Department Of Intensive Care Medicine Research Articles

Rapid Resolution of Massive Lung Abscesses Complicating Tricuspid-Valve Endocarditis

HomeCirculationVol. 114, No. 14Rapid Resolution of Massive Lung Abscesses Complicating Tricuspid-Valve Endocarditis Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBRapid Resolution of Massive Lung Abscesses Complicating Tricuspid-Valve Endocarditis Yok-Ai Que, MD, PhD, Olivier Muller, MD, PhD and Lucas Liaudet, MD Yok-Ai QueYok-Ai Que From the Department of Intensive Care Medicine (Y.-A.Q., L.L.) and the Service of Cardiology (O.M.), University Hospital, Lausanne, Switzerland. Search for more papers by this author , Olivier MullerOlivier Muller From the Department of Intensive Care Medicine (Y.-A.Q., L.L.) and the Service of Cardiology (O.M.), University Hospital, Lausanne, Switzerland. Search for more papers by this author and Lucas LiaudetLucas Liaudet From the Department of Intensive Care Medicine (Y.-A.Q., L.L.) and the Service of Cardiology (O.M.), University Hospital, Lausanne, Switzerland. Search for more papers by this author Originally published3 Oct 2006https://doi.org/10.1161/CIRCULATIONAHA.106.626317Circulation. 2006;114:e523–e524A 33-year-old female intravenous drug abuser presented with fever and acute respiratory failure requiring mechanical ventilation. Chest x-ray and a thoracic computed tomographic scan revealed multiple nodular lesions with cavitation (Figure 1). A transesophageal echocardiogram disclosed a tricuspid-valve vegetation (Figure 2), and blood cultures were positive for Staphylococcus aureus. A diagnosis of tricuspid-valve endocarditis with septic pulmonary emboli (SPE) was made. Antibiotherapy with intravenous flucloxacillin and gentamicin induced a spectacular regression of the lung abscesses, allowing weaning from mechanical ventilation after 8 days and discharge from the hospital after 4 weeks (Figure 1). Download figureDownload PowerPointFigure 1. Repeated computed tomographic scans of the chest from apex to base showing massive, bilateral, nodular lesions with cavitation on admission (A, B, and C). Spectacular improvement of the lesions under appropriate antibiotic therapy was noted after 14 days (D, E, and F), and almost complete resolution was noted after 4 weeks (G, H, and I).Download figureDownload PowerPointFigure 2. Transesophageal echocardiography (4-chamber view) showing a large mobile mass attached to the atrial surface of the anterior leaflet of the tricuspid valve.Infective endocarditis is a serious complication of intravenous drug abuse, with a reported mortality of 5% to 10%.1 In a recent retrospective series of 493 cases of infective endocarditis, 220 (44.6%) occurred in intravenous drug users. The tricuspid valve was most frequently affected (88% of cases), and S aureus was the most frequently encountered pathogen.2 SPE are relatively common in this setting. Intravenous drug users comprised 78% of a cohort of 60 patients with SPE reported in 1978,3 and tricuspid endocarditis was the embolic source in 53% of the cases. Although SPE may be particularly severe and life-threatening, appropriate antibiotherapy may result in rapid resolution of the lung abscesses, as indicated here, and thus such a complication should not be considered an indication for valve surgery in the setting of tricuspid endocarditis.DisclosureDr Liaudet is supported by the Swiss National Fund for Scientific Research (Grant Nr PP00B-68882/1). The other authors have no potential conflicts of interest to disclose.FootnotesCorresponding to Professor Lucas Liaudet, MD, Department of Intensive Care Medicine, BH 10-982, University Hospital, 1011 Lausanne, Switzerland. E-mail [email protected]References1 Moreillon P, Que YA. Infective endocarditis. Lancet. 2004; 363: 139–149.CrossrefMedlineGoogle Scholar2 Martin-Davila P, Navas E, Fortun J, Moya JL, Cobo J, Pintado V, Quereda C, Jimenez-Mena M, Moreno S. Analysis of mortality and risk factors associated with native valve endocarditis in drug users: the importance of vegetation size. Am Heart J. 2005; 150: 1099–1106.CrossrefMedlineGoogle Scholar3 MacMillan JC, Milstein SH, Samson PC. Clinical spectrum of septic pulmonary embolism and infarction. J Thorac Cardiovasc Surg. 1978; 75: 670–679.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails October 3, 2006Vol 114, Issue 14 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.106.626317PMID: 17015799 Originally publishedOctober 3, 2006 PDF download Advertisement SubjectsImagingValvular Heart Disease

