Brain Death Determination.

In the United States, each year 1% to 2% of deaths are brain deaths. Considerable variation in the practice of determining brain death still remains, despite the publication of practice parameters in 1995 and an evidence-based guideline update in 2010. This review is intended to give bedside clinicians an overview of definition, the causes and pitfalls of misdiagnosing brain death, and a focus on the specifics of the brain death determination process.

Splenic artery aneurysm rupture: a rare but fatal cause for peripartum collapse.

Splenic artery aneurysm (SAA) is the most common (60%) of all visceral artery aneurysms. The majority of these cases are asymptomatic, but the presentation of their rupture can vary from abdominal/chest pain to cardiovascular collapse (Sadat U, Dar O, Walsh S, Varty K. Splenic artery aneurysms in pregnancy-a systematic review. Int J Surg. 2008;6(3):261-265.). Although rare, the mortality associated with the rupture is as high as 25% (De Vries JE, Schattenkerk ME, Malt RA. Complications of splenic artery aneurysm other than intraperitoneal rupture. Surgery. 1982;91(2):200-204; Caillouette JC, Merchant EB: Ruptured splenic artery aneurysm in pregnancy. Twelfth reported case with maternal and fetal survival. Am J Obstet Gynecol 1993;168(6 Pt 1):1810-1811) and increases to 75% among pregnant women with a concomitant fetal mortality of 95% (O'Grady JP, Day EJ, Toole AL, et al. Splenic artery aneurysm rupture in pregnancy. A review and case report. Obstet Gynecol. 1977; 50(5):627-630). Because of such high maternal and fetal mortality prompt management of SAAs is of utmost importance. We are presenting a case of a 35-year-old woman with a missed ruptured SAA who after an emergent cesarean section went into profound shock and was unable to be resuscitated. This case illustrates the importance of considering the diagnosis of SAA rupture in hemodynamically unstable peripartum females.

End-of-life care in ICU: a practical guide.

Proper critical care training and management rests on 3 pillars-evidence-based patient care, proficient procedural skills, and compassionate end-of-life (EOL) management. The purpose of this manuscript is to provide a practical guide to EOL management for all bedside practitioners. The manuscript outlines not all but some fundamentally important ethical concepts and provides helpful rules and steps on end-of-life management based on my own personal experience and practice. Moreover, nowhere in the rigorous training of critical care or hospitalist physicians do we teach the procedure for removal of life-sustaining measures. Like any other procedure in medicine, it requires preparation, implementation and conclusion, as well as supervision and repetition to become proficient. Therefore, at the conclusion of this paper, an attempt is made to correct this lack of training by providing such outline and a guide.

A 44 year-old lady with chronic renal disease and intractable ulcers: a case report.

Calciphylaxis is a rare but potentially fatal condition occurring in patients with end stage renal disease on dialysis. Due to interplay of various factors, disturbances occur in the metabolism of calcium and phosphate leading to calcification within the vessel walls. The net result is tissue ischemia and necrosis. Clinically this presents as painful non-healing skin ulcers, which contribute to significant morbidity and mortality due to septic progression of the lesion. In this case report, we highlight the rapidly progressive nature of this disease, its etiopathogenesis and the role of early diagnosis in preventing life-threatening complications.

Large-volume paracentesis: a fast, convenient, and safe technique.

BACKGROUND: Ascites is a common complication of liver cirrhosis, malignancy, cardiac failure, pancreatitis, and tuberculosis, with cirrhosis of the liver being the most common cause. Onset of ascites in cirrhosis of the liver is associated with worsened quality of life, increased risk of spontaneous bacterial peritonitis, and renal failure. Management of ascites caused by cirrhosis requires sodium restriction in diet, sodium excretion with diuretics and, in refractory cases, large volume paracentesis. TECHNIQUE: We describe a simple adjustment to the standard paracentesis technique that does not require additional equipment or manpower. CONCLUSION: Removing over 5 L of ascitic fluid can become a time-consuming and labor-intensive process. We describe a setup that makes this commonly performed procedure fast, convenient, and safe.

Pulmonary coccidioidomycosis.

Coccidioidal infection can manifest as pulmonary or extrapulmonary disease. Pulmonary coccidioidomycosis occurs in 95% of all cases and can be divided into three main categories: primary, complicated, and residual pulmonary coccidioidomycosis. The primary infection occurs with inhalation of airborne arthroconidia. As few as 10 arthroconidia are capable of causing an infection in animal models. Sixty percent of infected individuals will remain asymptomatic. This results in a positive skin test and, with rare exception, lifelong immunity. The other 40% will develop symptomatic disease that manifests with variable signs and symptoms, predominantly an influenza-like syndrome, pneumonia, or pleural effusion. The category of complicated pulmonary coccidioidomycosis includes clinical entities as severe and persistent pneumonia, progressive primary coccidioidomycosis, fibrocavitary coccidioidomycosis, cavities, and empyema, a complication of a ruptured cavity. Progression of primary pulmonary disease to acute respiratory distress syndrome (ARDS) can also qualify as a complication. The third category of residual disease comprises only two entities: pulmonary nodule and fibrosis. This review focuses on uncomplicated and complicated pulmonary coccidioidomycosis and its management as outlined earlier in addition to special considerations of coccidioidal fungemia, pulmonary coccidioidomycosis in pregnancy, and organ transplantation.

Coccidioidomycosis and pregnancy: a review.

Coccidioidomycosis (CM) is a fungal infection endemic to the southwestern United States, northwestern Mexico, and parts of Central and South America. CM has been recognized as a complicating factor in pregnancy since at least the 1940s, and seems to be a relatively uncommon infection during pregnancy. The disease presentation during pregnancy includes a wide clinical spectrum that ranges from mild influenza-like illness and pneumonia, especially in the first two trimesters of pregnancy. The third trimester of pregnancy is a time of high risk for dissemination. Immunologic and hormonal changes during pregnancy and the postpartum period may account for any increased frequency and severity of disease observed during pregnancy. Early diagnosis and appropriate aggressive therapeutic intervention with careful monitoring usually result in good outcome.