Hemophagocytic lymphohistiocytosis complicated by multiorgan failure: A case report.

RATIONALE: We present a case of hemophagocytic lymphohistiocytosis (HLH) with severe pulmonary complication and acute respiratory distress syndrome (ARDS) hospitalized in our intensive care unit (ICU) in 2014; distinctive trait of this case has been the challenging diagnosis, with a bone marrow biopsy always negative, the severe pulmonary complication with ARDS and severe pulmonary hypertension, and the ferritin temporal kinetics that precisely followed the clinical course of disease. PATIENT CONCERNS: A 32-year-old woman from the Philippines first diagnosed with upper airway infection, was subsequently hospitalized in infectious disease department and treated for community acquired pneumonia. DIAGNOSES: After clinical picture worsened with a profound respiratory insufficiency, the patient was intubated and transferred to our ICU. During this hospitalization, the clinical picture of fever, cutaneous rashes, lymphadenitis, hepatitis, leukopenia, anemia, hyperferritinemia, hypertriglyceridemia, high level of auto-antibodies, and low NK activity suggested an hemophagocytic lymphohistiocytosis syndrome, even if bone marrow biopsy was negative for hemophagocytosis. INTERVENTIONS: Immunosuppressive therapy with dexamethasone and etoposide was started, and the patient was discharged from ICU 4 months after admission. LESSONS: HLH is a rare disorder of the mononuclear phagocytic system, characterized by systemic proliferation of non- neoplastic histiocytes. The diagnosis is often challenging and not all of the diagnostic criteria may be present at the same time; this case shows how complex the diagnosis could be, how hematic ferritin levels could help in following the course of the disease, and the possibility of severe pulmonary complication either due to the disease itself and to possible sovra infections.

Validation of a novel index of hemorrhage using a lower body negative pressure shock model.

BACKGROUND: Vital signs are late indicators of blood loss in trauma patients. Indexed Heart to Arm Time (iHAT) is a non-invasive index based on a modified pulse transit time (mPTT) indexed to the time between R waves on the electrocardiogram (RR interval). We aimed to investigate how early iHAT is able to detect central hypovolemia during the progression from mild to severe simulated hemorrhage induced by applying lower body negative pressure (LBNP). METHODS: Thirty healthy volunteers were enrolled. Central hypovolemia was induced by application of increasing LBNP from 0 to -80 mmHg. At every step, non-invasive blood pressure, heart rate, cardiac echo Doppler measurements and iHAT were recorded. RESULTS: Aortic flow Velocity Time Integral (VTI) reduction from 21.8±3.7 (baseline) to 11.2±3 cm (-70 mmHg) (P<0.001) was progressive with LBNP increase and represented a significant change in stroke volume and preload and induced an increase in heart rate from 69±2 to 107±4 bpm. iHAT increased from 34.2±4.65% (baseline) to 53.9±14.34% (-80 mmHg), P<0.001. The increase in iHAT became significant after -30 mmHg level was reached, corresponding to 500-1000 mL blood loss. CONCLUSIONS: iHAT measures both the reduction in preload and the parabolic heart rate increase due to the linear decrease in stroke volume. iHAT was able to detect a progressive central volume loss in a model of hemorrhage in healthy volunteers undergoing LBNP. A rising trend in iHAT can be a useful marker for progressive volume loss during moderate to severe bleeding.

International consensus conference on open abdomen in trauma.

BACKGROUND: A part of damage-control laparotomy is to leave the fascial edges and the skin open to avoid abdominal compartment syndrome and allow further explorations. This condition, known as open abdomen (OA), although effective, is associated with severe complications. Our aim was to develop evidence-based recommendations to define indications for OA, techniques for temporary abdominal closure, management of enteric fistulas, and methods of definitive wall closure. METHODS: The literature from 1990 to 2014 was systematically screened according to PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-analyses] protocol. Seventy-six articles were reviewed by a panel of experts to assign grade of recommendations (GoR) and level of evidence (LoE) using the GRADE [Grading of Recommendations Assessment, Development, and Evaluation] system, and an international consensus conference was held. RESULTS: OA in trauma is indicated at the end of damage-control laparotomy, in the presence of visceral swelling, for a second look in vascular injuries or gross contamination, in the case of abdominal wall loss, and if medical treatment of abdominal compartment syndrome has failed (GoR B, LoE II). Negative-pressure wound therapy is the recommended temporary abdominal closure technique to drain peritoneal fluid, improve nursing, and prevent fascial retraction (GoR B, LoE I). Lack of OA closure within 8 days (GoR C, LoE II), bowel injuries, high-volume replacement, and use of polypropylene mesh over the bowel (GoR C, LoE I) are risk factors for frozen abdomen and fistula formation. Negative-pressure wound therapy allows to isolate the fistula and protect the surrounding tissues from spillage until granulation (GoR C, LoE II). Correction of fistula is performed after 6 months to 12 months. Definitive closure of OA has to be obtained early (GoR C, LoE I) with direct suture, traction devices, component separation with or without mesh. Biologic meshes are an option for wall reinforcement if bacterial contamination is present (GoR C, LoE II). CONCLUSION: OA and negative-pressure techniques improve the care of trauma patients, but closure must be achieved early to avoid complications.