Letters to the Editor

Department of Intensive Care Medicine, Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands (Schultz) Department of Intensive Care Medicine, Gelre Hospitals, Lukas, Apeldoorn, the Netherlands (Spronk)

Hyperglycemia and intensive care patients: An expanding story*

Department of Intensive Care Medicine and Department of Pediatric Cardiology, University Hospital Leuven, Belgium *See also p. 351. The authors have not disclosed any potential conflicts of interest.

Toxic-shock-like-Syndrom durch β-hämolysierende Streptokokken der Gruppe G bei einem multimorbiden Patienten mit Erysipel

A 41-year-old, obese man with a history of incomplete paraplegia of both legs and chronic venous insufficiency with stasis dermatitis presented with acute respiratory and hyperdynamic hemodynamic failure. He was transferred from another hospital to the department of intensive care medicine for further diagnosis and treatment. A livid coloured, necrotizing-hemorrhagic swelling of the right lower leg was noted. Laboratory tests revealed an inflammation probably due to bacterial infection, anemia, acute renal failure, acute hepatic dysfunction, coagulopathy and lactic acidosis, indicating multi-organ failure and septic shock. No focus of sepsis was found at abdominal sonography and exploratory laparotomy. Chest X-Ray and computed tomography revealed bilateral pneumonia. Doppler ultrasonography of both legs showed acute isolated thrombosis of the right posterior tibial vein. In addition to a chronic venous ulcer-necrotizing hemorrhagic erysipelas had developed in the right lower leg. A swab taken at surgery and blood cultures grew Streptococcus dysgalactiae ssp. equisimilis (group G streptococci, GGS). Despite intensive care treatment and high dosage penicillin G therapy the patient died two days after admission from septic shock and multi-organ failure. Group G streptococci cause a variety of common and severe infections. Erysipelas is infrequently associated with GGS but, much more often, with group A streptococci (GAS). This unusual and fulminant case emphasizes the importance of considering Streptococcus dysgalactiae as a causative agent in septicemia with multiple predisposing factors and soft-tissue infections.

Derivative weighted active insulin control modelling and clinical trials for ICU patients

Close control of blood glucose levels significantly reduces vascular complications in Type 1 and Type 2 diabetic individuals. Heavy derivative controllers using the data density available from emerging biosensors are developed to provide tight, optimal control of elevated blood glucose levels, while robustly handling variation in patient response. A two-compartment glucose regulatory system model is developed for intravenous infusion from physiologically verified subcutaneous infusion models enabling a proof-of-concept clinical trial at the Christchurch Hospital Department of Intensive Care Medicine. This clinical trial is the first of its kind to test a high sample rate feedback control algorithm for tight glucose regulation. The clinical trial results show tight control with reductions of 79–89% in blood glucose excursions for an oral glucose tolerance test. Experimental performance is very similar to modelled behaviour. Results include a clear need for an additional accumulator dynamic for insulin behaviour in transport to the blood and strong correlation of 10% or less between modelled insulin infused and the amounts used in clinical trials. Finally, the heavy derivative PD control approach is seen to be able to bring blood glucose levels below the (elevated) basal level, showing the potential for truly tight control.

Duplicate publication.

