failure. LFTs peaked 72 hours after discontinuation of Amiodarone. Kidney functions improved 5 days after discontinuation of amiodarone and hemodialysis stopped. DISCUSSION: Acute hepatic failure due to intravenous amiodarone is extremely rare with incidence of 3%. The underlying mechanism is still not fully understood. However, a case–control retrospective study argues that hepatotoxicity due to intravenous amiodarone cannot be differentiated from ischemic hepatitis from concomitant hypotension. Intravenous amiodarone is formulated with polysorbate 80 as a solubilizer, which has been shown to induce hypotension. In this case, patient had a stable blood pressure when amiodarone was started. Intravenous (IV) amiodarone toxicity can raise AST/ALT up to 100–200-fold (AST of 21000 and ALT of 9020 in our case) within a day of infusion which then reverses quickly after discontinuation of amiodarone. In this case, liver function tests increased after 26 hours of starting intravenous amiodarone and peaked after 72 hours of stopping the infusion. All cases of acute liver failure due amiodarone didn't survive except for one case. The most common cause of death is encephalopathy. Administration of N-Acetylcysteine was administered is associated with good outcome. Incidence of concomitant renal failure is extremely rare. It is caused by concomitant acute tubular necrosis.

Sickle Cell Disease Is Associated With Higher Mortality Among Patients Hospitalized With Ischemic Bowel Disease

Introduction: Sickle Cell Disease (SCD) is the most common inheritable hematologic disorder in the United States and is associated with ischemic organ diseases. SCD-associated Ischemic Bowel Disease is being increasingly recognized, but studies on the hospitalization outcomes of such patients is limited. We compared the inpatient outcomes of Ischemic Bowel Disease among patients with SCD compared with patients without SCD. Methods: This is a case-control study using data from the National Inpatient Sample Database (2007-2014). We analyzed and compared outcomes between cases (Ischemic Bowel Disease with SCD) and controls (Ischemic Bowel Disease without SCD), matched in a ratio 1:5. The primary outcome was inhospital mortality, and secondary outcomes were health-care resource utilization including mechanical ventilation, hemodialysis, transfusion, length of stay and hospital charges. Results: Of the 194,262 patients admitted with Ischemic Bowel Disease, 98 had a diagnosis of SCA and were successfully matched to controls. In multivariate analysis, patients with SCD had twice the mortality of those without (aOR = 2.06, 95% CI 1.13-3.74). They were more likely to need mechanical ventilation, blood transfusion and to be discharged to secondary health facilities (1.68[1.02-2.76], 3.32[2.15-5.12] & 1.84[1.02-3.35]). Patients with SCD also had a higher frequency of pneumonia, acute respiratory failure, and hemodialysis for acute renal failure. There was no significant difference in length of stay or total hospital charge between the two groups. Conclusion: In patients hospitalized with Ischemic Bowel Disease, SCD is associated with significantly increased mortality and healthcare burden.172_A Figure 1. Flow chart of how sample was selected from the HCUP-NIS dataset172_B Figure 2. Adjusted odds ratio for mortality and other outcomes

Sickle cell disease is associated with higher mortality among patients hospitalized with ischemic bowel disease.

Sickle cell disease (SCD) is the most common inheritable hematologic disorder in the USA and is associated with ischemic organ diseases. SCD-associated ischemic bowel disease is increasing being recognized, and studies on the hospitalization outcomes of such patients are limited. This study aimed to compare the inpatient outcomes of ischemic bowel disease among patients with SCD compared with patients without SCD. This is a case-control study using data from the National Inpatient Sample Database (2007-2014). We analyzed and compared outcomes between cases (ischemic bowel disease with SCD) and controls (ischemic bowel disease without SCD), matched in a 1 : 5 ratio. The primary outcome was in-hospital mortality, and the secondary outcomes were healthcare resource utilization including mechanical ventilation, hemodialysis, transfusion, length of stay, and hospital charges. Of the 194 262 patients admitted with ischemic bowel disease, 98 had a diagnosis of SCD and were matched successfully to the controls. In multivariate analysis, patients with SCD had twice the mortality odds of those without (adjusted odds ratio=2.06, 95% confidence intervals: 1.13-3.74). They were more likely to require mechanical ventilation and blood transfusion, and to be discharged to secondary health facilities [1.68 (1.02-2.76), 3.32 (2.15-5.12), and 1.84 (1.02-3.35)]. Patients with SCD also had a higher frequency of pneumonia, acute respiratory failure, and hemodialysis for acute renal failure. There was no significant difference in the length of stay or the total hospital charge between the two groups. In patients hospitalized with ischemic bowel disease, SCD is associated with significantly increased mortality and healthcare burden.

