Paradoxical Brain Herniation: An Unexpected Diagnosis.

Paradoxical herniation is a dreadful neurosurgical complication often underdiagnosed, which typically becomes evident over the course of weeks to months after the initial intervention. Here we present a unique case with manifestations in the post-operative period. A patient initially referred to neurosurgery for a meningioma underwent an uneventful surgical excision, followed by the transient placement of a lumbar drain for 48 hours. On the first post-operative day, the patient exhibited progressively altered neurological status, with corresponding imaging revealing a transfalcine herniation, necessitating emergent decompressive craniectomy. Despite the medical and surgical interventions, there were continuous signs of neurological and imaging worsening, with increase in herniation, which led to the diagnosis suspicion of a paradoxical brain herniation. Consequently, a rapid reversal of neurological deficits was observed after applying maneuvers to augment the intracranial pressure, followed by cranioplasty. This case illustrates the utmost importance of clinical suspicion for the uncommon complications of neurointerventions.

Recovery from acute haemorrhagic leucoencephalitis secondary to COVID-19.

A man in his 50s presented with sudden onset expressive aphasia and right-sided facial droop after experiencing coryzal symptoms and malaise for 7 days prior to admission. A brain MRI showed a rapidly progressive mass effect across both hemispheres and cerebrospinal fluid analysis revealed neutrophil predominance with raised protein levels. Acute disseminated encephalomyelitis was provisionally diagnosed, and high-dose methylprednisone was initiated.On admission to the high dependency unit, the patient tested positive for COVID-19 and was treated with appropriate therapeutic agents for severe COVID-19. A subsequent brain biopsy confirmed a demyelinating process, strongly indicating a diagnosis of acute haemorrhagic leucoencephalitis when correlated with the presence of severe oedema on imaging. Nine sessions of plasma exchange were provided over 18 days.At the time of writing, the patient has made an excellent recovery. We urge clinicians to consider this diagnosis and these treatment options for an otherwise devastating condition.

Probiotics-related Clostridium butyricum bacteraemia after COVID-19, confirmed by whole-genome sequencing.

A man in his 70s was admitted to an intensive care unit with severe COVID-19 and treated with dexamethasone and tocilizumab. After recovery from COVID-19, he developed Clostridium butyricum bacteraemia and non-occlusive mesenteric ischaemia, with fatal outcome. He had been prescribed C. butyricum MIYAIRI 588 fine granules as probiotics for a month. The genome sequences of the C. butyricum isolate from the blood culture and C. butyricum MIYAIRI 588 fine granules were identical by single nucleotide polymorphism analysis. This is the first case of definitive probiotics-related C. butyricum bacteraemia after treatment of severe COVID-19.

Haemophagocytic lymphohistiocytosis (HLH) secondary to disseminated histoplasmosis infection in a patient with HIV.

A male in his 30s who was recently diagnosed with HIV arrived at the emergency department exhibiting an altered mental state and acute respiratory distress. Initial laboratory tests revealed a high anion gap metabolic acidosis, elevated liver enzyme levels and bicytopenia. A CT scan identified a miliary pattern. Bronchoscopy with bronchoalveolar lavage displayed epithelial and inflammatory cells. However, subsequent tests ruled out the presence of fungi, Pneumocystis organisms, malignancies, granulomas and viral inclusions. Broad-spectrum antibiotics with emphasis on Mycobacterium tuberculosis and antifungal treatments were administered. The regimen was adjusted after a positive urine test for the Histoplasma antigen.The patient later manifested signs and symptoms, including increased ferritin level, fever, splenomegaly, diminished natural killer cell function and heightened interleukin-2 receptor levels, confirming haemophagocytic lymphohistiocytosis. Given the patient's gravely decompensated state, the treatment incorporated dexamethasone, and the patient's vasopressor-resistant septic shock was addressed with methylene blue.

Concurrent existence of cold agglutinin disease and ANCA-associated vasculitis with fulminant pulmonary-renal syndrome poses significant treatment challenges.

We present a case of a man in his 40s with pulmonary-renal syndrome due to myeloperoxidase-positive antineutrophil cytoplasmic antibodies-associated vasculitis and concurrent cold agglutinin disease, a combination that has not yet been described in the literature. The fulminant course of the disease, including the need for kidney replacement therapy and mechanical ventilation posed a significant treatment challenge due to haemolytic complications.

Nurses' perceptions of patient pain, delirium, and sedation assessments in the intensive care unit: A qualitative study.

