Extracorporeal membrane oxygenation in the management of granulomatosis with polyangiitis.

Granulomatosis with polyangiitis (GPA, also known as Wegener's granulomatosis) is a type of systematic vasculitis that primarily involves the lung and kidney. Diffuse alveolar hemorrhage (DAH) and associated acute respiratory failure are uncommon but devastating complications of GPA. Experience in using extracorporeal membrane oxygenation (ECMO) to manage DAH caused by GPA is limited. We report two GPA patients with DAH that were successfully managed using ECMO support. Examining 13 cases identified in the literature and two of our own, we observed that most patients experienced rapid deterioration in respiratory function in conjunction with a precedent respiratory infection. All 15 patients received veno-venous ECMO support. The median duration of ECMO support was 11 days (interquartile range: 7.5-20.75 days). Bleeding was the most common complication, seen in four (26.7%) cases. All patients were successfully weaned off ECMO after a median length of hospital stay of 42 days (interquartile range: 30-78 days). We demonstrated that the use of ECMO is a reasonable and effective support option in the management of GPA patients with DAH. The risk of bleeding is high but maybe reduced using a lower anticoagulation goal.

Combination of High-Calorie Delivery and Organ Failure Increases Mortality Among Patients With Acute Respiratory Distress Syndrome.

OBJECTIVES: Among critically ill patients, the benefits of nutrition support may vary depending on severity of organ dysfunction. The objective of the current article was to explore the relationship between organ failure and calories exposure with hospital mortality during the first week of acute respiratory distress syndrome. DESIGN: Retrospective observational study. SETTING: Single-center ICU. PATIENTS: Adults admitted to the ICU with a diagnosis of acute respiratory distress syndrome. INTERVENTIONS: Calorie delivery from enteral nutrition, parenteral nutrition, propofol, and dextrose containing fluids were collected for 7 days following intubation. Sequential Organ Failure Assessment score was calculated at ICU admit and for the same 7 days to describe organ dysfunction; four different Sequential Organ Failure Assessment variables were created 1) Sequential Organ Failure Assessment at ICU admit, 2) average Sequential Organ Failure Assessment for the first 7 days following intubation, 3) the highest Sequential Organ Failure Assessment for the first 7 days following intubation, and 4) change in Sequential Organ Failure Assessment from intubation to 7 days later. MEASUREMENTS AND MAIN RESULTS: A total of 298 patients were included. Sequential Organ Failure Assessment at ICU admit, average Sequential Organ Failure Assessment for the first 7 days following intubation, highest Sequential Organ Failure Assessment for the first 7 days following intubation, change in Sequential Organ Failure Assessment from intubation to 7 days later, and calorie delivery the first 7 days following intubation were all associated with increased likelihood of mortality. Compared with patients with low organ failure and low-calorie delivery, those with high-calorie delivery and low organ failure, low-calorie delivery and high organ failure, and the combination of both high organ failure with high-calorie delivery were associated with an incremental increase in the likelihood or mortality. CONCLUSIONS: Organ failure appears to modify the relationship between calorie exposure and ICU outcome. Additional research is needed to identify appropriate thresholds for safe calorie exposure with increased organ failure.

Author Response to "Unraveling Methodology to Ensure the Search for Optimal Nutrition Quantity in Acute Respiratory Distress Syndrome Remains INTACT".

We thank Drs. Patel, Martindale, and Heyland1 for their interest in our most recent study2 exploring the role of early exposure to recommended energy delivery in critically ill patients with acute respiratory distress syndrome. Their stated concerns center around 3 major areas: (1) the comparability of the population in our study2 with those of INTACT (Intensive Nutrition in Acute Lung Injury: A Clinical Trial); (2) their confusion on the analysis of the relationship between the likelihood of death with energy exposure (table 1 in our article2 ); and (3) their apparent misunderstanding of type I error, type II error, P-values, and power analysis. Our responses to each of these areas are detailed as follows.

Early Exposure to Recommended Calorie Delivery in the Intensive Care Unit Is Associated With Increased Mortality in Patients With Acute Respiratory Distress Syndrome.

