Use of mechanical ventilation and renal replacement therapy in critically ill hematopoietic stem cell transplant recipients.

Hematopoietic stem cell transplantation (HSCT) is a treatment option for both malignant and nonmalignant disorders. HSCT patients remain at high risk for multiorgan failure, with previous studies noting mortality rates exceeding 90% when mechanical ventilation (MV) is required. We propose that advancements in critical care management and HSCT practices have improved these dismal outcomes. We performed a retrospective review of admissions to our bone marrow transplant unit between 2006 and 2010. All HSCT recipients requiring admission to the bone marrow transplant unit who received MV or renal replacement therapy (RRT) were evaluated. A total of 68 patients required MV. Twenty patients required RRT, all of whom required MV. Fifty-nine of the 68 ventilated patients died, for an overall mortality rate of 86.8%. The presence of renal failure and concomitant respiratory or liver dysfunction at the time of intubation was associated with a mortality rate of 100%. High mortality persists in our HSCT population requiring artificial support despite overall advances in critical care and HSCT practices. Critical care triage and management decisions in this high-risk population remain challenging.

Norepinephrine or dopamine for septic shock: systematic review of randomized clinical trials.

BACKGROUND: There is debate as to the vasopressor agent of choice in patients with septic shock. According to current guidelines either dopamine or norepinephrine may be considered as the first-line agent for the management of refractory hypotension of septic shock. OBJECTIVE: The aim of this systematic review was to evaluate randomized clinical trials which compared norepinephrine versus dopamine in critically ill patients with septic shock or in a population of critically ill patients with shock predominantly secondary to sepsis. DATA SOURCES: MEDLINE, Embase, Scopus, Cochrane Register of Controlled Trials and citation review of relevant primary and review articles. STUDY SELECTION: Randomized clinical trials that compared norepinephrine with dopamine in critically ill adults with sepsis and reported the 28-day or in-hospital mortality. DATA EXTRACTION: We abstracted data on study design, study setting, patient population, 28-day mortality or in-hospital mortality, rate of arrhythmias, hospital length of stay, and ICU length of stay. DATA SYNTHESIS: Six studies met our inclusion criteria. These studies included a total of 2043 participants, with 995 in the norepinephrine and 1048 in the dopamine groups. There were 479 (48%) deaths in the norepinephrine group and 555 (53%) deaths in the dopamine group. There was statistically significant superiority of norepinephrine over dopamine for the outcome of in-hospital or 28-day mortality: pooled RR: 0.91 (95% CI 0.83 to 0.99; P = .028). We also found a statistically significant decrease in the rate of cardiac arrhythmias in the norepinephine group as compared to the dopamine group: pooled RR: 0.43 (95% CI 0.26 to 0.69; P ≤ .001). A subgroup analysis that pooled studies in which all the randomized patients had septic shock demonstrated that norepinephrine improved in-hospital or 28-day mortality; however, the results were no longer statistically significant. CONCLUSIONS: The analysis of the pooled studies that included a critically ill population with shock predominantly secondary to sepsis showed superiority of norepinephrine over dopamine for in-hospital or 28-day mortality.

A 64-year-old male with fever and persistent lung infiltrate.

Acute fibrinous and organizing pneumonia is a newly recognized pattern of lung injury. It may be idiopathic or secondary to a variety of lung injuries. In this case report we describe a 64-year-old male with acute fibrinous and organizing pneumonia caused by decitabine. He had substantial clinical and radiological improvement after the discontinuation of decitabine and a course of corticosteroids.

Clinical and radiologic distinctions between secondary bronchiolitis obliterans organizing pneumonia and cryptogenic organizing pneumonia.