BACKGROUND: Pain, delirium, and sedation should be assessed routinely using validated assessment scales. Inappropriately managed pain, delirium, and sedation in critically ill patients can have serious consequences regarding mortality, morbidity, and increased healthcare costs. Despite the benefits of a bundled approach to pain, delirium, and sedation assessments, few studies have explored nurses' perceptions of using validated scales for such assessments. Furthermore, no studies have examined nurses' perceptions of undertaking these assessments as a bundled approach. OBJECTIVES: The objective of this study was to explore nurses' knowledge, perceptions, attitudes, and experiences regarding the use of validated pain, delirium, and sedation assessment tools as a bundled approach in the intensive care unit (ICU). METHODS: A qualitative exploratory descriptive design was adopted. We conducted four focus groups and 10 individual interviews with 23 nurses from a 26-bed adult ICU at an Australian metropolitan tertiary teaching hospital. Data were analysed using thematic analysis techniques. FINDINGS: Four themes were identified: (i) factors impacting nurses' ability to undertake pain, delirium, and sedation assessments in the ICU; (ii) use, misuse, and nonuse of tools and use of alternative strategies to assess pain, delirium, and sedation; (iii) implementing assessment tools; and (iv) consequences of suboptimal pain, delirium, and sedation assessments. A gap was found in nurses' use of validated scales to assess pain, delirium, and sedation as a bundled approach, and they were not familiar with using a bundled approach to assessment. CONCLUSION: The practice gap could be addressed using a carefully planned implementation strategy. Strategies could include a policy and protocol for assessing pain, delirium, and sedation in the ICU, engagement of change champions to facilitate uptake of the strategy, reminder and feedback systems, further in-service education, and ongoing workplace training for nurses.

A Culture of Early Mobilization in Adult Intensive Care Units: Perspective and Competency of Physicians.

BACKGROUND: Early mobility (EM) is vital in the intensive care unit (ICU) to counteract immobility-related effects. A multidisciplinary approach is key, as it requires precise initiation knowledge. However, physicians' understanding of EM in adult ICU settings remains unexplored. This study was conducted to investigate the knowledge and clinical competency of physicians working in adult ICUs toward EM. METHODS: This cross-sectional study enrolled 236 physicians to assess their knowledge of EM. A rigorously designed survey comprising 30 questions across the demographic, theoretical, and clinical domains was employed. The criteria for knowledge and competency were aligned with the minimum passing score (70%) stipulated for physician licensure by the medical regulatory authority in Saudi Arabia. RESULTS: Nearly 40% of the respondents had more than 5 years of experience. One-third of the respondents received theoretical knowledge about EM as part of their residency training, and only 4% of the respondents attended formal courses to enhance their knowledge. Almost all the respondents (95%) stated their awareness of EM benefits and its indications and contraindications and considered it safe to mobilize patients on mechanical ventilators. However, 62.3% of the respondents did not support EM for critically ill patients on mechanical ventilators until weaning. In contrast, 51.7% of respondents advised EM for agitated patients with RASS > 2. Only 113 (47.9%) physicians were competent in determining the suitability of ICU patients for EM. For critically ill patients who should be mobilized, nearly 60% of physicians refused to initiate EM. CONCLUSIONS: This study underscores insufficient practical knowledge of ICU physicians about EM criteria, which leads to suboptimal decisions, particularly in complex ICU cases. These findings emphasize the need for enhanced training and education of physicians working in adult ICU settings to optimize patient care and outcomes in critical care settings.

Systemic loxoscelism leading to autoimmune haemolytic anaemia in a healthy young adult.

The brown recluse spider (Loxosceles reclusa) is endemic to the southcentral Midwest and the Southern United States. A bite from a brown recluse spider may result in symptoms that range from local skin necrosis to systemic complications such as acute haemolytic anaemia, disseminated intravascular coagulopathy, rhabdomyolysis and death. Although rare, systemic loxoscelism is a clinical diagnosis of exclusion that should be considered in a patient with acute autoimmune haemolytic anaemia. We describe a case of a young man with autoimmune haemolytic anaemia secondary to systemic loxoscelism successfully treated with intravenous immunoglobulin and steroids.

Weil's disease in a temperate climate: diagnostic uncertainty and the importance of prompt antibiotic treatment.

A man in his 50s presents with a short history of rigors, back pain and dark urine. This was associated with scleral icterus. He was initially treated as urosepsis due to perinephric fat stranding on his first CT but continued to deteriorate with worsening sepsis requiring intensive care admission. He had a conjugated hyperbilirubinaemia (peak 708 µmol/L) with normal liver enzymes, anaemia, thrombocytopaenia, acute kidney injury requiring filtration and respiratory failure requiring ventilatory support. A subsequent CT revealed mediastinal lymphadenopathy and extensive ground-glass changes with patchy consolidation. When his history was revisited, exposure to rodents was identified, and serological testing for leptospirosis subsequently came back positive. This case explores the causes of hyperbilirubinaemia in leptospirosis, the dangers of tunnel vision in diagnostic medicine and the importance of prompt antibiotic therapy in Weil's disease.

Anti-melanoma differentiation-associated gene 5 (anti-MDA5) positive dermatomyositis: early detection is crucial.