BACKGROUND: The Intensive Nutrition in Acute Lung Injury: Clinical Trial (INTACT), designed to evaluate outcomes of calorie delivery from acute respiratory distress syndrome (ARDS) diagnosis through hospital discharge, was stopped due to higher mortality in the intervention group. Post hoc analysis found timing and dose of calorie delivery influenced mortality. The objective of this retrospective cohort study was to determine if early vs late calorie exposure changed the hazard of death among a larger sample of patients with ARDS. METHODS: Adult patients who met the eligibility criteria for INTACT but did not participate were included. Daily calorie delivery was collected from the date INTACT eligibility was determined to extubation or death. Cox proportional hazards regression was used to model the relationship between hazard of hospital death with average calorie exposure received over increasing study days and after day 7. RESULTS: A total of 298 patients were included; overall mortality was 33%. Among patients who remained intubated at 1 week (n = 202), higher kcal/kg received from intensive care unit (ICU) days 1-6 increased hazards of subsequent death on days 7+ (hazard ratio [HR], 1.04; 95% confidence interval [CI], 1.01-1.06); kcal/kg received after ICU day 7 decreased the hazards of death on day 7+ (HR, 0.53; 95% CI, 0.33-0.84). CONCLUSIONS: Higher calorie exposure between ICU days 1 and 7 was associated with higher subsequent hazard of mortality, and provision of high-calorie exposure after day 8 decreased the hazards of death.

Acute lung injury induced by arsenic trioxide in a patient with refractory myelodysplastic syndrome.

Arsenic trioxide has been used successfully for the treatment of refractory acute promyelocytic leukemia and has shown promise in the treatment of myelodysplastic syndrome (MDS), although it is not a labeled indication. Retinoic acid syndrome is manifested by fever, dyspnea, peripheral edema, pulmonary infiltrates, and pleural and/or pericardial effusions and is typically seen in conjunction with all- trans retinoic acid therapy of acute promyelocytic leukemia. We report a case of acute lung injury and a retinoic acid syndrome-like illness in a patient who received arsenic for MDS. To our knowledge, this is the first such report, and clinicians should be aware of this potentially life-threatening complication of arsenic trioxide treatment in patients with MDS.

Attitudes Toward and Experiences in End-of-life Care Education in the Intensive Care Unit: A Survey of Resident Physicians.

INTRODUCTION: Resident physicians provide the most physician care to intensive care unit (ICU) patients. The body of literature about residents' palliative and end-of-life care (PC/EOLC) experiences in the ICU is limited. To our knowledge, this is the first study to assess resident physicians in multiple specialties regarding PC/EOLC in the ICU. METHODS: A Web-based survey was developed and administered to all resident physicians in a single academic institution who had completed at least 1 dedicated ICU rotation. RESULTS: Residents reported moderate comfort in dealing with end-of-life (EOL) issues and felt somewhat prepared to care for critically ill patients at the EOL. Feedback should be provided to residents regarding their PC/EOLC skills, and education should be tailored to residents rotating in the ICU.

A novel expression of exercise induced pulmonary hypertension in human immunodeficiency virus patients: a pilot study.

BACKGROUND: Patients with the human immunodeficiency virus (HIV) are at risk for multiple pulmonary complications including pulmonary hypertension. Exercise induced pulmonary hypertension (EIPH) has been previously described in patients with scleroderma, sickle cell disease and chronic obstructive pulmonary disease, yet has not been associated with the HIV population. METHODS: A prospective case-control study design was implemented. Four HIV patients with unexplained dyspnea and four healthy controls underwent symptom-limited stationary bicycle exercise. Transthoracic Doppler Echocardiography was used to measure tricuspid regurgitation velocity which was used to calculate the right ventricular to right atrial pressure (RV-RA) gradient at rest and at peak exercise using the simplified Bernoulli's equation. Change in RV-RA gradient between rest and peak exercise was calculated and considered to represent change in pulmonary arterial systolic pressure. RESULTS: The mean age was 41.25 years (±8.7) for patients and 33.5 years (±6.0) for controls. The mean CD4 count of patients was 191.5 cells/µL (±136.2). Patients had a significantly higher increase in RV-RA gradient as compared to controls (180.2% vs. 27.5%, p = 0.03). DISCUSSION: This pilot study suggests that it is feasible to use recumbent bicycle and transthoracic Doppler echocardiography for the evaluation of EIPH among HIV patients with dyspnea of unknown etiology. The study is too small to draw any broad conclusion. Further evaluation of this concept with a larger study is warranted.

Metal fume fever presenting as aseptic meningitis with pericarditis, pleuritis and pneumonitis.

BACKGROUND: Metal fume fever (MFF) is a well-known complication of zinc oxide fume inhalation. Prompt recognition of this condition is essential for the proper medical management of this self-limited disease. AIM: To present a unique and unusual case of MFF. RESULTS: Our patient is a 25-year-old male welder who had MFF and presented with aseptic meningitis with pericarditis, pleuritis and pneumonitis. To our knowledge, this is the first case of MMF presenting with these signs and symptoms. CONCLUSIONS: MFF can present with a systemic inflammatory response causing a multi-organ serositis. Our case highlights the utmost importance of obtaining an occupational history on all our patients, even if they are critically ill.