Comparison of Outcomes in Patients Having Acute Myocardial Infarction With Versus Without Sickle-Cell Anemia

Sickle-cell disease (SCD) affects millions worldwide. Sickle-cell anemia (SCA), the most severe form of this disease, is the most common inherited blood disorder in the United States. There are limited data on the incidence, clinical characteristics, and outcomes of acute myocardial infarction (AMI) in these patients. Using data from the National Inpatient Sample database, we matched cases (AMI with SCA) with controls (AMI without SCA) in a 1:1 ratio for age, gender, race, and year of admission. We compared both groups in terms of clinical characteristics and inpatient outcomes and performed a logistic regression with mortality as the primary outcome. Using weighted samples, we also described trends of SCA in the general population of patients with AMI. Of the 2,386,657 admissions with AMI, SCA was reported in 501 (0.02%) patients, and 495 were successfully matched to controls. Patients with SCA were less likely to have risk factors for coronary artery disease than those without SCA. Patients with SCA were more likely to develop pneumonia, respiratory failure, and acute renal failure, and require mechanical ventilation, hemodialysis for acute renal failure and blood transfusion. In-hospital mortality was significantly higher in patients with SCA. In a multivariate analysis, SCA was an independent predictor of mortality (odds ratio 3.49; 95% confidence interval 1.99 to 6.12; p = < .001). In conclusion, myocardial infarction occurs in patients with SCA at a relatively early age. These patients do not typically have the traditional risk factors for the acute coronary syndrome. Mortality in these patients is significantly higher in age-, gender-, and race-matched controls.

Renal Support for Acute Kidney Injury in the Developing World

There is wide variation in the management of acute kidney injury (AKI) and the practice of renal replacement therapy (RRT) around the world. Clinicians in developing countries face additional challenges due to limited resources, reduced availability of trained staff and equipment, cultural and socioeconomic aspects, and administrative and governmental barriers. In this article, we report the consensus recommendations from the 18th Acute Dialysis Quality Initiative conference in Hyderabad, India. We provide the minimal requirements for provision of acute RRT in developing countries, including patient selection, choice of RRT modality and monitoring, transition, and termination of acute RRT. We also discuss areas of uncertainty and propose themes for future research. These recommendations can serve as a foundation for clinicians to implement renal support for AKI in low resource settings.

Hospital Variation in Utilization of Life-Sustaining Treatments among Patients with Do Not Resuscitate Orders.

To determine between-hospital variation in interventions provided to patients with do not resuscitate (DNR) orders. United States Agency of Healthcare Research and Quality, Healthcare Cost and Utilization Project, California State Inpatient Database. Retrospective cohort study including hospitalized patients aged 40 and older with potential indications for invasive treatments: in-hospital cardiac arrest (indication for CPR), acute respiratory failure (mechanical ventilation), acute renal failure (hemodialysis), septic shock (central venous catheterization), and palliative care. Hierarchical logistic regression to determine associations of hospital "early" DNR rates (DNR order placed within 24hours of admission) with utilization of invasive interventions. California State Inpatient Database, year 2011. Patients with DNR orders at high-DNR-rate hospitals were less likely to receive invasive mechanical ventilation for acute respiratory failure or hemodialysis for acute renal failure, but more likely to receive palliative care than DNR patients at low-DNR-rate hospitals. Patients without DNR orders experienced similar rates of invasive interventions regardless of hospital DNR rates. Hospitals vary widely in the scope of invasive or organ-supporting treatments provided to patients with DNR orders.