Raja et al. take the defense for small-dose dopamine and do not accept the available evidence for advising against the use small-dose dopamine in the ICU. We agree with these authors that extrapolating data from animal studies or from human studies measuring surrogate markers of outcome to the clinical practice should be done with great caution. It is exactly this kind of misinterpretation that has lead to the multiple doubtful recommendations for the use of small-dose dopamine in the past. However, a well-designed, large, prospective, randomized, placebo-controlled clinical trial has showed that small-dose dopamine does not prevent or reverse acute renal failure, nor does it improve outcome (1). In addition, two meta-analyses were performed very carefully and came to the same conclusion (2,3). Besides the lack of clinical efficacy, small-dose dopamine has multiple side effects, as revealed form well-controlled clinical studies (4). We thus conclude that there is sound scientific evidence that no longer justifies the use of small-dose dopamine in the ICU. Yves A. Debaveye, MD Greet H. Van den Berghe, MD, PhD Department of Intensive Care Medicine, Catholic University of Leuven, Leuven, Belgium

A double-lumen tube technique for selective lobar isolation

EDITOR: A 72-yr-old female (height 162 cm, weight 55 kg) was admitted to our Intensive Care Unit (ICU) because of acute respiratory failure (PaO2/inspired O2 fraction (FiO2) 10.3 kPa). On admission, her trachea was intubated with a 7.5 mm inner diameter endotracheal tube (Portex, Kent, UK) and lungs mechanically ventilated in a pressure-regulated volume-controlled mode (Siemens 300C®, Berlin, Germany). Tidal volume was set at 380-400 mL, respiratory rate 20 breaths min−1, externally applied positive end-expiratory pressure (PEEP) 0 cmH2O. The achieved PaO2/FiO2 was 12 kPa. The patient was sedated with propofol (4 mg kg−1 h−1). The admission chest radiograph revealed diffuse, bilateral pulmonary infiltrates. She had no prior history of chronic inhalation of dusts causing inflammation and pulmonary fibrosis. Microbiological, serological and imaging investigations for patients with suspected interstitial lung disease [1] failed to establish a definitive, causal diagnosis. Thus, surgical lung biopsy [1-4] under selective lobar collapse [5] was decided. For selective left upper lobar collapse, the following technique was employed. (a) Determination of left mainstem bronchus length. A 3.4 mm fibreoptic bronchoscope was inserted through the original endotracheal tube; the upper incisor-to-carina distance (23.5 cm) was determined by subtracting the endotracheal tube connector-to-upper incisor length (part of endotracheal tube protruding from the patient's mouth) from the fibreoptic bronchoscope insertion length at the level of carina (endotracheal tube connector-to-carina); in a similar way, the upper incisor-to-left upper bronchus orifice distance (26.0 cm) was determined by subtracting the endotracheal tube connector-to-upper incisor length from the fibreoptic bronchoscope insertion length at the level of the left upper bronchus orifice; lastly, the difference of the aforementioned distances yielded the left mainstem bronchus length (2.5 cm). (b) LUL isolation. Additional propofol (1 mg kg−1), fentanyl (3 μg kg−1) and cisatracurium (0.2 mg kg−1) were given. Then the original endotracheal tube was replaced by a 37-FG, left-sided, double-lumen tube (BronchoCath®; Mallinckrodt Medical Inc., St. Louis, MO, USA); the double-lumen tube was inserted to the 28.0 cm mark at upper incisor level, and the inflation of both tracheal and bronchial cuffs resulted in the desired selective LUL isolation (Fig. 1).Figure 1: Selective isolation of the left upper lobe with the left-sided double-lumen tube inserted to the 28 cm mark.(c) Confirmation of LUL isolation. A fibreoptic bronchoscope inspection via the tracheal lumen of the double-lumen tube revealed the carina and both mainstem bronchial orifices; on inspection through the bronchial lumen only the segmental left lower bronchial orifices were visualized; on chest auscultation, with both double-lumen tube cuffs inflated, breath sounds were diminished solely over the left upper lobe. In the right lateral decubitus position, the desired double-lumen tube positioning was reconfirmed as above. Following left upper lobe collapse [5], an uneventful videothoracoscopic biopsy of the left upper lung was performed within 40 min. Intraprocedural ventilator settings were: FiO2, 1.0; tidal volume, 350-360 mL; respiratory rate, 23 breaths min−1; inspiratory time-to-total respiratory cycle time ratio 0.5; externally applied PEEP 0 cmH2O. Peak, plateau and mean airway pressures were 45-46, 28-30 and 8-9 cmH2O, respectively; intrinsic PEEP was 2 cmH2O. PaO2 was maintained ≥8 kPa throughout the procedure. In patients in respiratory failure with a short (≈2.5 cm) left mainstem bronchus [6], we recommend our selective left upper lung isolation technique for open lung biopsy. The left lower lobe can still be ventilated through the left endobronchial lumen of the double-lumen tube and the right lung is ventilated through the tracheal lumen. This is likely to minimize the risk of intraoperative hypoxaemia. S. D. Mentzelopoulos K. Rellos M. J. Tzoufi A. S. Michalopoulos Department of Intensive Care Medicine; Henry Dunant General Hospital; Athens, Greece E. P. Papageorgiou Department of Anaesthesiology; Henry Dunant General Hospital; Athens, Greece

