[Ruptured spleen after subarachnoid haemorrhage]. / Een miltruptuur na een subarachnoïdale bloeding.

BACKGROUND: Subarachnoid hemorrhage is a severe neurological condition which can cause a broad range of symptoms. Often, these symptoms are the direct consequence of the hemorrhage. CASE DESCRIPTION: A 58-year-old female was admitted to the emergency department with extreme headache and a sudden and brief loss of consciousness. She was diagnosed with aneurysmal subarachnoid hemorrhage and underwent endovascular treatment. Seven days after admission she developed hypotension, bilateral fixed and dilated pupils and a second sudden and brief loss of consciousness. A CT scan of the brain was unchanged compared to the initial CT scan. An external ventricular drain was placed and the patient was admitted to the ICU where she was diagnosed with hemorrhagic shock due to a ruptured spleen. CONCLUSION: Bilateral fixed and dilated pupils can in rare cases be caused by hemorrhagic shock due to strong sympathetic activity or parasympathetic inactivity. When a patient presents with loss of consciousness and/or pupil deviation, extracranial diagnoses should be considered after intracranial causes have been excluded.

Achieving protein targets without energy overfeeding in critically ill patients: A prospective feasibility study.

BACKGROUND & AIMS: High protein delivery during early critical illness is associated with lower mortality, while energy overfeeding is associated with higher mortality. Protein-to-energy ratios of traditional enteral formulae are sometimes too low to reach protein targets without energy overfeeding. This prospective feasibility study aimed to evaluate the ability of a new enteral formula with a high protein-to-energy ratio to achieve the desired protein target while avoiding energy overfeeding. METHODS: Mechanically ventilated non-septic patients received the high protein-to-energy ratio nutrition during the first 4 days of ICU stay (n = 20). Nutritional prescription was 90% of measured energy expenditure. Primary endpoint was the percentage of patients reaching a protein target of ≥1.2 g/kg ideal body weight on day 4. Other endpoints included a comparison of nutritional intake to matched historic controls and the response of plasma amino acid concentrations. Safety endpoints were gastro-intestinal tolerance and plasma urea concentrations. RESULTS: Nineteen (95%) patients reached the protein intake target of ≥1.2 g/kg ideal body weight on day 4, compared to 65% in historic controls (p = 0.024). Mean plasma concentrations of all essential amino acids increased significantly from baseline to day 4. Predefined gastro-intestinal tolerance was good, but unexplained foul smelling diarrhoea occurred in two patients. In one patient plasma urea increased unrelated to acute kidney injury. CONCLUSIONS: In selected non-septic patients tolerating enteral nutrition, recommended protein targets can be achieved without energy overfeeding using a new high protein-to-energy ratio enteral nutrition.