Successful use of extracorporeal life support and hemadsorption in the context of venlafaxine intoxication requiring cardiopulmonary resuscitation: a case report.

Venlafaxine is a serotonin and noradrenalin reuptake inhibitor prescribed as an antidepressant. Overdose clinically manifests with neurological, cardiovascular and gastrointestinal abnormalities based on, amongst others, serotonin syndrome and can be life-threatening due to cardiovascular collapse. Besides immediate decontamination via gastric lavage and inhibition of enteral absorption through active charcoal, successful hemadsorption with CytoSorb® has been reported. We present the case of a 17-year-old female who required extracorporeal life support (ECLS) for cardiovascular collapse as a result of life-threatening venlafaxine intoxication. Serial serum blood concentrations of venlafaxine/desmethylvenlafaxine on admission at a tertiary hospital (approx. 24 h after ingestion) and subsequently 6 h and 18 h thereafter, as well as on days 2 and 4, were measured. CytoSorb® was initiated 6 h after admission and changed three times over 72 h. The initial blood concentration of venlafaxine/desmethylvenlafaxine was 53.52 µmol/l. After 6 h, it declined to 30.7 µmol/l and CytoSorb® was initiated at this point. After 12 h of hemadsorption, the blood level decreased to 9.6 µmol/l. On day 2, it was down to 7.17 µmol/l and decreased further to 3.74 µmol/l. Additional continuous renal replacement therapy using CVVHD was implemented on day 5. The combination of hemadsorption, besides traditional decontamination strategies along maximal organ supportive therapy with ECLS, resulted in the intact neurological survival of the highest venlafaxine intoxication reported in the literature to date. Hemadsorption with CytoSorb® might help to reduce blood serum levels of venlafaxine. Swift clearance of toxic blood levels may support cardiovascular recovery after life-threatening intoxications.

The long-term fate of epistaxis patients with exposure to antithrombotic medication.

UNLABELLED: The goal of this study was to evaluate independent risk factors for long-term epistaxis recurrences and their severity. Individual retrospective cohort study-2b level of evidence. The medical information of 603 emergency epistaxis patients was acquired during a former study. This cohort has been contacted 6 years later by conventional mail and asked to answer a specific paper questionnaire. The following parameters were evaluated: recurrent epistaxis episodes, need for a surgical intervention to stop the recurrent bleeding, patient's history for hypertension and diabetes, intake of hemostasis impairing medication now and in the past. One hundred and six (106) patients were included in the study (35.8 % response rate). The mean observation period was 76.58 months. Almost half of the patients (41.5 % = 44/106) reported at least one recurrent epistaxis episode. Patients with exposure to VKA (vitamin K antagonists) showed significantly more frequently a recurrent epistaxis episode. The binary logistic regression confirmed the intake of VKA as an independent and significant risk factor with an odds ratio of 11.6. Every single patient who had to undergo a surgical intervention to stop a recurrent bleeding stated ASA (Acetylsalicylic Acid) intake. We provide evidence that the intake of a vitamin K antagonist is an independent long-term risk factor for recurrent epistaxis episodes. The intake of ASA is a risk factor for the severity of recurrent epistaxis with the increased need for a surgical intervention not only in a short- but also in a long-term perspective. LEVEL OF EVIDENCE: This prognostic investigation, designed as a combined prospective and retrospective cohort study, reaches level 2b level of evidence as it includes retrospective aspects.

[Record-Breaking Acidosis]. / Rekordverdächtig sauer.

Record-Breaking Acidosis Abstract. To maintain a stable cellular metabolism, tight regulation of blood pH within a normal range (pH 7,35-7,45) is essential. Even small aberrations can have detrimental effects, and pH values <6,8 or pH >7,8 are considered - based on current medical and physiological knowledge - incompatible with life [9-19].

[Death within Hours]. / Tod innerhalb von Stunden.

Death within Hours Abstract. The clinical picture of invasive meningococcal disease is broad, it mostly manifests as meningitis and/or sepsis. The severity ranges from a simple bacteremia associated with mild, unspecific symptoms to fulminant sepsis with multiorgan failure and death, which happens in 10-15 % of cases. Sometimes purely local infections (e.g. septic arthritis or conjunctivitis) or rarely a chronic course (prolonged, intermittent fever, rash, arthritis and headache) are the only clinical manifestation - which can also lead to a disseminated fulminant disease. Our case illustrates the tragic progression of a fulminant meningococcal sepsis with rapid death.

Emergency consultation for epistaxis: A bad predictor for overall health?

OBJECTIVE: To compare the mortality rate of a large epistaxis cohort with the fatalities of the general Swiss population and to evaluate significant risk factors for impending early death. METHODS: 568 patients out of an epistaxis cohort from a former study were contacted by mail to answer a questionnaire. Deceased patients were identified from March, 2007 through April, 2014. Death rates were compared to the general Swiss population. Different potential risk factors were evaluated by multivariate analysis. RESULTS: Thirty-four percent of the included patients (61 of total n=181) died during the observation period. The mean number of deaths per year was 8.7. Binary logistic regression identified anterior localization (p=0.027), comorbid endogenous bleeding predisposition including hemorrhagic hereditary telangiectasia (p=0.017) and age (p<0.01) as independent and significant risk factors for early death in epistaxis patients. A significantly higher mortality was found within our epistaxis cohort compared to the Swiss general population. CONCLUSION: With the present data a trivial event such as epistaxis, especially when anteriorly located, needs to be seen in a new light. Emergency consultation because of nose bleeding might be an unexpected bad predictor for mortality. Although conclusions need to be considered with caution due to the retrospective character of the study, we regard epistaxis as an independent alarm-signal. After an acute nose bleed requiring emergency consultation, active collaboration with the patient's general practitioner and additional efforts to check for the patient's general health might be more useful than so far assumed.

The high rate of long-term recurrences and sequelae after epistaxis treatment.

OBJECTIVE: Epistaxis is the most frequent rhinologic emergency with a high treatment morbidity. This study assessed the long-term outcome after epistaxis treatment with regard to patient comfort during the treatment, long-term complications and rate of recurrences. METHODS: A questionnaire cohort study was performed at the ENT department of the University Hospital Zurich. In April 2014, 363 patients were contacted, who were treated between March 2007 and April 2008 for the reason of epistaxis using a written questionnaire to elucidate the patients' condition after the treatment. The type of treatment, subjective discomfort as well as degree of pain, complications, permanent sequelae and recurrences were assessed. RESULTS: 109 questionnaires were analyzed (response rate of 36%). The overall same-sided recurrence rate after successful treatment during the 6.4-year follow-up was 22%. Discomfort was reported in 48% after cautery, 86% after packing and in 11% after surgery. Strong or very strong pain was perceived in 8% after cautery, 26% after packing and in 0% after surgery alone. Complications consisted of nasal crusting in 15% after cautery and nasal breathing impairment in 24% after packing. Permanent harm was reported in 4% after cautery versus 20% after packing plus surgery. CONCLUSIONS: The data confirm the high rate of recurrences despite adequate treatment in the long-term analysis. The rate of post-treatment complications is considerably high with nasal crusting being the main inconvenience. It further shows that patients keep a vivid memory of the treatment even many years later and that packing is extremely uncomfortable to patients.