SUBLINGUAL PCO2 IN PATIENTS WITH CIRCULATORY SHOCK.

Department of Intensive Care medicine. Erasme University Hospital. Free University of Brussels. Belgium.

Bad news about growth hormone treatment in the intensive care unit: need for some clarification

Department of Intensive Care Medicine, Catholic University of Leuven, Leuven, Belgium Correspondence to Greet Van den Berghe, MD, PhD, Department of Intensive Care Medicine, Catholic University of Leuven, B-3000 Leuven, Belgium e-mail: [email protected]

Euthyroid sick syndrome

Department of Intensive Care Medicine, University Hospital Gasthuisberg, Leuven, Belgium Department of Intensive Care Medicine, University Hospital Gasthuisberg, Catholic University of Leuven, B-3000 Leuven, Belgium. Tel: +32 16 34 40 21/+32 16 34 40 13; fax: +32 16 34 40 15; e-mail: [email protected]

Abdominal pressure in the critically ill

Gut dysfunction resulting in increased gut permeability and subsequent bacterial translocation may play an important role in the development of multiple organ system failure in the critically ill within this concept. Intra-abdominal pressure is an important parameter and prognostic indicator of the

Invasive monitoring combined with two-dimensional echocardiographic study in septic shock

An investigation into the incidence and the clinical implication of discrepancies which may sometimes occur between invasive and non-invasive hemodynamic evaluation in septic patients. A prospective, consecutive comparison. Department of Intensive Care Medicine at a University Hospital. 32 patients undergoing therapy for an episode of septic shock. Conventional hemodynamic support (including volume expansion in all cases and inotropic support if necessary) required to obtain a stable hemodynamic status. Cardiac output (thermodilution method), cardiac pressures (right heart catheterization) and left ventricular (LV) volumes (two-dimensional echocardiography) were simultaneously recorded. A comparison was thus made between both procedures, particularly concerning preload evaluation and assessment of left ventricular systolic function. Pulmonary artery occlusion pressure measurement was evidence as an unreliable index of LV end-diastolic volume, determining preload. Assessment of LV systolic function by both methods was conflicting in 11 cases out of the 32. Frequent discrepancies between to invasive and non-invasive procedure were observed. The reasons for these discrepancies, including low vascular resistance, reduced LV compliance, and a possible overestimation of cardiac output by the thermodilution method, are examined in the light of data recorded. It was concluded that invasive hemodynamic evaluation by right heart catheterization in septic patients should be seriously questioned.