BACKGROUND: Bronchiolitis obliterans organizing pneumonia (BOOP) is a distinct pattern of reaction of the lung to injury. It may be idiopathic or secondary to a variety of injuries. The term cryptogenic organizing pneumonia (COP) is used for patients with idiopathic BOOP. In this study we describe clinical and radiologic features of patients with BOOP. METHODS: The medical records of 33 patients with diagnosis of BOOP on surgical lung biopsy over a 10-year time period were reviewed retrospectively. We obtained data on clinical and radiologic manifestations, etiology, and outcome of these patients. RESULTS: Dyspnea was the most common symptom, followed by dry cough and fever. Crackles was the most common physical finding. Mean age at diagnosis of BOOP was 59 years, and 42% were females. The main radiologic manifestation was bilateral patchy consolidation. Most patients had favorable prognosis; however, 17% did not respond to treatment. Female sex was more common in COP than in secondary BOOP (P = .004). Patients with COP had longer symptom duration before the diagnosis than secondary BOOP (P = .01). Patients with secondary BOOP reported fever more frequently, compared to COP (P = .005). Pleural effusion was present in 60% of patients with secondary BOOP, whereas none of the patients with COP had effusion (P = .004). CONCLUSIONS: COP and secondary BOOP have diverse clinical and radiologic manifestations. Patients with secondary BOOP are more symptomatic. Both COP and secondary BOOP patients have good prognosis, and most respond to treatment with corticosteroids or by discontinuing the injurious drug.

Massive pulmonary embolism secondary to anticardiolipin antibody syndrome.

Antiphospholipid antibody syndrome, also known as Hughes syndrome, is a hypercoagulable disorder that increases the risk of recurrent vascular thrombosis. We present a case of 26-year-old female who developed massive bilateral pulmonary emboli after being started on oral contraceptive pills. Further work-up of the patient revealed that she had anticardiolipin antibody syndrome and the thrombotic event was precipitated by oral contraceptive pills.

Bilateral ureteroceles progressing to reversible acute renal failure in an adult.

We present a case of an adult male who was admitted with acute renal failure. In evaluating the potential causes of renal failure, workup discovered bilateral ureteroceles. Surgical treatments of the ureteroceles lead to reversal of his acute renal failure. This is the first time that treatment of ureteroceles has been reported to correct acute renal failure in the English literature.

Obstructive sleep apnea and oxygen therapy: a systematic review of the literature and meta-analysis.

BACKGROUND: Hypoxemia is an immediate consequence of obstructive sleep apnea. Oxygen (O2) administration has been used as an alternative treatment in patients with obstructive sleep apnea (OSA) who do not adhere to continuous positive airway pressure (CPAP) in order to reduce the deleterious effects of intermittent hypoxemia during sleep. This systematic review aims to investigate the effects of O2 therapy on patients with OSA. METHOD: We conducted a systematic search of the databases Medline, Embase, Cochrane Central Register of Controlled Trials (1(st) Quarter 2011), Cochrane Database of Systematic Reviews (from 1950 to February 2011). Our search strategy yielded 4,793 citations. Irrelevant papers were excluded by title and abstract review, leaving 105 manuscripts. We reviewed all prospective studies that included: (1) a target population with obstructive sleep apnea, (2) O2 therapy and/or CPAP as a study intervention, (3) the effects of O2 on the apnea-hypopnea index (AHI), nocturnal hypoxemia, or apnea duration. RESULTS: We identified 14 studies including a total of 359 patients. Nine studies were of single cohort design, while 5 studies were randomized control trials with 3 groups (CPAP, oxygen, and placebo/sham CPAP). When CPAP was compared to O2 therapy, all but one showed a significant improvement in AHI. Ten studies demonstrated that O2 therapy improved oxygen saturation vs. placebo. However, the average duration of apnea and hypopnea episodes were longer in patients receiving O2 therapy than those receiving placebo. CONCLUSION: This review shows that O2 therapy significantly improves oxygen saturation in patients with OSA. However, it may also increase the duration of apnea-hypopnea events.

Obstructive sleep apnea syndrome and perioperative complications: a systematic review of the literature.