Intravenous catheter complications in hemodialysis

Background: Vascular access, still is a problem for hemodialysis. Venous catheters are commonly used for acute angioaccess during maintenance hemodialysis in acute renal failure and end-stage renal failure patients. However, the catheters are often complicated by mechanical or infectious complications which may result in morbidity and or premature removal of the catheter. Even though, there are various studies on central venous catheters used in hemodialysis in western countries less is documented in India. Aims and Objectives: Complications of intravenous catheter used during hemodialysis in our set up. Materials and Methods: This prospective study was conducted on 110 patients selected by random sampling in dialysis units of a government district hospital from October 2014 to September 2015. Patient age, sex, history, type of kidney disease, and associated conditions were also noted according to the pro forma. Date of intravenous catheter insertion, site of insertion, and insertion complications were noted. All patients were followed up until the day of catheter removal. Date of catheter removal, reason for catheter removal, and duration of catheter days were noted. Data were collected and tabulated. Result: Only 47.8% of patients suspected with infections showed bacterial growth in catheter tip culture. However, blood culture showed bacterial growth only in 19.6% of infection suspected patients. Blood culture reported 55.6% Staphylococcus aureus growth followed by Pseudomonas (22.2%), Escherichia coli, and Acinetobacter (11.15%) growth in samples collected from infection suspected dialysis patients. Conclusion: Fever due to infections is the most common cause for catheter removal.

Relapse of HCV Genotype 1b Infection After Sofosbuvir/Ledipasvir Treatment Presenting as De Novo Cryoglobulinemic Vasculitis

Relapse of hepatitis C virus (HCV) genotype 1 infection after combination therapy with sofosbuvir and ledipasvir is unusual. We report a treatment-naïve, non-cirrhotic patient in whom the relapse of genotype 1b HCV infection was accompanied by de novo cryoglobulinemic vasculitis and glomerulonephritis, requiring hemodialysis for acute renal failure. Sequence analysis revealed several resistance-associated variants in the HCV NS5a gene but not in NS3/4A. The patient’s vasculitis was successfully treated with immunosuppression and plasmapheresis, followed by retreatment of HCV with a combination of sofosbuvir, simeprevir, and ribavirin. The patient achieved sustained virological response, recovered his renal function, and remains in remission from cryoglobulinemia.

A Rare Case of Emphysematous Pyelonephritis

Background: This case illustrates the potential for class 3A emphysematous pyelonephritis with the presence of nephrolithiasis to be initially treated solely by relieving the hindered urinary outflow and with systemic antibiotics if diagnosed early with appropriate imaging studies. Case Presentation: 64-year-old Caucasian female with history of diabetes mellitus type 2, hyperlipidemia, hypertension, coronary artery disease and diastolic congestive heart failure presented to the emergency department with respiratory distress of 2 days duration. Her chief complaint was associated with anuria for two days, abdominal pain, generalized weakness, and loss of appetite. The patient was admitted to the medical intensive care unit (MICU) for hypotension, severe mixed respiratory and metabolic acidosis, and uremia. She was intubated for pending respiratory failure and underwent emergency hemodialysis for acute renal failure. She received hemodynamic support and was also started on systemic antibiotics. A computerized tomography (CT) scan of the abdomen/pelvis revealed class 3A emphysematous pyelonephritis (EPN) of the left kidney and an 8 mm nonobstructing calculus in the left proximal ureter. Subsequently a left ureteral stent was placed to relieve the obstruction. In addition, blood cultures revealed bacteremia with Klebsiella pneumoniae. Although she had thrombocytopenia, acute renal failure and shock, the intra-renal emphysema improved with the stent and she was eventually weaned off of vasopressors, extubated and showed marked clinical improvement. Conclusion: Rare cases of class 3A EPN precipitated by any degree of urinary tract obstruction may be treated initially with relief of outflow hindrance and aggressive supportive care if an early diagnosis can be made with appropriate imaging studies.

METABOLIC SYNDROME AND THE RISK OF ACUTE KIDNEY DAMAGE DEVELOPMENT AFTER CORONARY ARTERY BYPASS PROCEDURE

Aim. To find out the causal relationship of metabolic syndrome (MS) with acute kidney damage (AKD) in coronary bypass grafting patients (CABG). Material and methods. To the clinical comparative study totally 742 patients included (489 men и 253 women) at the age 53 to 67 y. o. (mean 62,1±4,7), who underwent CABG on-pump. Of those 477 (64,3%) did not have the metabolic criteria for MS (1st group), and 265 pts. (35,7%) had MS (2nd group). Depending on the maximum increase of serum creatinine (sCr) during early post-operation period ARF was diagnosed in the 1st group on 119 patients (24,9%) in the 2nd — 92 patients (34,7%). AKD was diagnosed by AKIN. Results. It was shown that early post operational cardiovascular complications significantly more frequently developed in AKD in both groups, and in the 2nd group comparing to the 1st. Also the procedures of hemodialysis in acute renal failure (3 stage of AKD) in the 1st group performed in 5,9% cases and in the 2nd — in 17,4% cases (p=0,015). In-hospital mortality was 2,0% to 16,3% depending on the development of AKD and MS. However in the 2nd group, in the development AKD as without this, intra-hospital mortality was significantly higher (p&lt;0,05), than in the 1st group. It was revealed that in the case of AKD the parameters of MS were significantly higher than in its absence, especially in the 1st group. Also in the 2nd group, not related to the development of AKD metabolic parameters were higher in the 2nd group than in the 1st. Also, 1st stage and transient AKD were more prevalent in the 1st group, and III stage and non-reversible AKD with the onset of CKD — in the 2nd group. The time of hospitalization in the 2nd group was significantly longer than in the 1st (p=0,008). Conclusion. It is shown that in MS patients after CABG, comparing to those without MS, the prevalence of AKD is higher 1,5 times, in-hospital mortality — 2,5 times.

Acute angle closure glaucoma with capilllary leak syndrome following snake bite.

Acute angle closure glaucoma is rarely seen as complication of snake bite.We report three cases of bilateral acute angle closure glaucoma with capillary leak syndrome and acute renal failure secondary to hematotoxic snake bites. We are also briefly discussing the association of capillary leak syndrome and angle closure glaucoma in hematotoxic snake bite. This is the first time an association between angle closure and capillary leak syndrome following snake bite is reported. Descriptive case series. Records of all patients admitted to ICU with snake bite were reviewed to identify cases developing acute angle closure glaucoma. These cases with acute angle closure glaucoma are analysed in detail for systemic condition. Diagnosis, management and outcome of cases are described Results: Of the 119 snake bites admitted, 47 patients had confirmed hematotoxic snake bite. Fifteen of these patients underwent hemodialysis for acute renal failure. Seven of them were diagnosed to have capillary leak syndrome and all of them complained of decreased vision. Three of the 7 cases had acute angle closure glaucoma on the second day of bite. One of the patients expired and other two recovered fully, both of them had normal IOP and good vision at one month follow-up. Acute angle closure glaucoma seems to be associated with systemic capillary leak syndrome in hematotoxic snake bite. High suspicion, early recognition, timely and appropriate treatment can prevent visual loss in this rare complication.

Hyperbaric-oxygen treatment: An adjunctive therapy in acute renal failure due to crush injury