Obstructive sleep apnea syndrome (OSAS) is a common sleep related breathing disorder. Its prevalence is estimated to be between 2% and 25% in the general population. However, the prevalence of sleep apnea is much higher in patients undergoing elective surgery. Sedation and anesthesia have been shown to increase the upper airway collapsibility and therefore increasing the risk of having postoperative complications in these patients. Furthermore, the majority of patients with sleep apnea are undiagnosed and therefore are at risk during the perioperative period. It is important to identify these patients so that appropriate actions can be taken in a timely fashion. In this review article, we will discuss the epidemiology of sleep apnea in the surgical population. We will also discuss why these patients are at a higher risk of having postoperative complications, with the special emphasis on the role of anesthesia, opioids, sedation, and the phenomenon of REM sleep rebound. We will also review how to identify these patients preoperatively and the steps that can be taken for their perioperative management.

Model for End-Stage Liver Disease score for predicting outcome in critically ill medical patients with liver cirrhosis.

PURPOSE: We hypothesized that the Model for End-Stage Liver Disease (MELD) score at admission to the intensive care unit (ICU) can predict in-hospital mortality for patients with liver cirrhosis. We also tested the MELD-natremia (Na) score and compared the predictive value of the 2 models. MATERIALS AND METHODS: This is a retrospective cohort study. A total of 441 consecutive patients with liver cirrhosis admitted to the ICU were included. The MELD and MELD-Na scores and other variables were obtained upon patients' admission to the ICU. RESULTS: The area under the receiver operating characteristic curve to predict in-hospital mortality was 0.77 (95% confidence interval, 0.73-0.82) for the MELD score and 0.77 (95% confidence interval, 0.73-0.81) for the MELD-Na score. CONCLUSION: The MELD scoring system provides useful prognostic information for critically ill patients with liver cirrhosis admitted to an ICU. The MELD and MELD-Na scores had similar predictive value.

Association between time of admission to the ICU and mortality: a systematic review and metaanalysis.

BACKGROUND: The organizational and staffing structure of an ICU influences the outcome of critically ill and injured patients. A change in the ICU staffing structure frequently occurs at nighttime and on weekends (off-hours). We postulated that patients who are admitted to an ICU during off hours may be at an increased risk of death. METHODS: We performed a systematic review of the literature to assess whether admission to an ICU during off-hours is associated with an increased mortality. We selected studies that evaluated the association between time of admission to the ICU and mortality, with adjustment for severity of disease. We excluded studies that included pediatric and non-ICU patients. Study characteristics extracted included date of publication, study design, country where study was done, study population, time factor (weekend or night shift), severity adjustment tool, and outcome. RESULTS: Ten cohort studies met our inclusion criteria; eight of these studies evaluated nighttime admissions, whereas six studies evaluated weekend admissions. The pooled analysis demonstrated that nighttime admission was not associated with an increased mortality (odds ratio [OR], 1.0 [95% CI, 0.87-1.17]; P = .956); however, patients admitted over the weekend had a significant increase in the adjusted risk of death (OR, 1.08 [95% CI, 1.04-1.13]; P < .001). Significant heterogeneity was found in the studies that evaluated nighttime admissions. CONCLUSIONS: Whereas patients admitted to an ICU over the weekend appear to be at an increased risk of death, nighttime admissions were not associated with an increased mortality. The lower level of staffing and intensity of care provided by many hospitals over the weekend may account for this finding. The heterogeneity noted between studies evaluating nighttime admissions likely reflects the diverse organizational structure of the hospitals and ICUs where these studies were carried out.

Obstructive sleep apnea syndrome and postoperative complications: clinical use of the STOP-BANG questionnaire.

OBJECTIVE: To determine whether high risk scores on preoperative STOP-BANG (Snoring, Tiredness during daytime, Observed apnea, high blood Pressure, Body mass index, Age, Neck circumference, Gender) questionnaires during preoperative evaluation correlated with a higher rate of complications of obstructive sleep apnea syndrome (OSAS). DESIGN: Historical cohort study. SETTING: Thomas Jefferson University Hospital, Philadelphia, Pennsylvania. PATIENTS: Adult patients undergoing elective surgery at a tertiary care center who were administered the STOP-BANG questionnaire for 3 consecutive days in May 2008. MAIN OUTCOME MEASURES: Number and types of complications. RESULTS: A total of 135 patients were included in the study, of whom 56 (41.5%) had high risk scores for OSAS. The mean (SD) age of patients was 57.9 (14.4) years; 60 (44.4%) were men. Patients at high risk of OSAS had a higher rate of postoperative complications compared with patients at low risk (19.6% vs 1.3%; P < .001). Age, American Society of Anesthesiologists class of 3 or higher, and obesity were associated with an increased risk of postoperative complications. On multivariate analysis, high risk of OSAS and American Society of Anesthesiologists class 3 or higher were associated with higher odds of complications. CONCLUSION: The STOP-BANG questionnaire is useful for preoperative identification of patients at higher than normal risk for surgical complications, probably because it identifies patients with occult OSAS.

Influence of malignancy on the decision to withhold or withdraw life-sustaining therapy in critically ill patients.

PURPOSE: To evaluate the influence of malignancy on the decision to limit life-sustaining therapy in the intensive care unit (ICU). METHODS: At the day of patients' admission to the ICU, we prospectively collected information on demographics, acute physiology and chronic health evaluation (APACHE) II score, and features related to malignancy. We retrospectively collected information on in-hospital survival and decision to withhold or withdraw life-sustaining treatment. RESULTS: This study included 122 adult critically ill patients. After adjusting for age and APACHE II score, patients with malignancy had 3.02 (95% CI 1.19 to 7.62) higher odds of having life-sustaining therapy withdrawn or withheld as compared to patients without active malignancy. CONCLUSION: Our study showed that critically ill patients with malignancy are more likely to have their life-sustaining therapy withheld or withdrawn than those without malignancy after adjusting for severity of disease. This finding may be related to a perception that critically ill patients with malignancy have worse prognosis as compared with those without malignancy.

Clinical manifestations and treatment of adult-onset asthma and periocular xanthogranuloma.

BACKGROUND: Adult-onset asthma and periocular xanthogranuloma is an uncommon and recently described disease. Little is known about the condition because only a few case reports and series are available. OBJECTIVE/METHODS: To describe the clinical manifestations, lung physiology, and response to systemic treatment of three patients with adult-onset asthma and periocular xanthogranuloma, followed by a review of the literature. RESULTS: Three men, with an age at diagnosis ranging from 48 to 51 years, presented with right periorbital swelling, asthma and chronic rhinosinusitis. The patients' lung physiology was consistent with airway obstruction. Diagnosis was established by periorbital biopsy. All patients received oral corticosteroids for their periorbital swelling, without significant clinical response. Two patients received oral methotrexate, with nearly complete resolution of periorbital swelling. A third patient received oral azathioprine, without clinical response. The three patients had improvement of their asthma with inhaled steroids/long-acting bronchodilator, and immunosuppressive medication. CONCLUSION: A triad consisting of periorbital swelling, asthma and chronic rhinosinusitis should raise the suspicion of adult-onset asthma and periocular xanthogranuloma. Oral methotrexate should be considered as an alternative to corticosteroids in the treatment of this disorder.

Sarcoidosis presenting as intrascrotal mass: case report and review.

Sarcoidosis is a multisystemic disease that usually involves the lungs and lymph nodes, but almost any organ can be involved. Genitourinary involvement with sarcoidosis is extremely rare. We report the case of a 30-year-old African-American male who presented with a right-sided intrascrotal mass and diffuse lymphadenopathy. On further workup, he was found to have sarcoidosis. Two months of corticosteroid treatment resulted in the disappearance of his intrascrotal mass.