Objective: Major seismic events leave their survivors trapped under the rubble leading to extensive muscle damage and its devastating sequale of hemodynamic and metabolic disturbances and acute renal failure. Hypoxemia aggravated during each hemodialysis (HD) session is important in acute renal failure patients with massive tissue injury. We retrospectively analyzed the adjunctive role of hyperbaric-oxygen (HBO) therapy in patients treated with HD for acute renal failure due to crush injury in terms of dialysis duration. Patients and methods: 16 patients admitted after the Marmara earthquake to Istanbul Faculty of Medicine were treated with HBO. Only 8 (2M, 6F, mean age: 24.8 + 7.3 years) of them had required HD treatment. 29 (16M, 13F, mean age: 34.6 + 12.9 years) crush syndrome patients treated with HD but not with HBO were taken as controls and the clinical and laboratory data of the two groups were compared. Results: The mean duration time under the rubble for the HBO group was 9.4 + 3.2 hours. Mainly lower extremity fasciotomies were performed at 15.6 + 14.8 hours after extrication. There were no amputations in this group. There were three amputations in the control group. The mean number of HD sessions was 9.2 + 6.7/patient for 10.9+9.6 days until renal functions recovered and the patients had 27.4 + 15.6 HBO sessions until the recovery of their lesions. There were no correlations between the number of HBO sessions and any laboratory parameter nor the number of HD sessions. There was no statistical difference in the need for HD between the HBO and control group. Conclusions: Our results could not demonstrate any beneficial effect of HBO treatment in terms of HD duration; however, the valuable contribution of the HBO treatment was to increase the salvage of crushed limbs.

Neurocognitive Problems in Critically Ill Older Adults: The Importance of History

Older adults are at greater risk for the development of neurocognitive problems during critical illness than are their younger counterparts, particularly if they have preexisting cognitive impairment. Neurocognitive problems result in longer duration of mechanical ventilation and extended intensive care unit (ICU) and hospital lengths of stay. These problems can persist after discharge and affect quality of life for both the patient and family caregivers. Accurate assessment of neurocognitive status necessarily guides selection of interventions. Consider the case of Mrs. Crane, an older woman who developed flank pain, nausea, vomiting, and altered mental status while travelling with her husband. She was first admitted emergently to a community hospital and then transferred to the University Medical Center with a diagnosis of intrahepatic abscesses. She developed septic shock and renal failure and was intubated and mechanically ventilated shortly after admission to the University Hospital. Medical management included vasopressor medications for hypotension and intermittent hemodialysis for acute renal failure. Mrs. Crane’s ICU course was notable for prolonged periods of psychomotor agitation, which were treated with intravenous lorazepam, morphine,and fentanyl. The sedative and analgesic medications were titrated to manage physiologic (hypertension, tachycardia, tachypnea) and behavioral symptoms (head thrashing, active in bed, facial grimacing, pulling at wrist restraints, “bucking” ventilator, wincing, lifting arms and legs off bed, and “resisting care”). Ventilator weaning attempts were avoided or aborted when agitation was associated with a reduction

Neurologic Recovery Following Prolonged Out-of-Hospital Cardiac Arrest With Resuscitation Guided by Continuous Capnography

A 54-year-old man with no known cardiac disease collapsed outdoors in a small rural community. The cardiac arrest was witnessed, and immediate cardiopulmonary resuscitation was begun by a bystander and a trained first responder who was nearby. The patient was moved into a building across the street for continued resuscitation. First responders arrived with an automated external defibrillator, and ventricular fibrillation was documented. First responders delivered 6 defibrillation shocks, 4 of which transiently restored an organized electrocardiographic rhythm but with no pulse at any time. Additional emergency medical services personnel from nearby communities and an advanced life support (ALS) flight crew arrived. The flight crew initiated ALS care. The trachea was intubated, ventilation controlled, and end-tidal carbon dioxide tension continuously monitored. Antiarrhythmic and inotropic drugs were administered intravenously. An additional 6 shocks were delivered using the ALS defibrillator. End-tidal carbon dioxide measurements confirmed good pulmonary blood flow with chest compressions, and resuscitation was continued until a stable cardiac rhythm was restored after 96 minutes of pulselessness. The patient was transported by helicopter to the hospital. He was in cardiogenic shock but maintained a spontaneous circulation. Coronary angiography confirmed a left anterior descending coronary artery thrombotic occlusion that was treated successfully. After hospital admission, the patient required circulatory and ventilatory support and hemodialysis for acute renal failure. He experienced a complete neurologic recovery to his pre-cardiac arrest state. To our knowledge, this is the longest duration of pulselessness in an out-of-hospital arrest with a good outcome. Good pulmonary blood flow was documented throughout by end-tidal carbon dioxide measurements.

Niacin Toxicity Resulting From Urine Drug Test Evasion Scheme

Niacin, a well-established agent for treating dyslipidemia, has been promoted on the Internet as a method for passing urine drug screening, although there are no data to support its use for this purpose. In a handful of cases, this practice has resulted in serious niacin toxicity. The aim of this article is to describe a unique clinical presentation of niacin toxicity. A 23-year-old previously healthy man presented to an Emergency Department with altered mental status, fever, acute renal failure, microangiopathic hemolytic anemia, thrombocytopenia, and coagulopathy. It was revealed that he had taken approximately 22.5 g of sustained-release niacin over the preceding 48 h in an attempt to pass a pre-employment urine drug screen. After a complicated hospital course that included mechanical ventilation for respiratory failure and hemodialysis for acute renal failure, the patient made a full recovery and was discharged 10 days after his initial presentation. After a massive niacin overdose, the young man in this case presented with a complex clinical picture that mimicked concurrent thrombotic thrombocytopenic purpura and disseminated intravascular coagulation. Although this patient was fortunate to make a full recovery, the case highlights the potential for multi-system toxicity with niacin overdose, and the potential for harm posed by medical misinformation on the Internet.

Burkitt lymphoma presenting as posterior reversible encephalopathy syndrome secondary to hypercalcaemia

A 50-year-old Caucasian female presented with fever and increasingly obtunded. Physical examination showed normal blood pressure and no focal neurological signs. There was no organomegaly or lymphadenopathy. A full blood count showed: haemoglobin 86 g/l, white cells 9AE9 · 10/l (with 6% blasts) and platelets 114 · 10/l. A coagulation screen showed evidence of disseminated intravascular coagulopathy. Biochemistry tests revealed hypercalcaemia with a calcium of 3AE91 mmol/l and increased ionized calcium to 2AE05 mmol/l, in association with raised lactate dehydrogenase to 345 iu/l but normal alkaline phosphatase level. The serum free kappa light chain level was increased to 33AE6 mg/l (reference interval: 3AE3–19AE4 mg/l) and there was generalized immunoparesis. Bone marrow aspiration showed hypercellular particles packed with 76% blasts (left upper panel). The blast cells were mostly medium sized showing round nuclei, dispersed chromatin, multiple small nucleoli and scanty basophilic cytoplasm that was sometimes vacuolated. Trephine biopsy showed hyperplastic marrow that was diffusely replaced by a monotonous population of medium-sized blasts with frequent mitotic figures. Blast cell immunophenotyping by flow cytometry supplemented by immunohistochemistry demonstrated clonal B-cells (CD19 CD20 CD22 CD79a surface IgM) that expressed CD10 and BCL2, but were negative for terminal deoxynucleotidyltransferase and BCL6. The Ki-67 labelling index was virtually 100%. Interphase FISH on bone marrow blasts showed MYC gene rearrangement (left lower panel) as detected by a dual colour break-apart probe (Abbott Molecular, IL, USA) but negative for IGH/MYC fusion, consistent with MYC translocation other than classical t(8;14). The IGH/BCL2 fusion was negative. The diagnosis was Burkitt lymphoma. Magnetic resonance imaging (MRI) of the brain showed symmetrical posterior cortical and subcortical lesions in axial (right upper panel) and coronal (right lower panel) sections. The cerebrospinal fluid was unremarkable. The patient was started on haemodialysis for acute renal failure (creatinine 463 lmol/l) and the calcium level was normalized after institution of cytotoxic therapy. A repeat MRI scan after treatment showed complete resolution of the brain lesion. The neurological diagnosis was posterior reversible encephalopathy syndrome (PRES) secondary to severe hypercalcaemia. The patient returned to her native country for further management. This case illustrated the uncommon presenting feature of PRES due to hypercalcaemia in Burkitt lymphoma.