Anti-melanoma differentiation-associated gene 5-positive (Anti-MDA5) dermatomyositis (DM) is an aggressive phenotype of DM associated with rapidly progressive interstitial lung disease (RP-ILD). It is a rare condition that carries high mortality. Diagnosis and management of patients with anti-MDA5 DM RP-ILD presents several challenges, including uncertainty around treatment algorithms and a lack of evidence to inform practice. This case report of a patient with anti-MDA5 DM RP-ILD highlights these challenges, emphasising the fulminant course of this disease despite aggressive immunosuppression. Further research is required to guide management and to minimise morbidity and mortality, and greater awareness of the condition is required to minimise delays in diagnosis.

Rhabdomyolysis secondary to a weight-loss prescription.

We present a case of a case of a man in his 70s on multiple medications (including treatment of ischemic heart disease and diabetes who developed significant rhabdomyolysis, complicated by acute kidney injury (AKI) and encephalopathy, while using a compounded medication for weight loss. The patient was admitted to the intensive care unit and progressed favourably after haemodialysis and supportive care. Information regarding the ingestion of weight-loss drugs was unknown at the time of admission and was only discovered after resolution of encephalopathy, raising the possibility of toxin-associated rhabdomyolysis. This case emphasises the need for a thorough clinical history and scrutiny of the safety of weight-loss prescriptions, including preparations that comprise a combination of drugs and supplements that may adversely interact with chronic medications, especially in polymedicated patients.

Mucosal bleeding while on venovenous extracorporeal membrane oxygenation in the setting of vitamin C deficiency.

A major complication with extracorporeal membrane oxygenation (ECMO) is bleeding which can occur in up to 40% of cases and can be life-threatening. Minor bleeding may be overlooked and under-reported. While some of the underlying mechanisms such as platelet injury and anticoagulation therapy have been identified, several other factors are still under-researched. Here, we describe a unique case of a subtle mucosal membrane bleeding that is found to be associated with vitamin C deficiency while on treatment with ECMO. Investigating vitamin C levels may be useful in understanding causes of bleeding in some patients on ECMO therapy, particularly if there are risk factors for malnutrition.

Actual versus perceived noise levels among critical care nurses and their related adverse effects: A cross-sectional study.

BACKGROUND: Critical care nurses should help in reducing noise to improve the well-being of patients and health care providers. AIM/S: To measure actual noise levels in intensive care units, identify nurses' perceived irritation levels of noise sources and examine the impact of noise on nurses' work performance and well-being. STUDY DESIGN: This cross-sectional study was conducted from January to April 2023 at a teaching hospital's six intensive care units. It involved three phases: mapping locations for noise measurement, actual noise measurements in decibels and a cross-sectional survey to identify nurses' perceptions and the adverse effects of noise. Actual noise was measured between patients' beds, nursing stations and beside 16 noise sources for 7 days 24 h a day. For nurse perceptions, the mean of perceived irritation levels by a Likert scale for each noise source was calculated to present perceived noise levels. Ranking of noise sources according to the actual measured and perceived irritation by nurses was done based on mean values. Curve estimation regression test was used to predict the relationship between actual and perceived noise and stepwise multiple linear regression identified factors associated with noise adverse effects. RESULTS: The mean noise level in the intensive care units was 65.55 dB. Nurses perceived mechanical ventilator alarms as the most irritating noise. However, the mean noise measurements showed that conversations among colleagues were the primary source of noise. There was no significant predictive relationship between the actual and perceived noise. Nurses reported feeling distressed, irritable, fatigued and less productive due to noise. CONCLUSIONS: There was a discrepancy between actual and perceived noise levels by nurses. Perceived noise levels had more impact on nurses than actual noise. RELEVANCE TO CLINICAL PRACTICE: By incorporating both objective measurements and subjective perceptions into efforts aimed at reducing noise, health care providers can create quieter intensive care units.

Popliteal venous access for renal replacement therapy in a critically ill patient with central access failure.

A woman in her 80s was admitted to the emergency department with an acute infective exacerbation of chronic obstructive pulmonary disease and type 2 respiratory failure, culminating in cardiac arrest for 2 min. She was successfully resuscitated, connected to a mechanical ventilator and subsequently transferred to the intensive care unit. Later in her hospital stay, the patient underwent a tracheostomy following prolonged intubation.During this period, she developed septic shock with complications, including acute kidney injury, metabolic acidosis and volume overload. As a result, the nephrologist recommended emergency haemodialysis. Initially, a left femoral haemodialysis catheter was established but had to be withdrawn a few days later due to the development of deep vein thrombosis (DVT). A left internal jugular catheter was then inserted but was removed after 5 days due to another DVT. It was subsequently replaced with a central line for vasopressor support.A Doppler scan revealed a large thrombus in the right internal jugular vein, extending to the area just above the superior vena cava. A similar thrombus was detected in the left internal jugular vein, with weak blood flow observed in both the right and left subclavian veins. Although the subclavian vein flows were deemed adequate, there was unsatisfactory blood flow through the catheter after insertion, rendering it unsuitable for haemodialysis.Due to an earlier central line-related infection, the right femoral site exhibited signs of infection and the presence of a pus pocket, making it unsuitable for haemodialysis access. To address this, the right popliteal vein was chosen for catheterisation using a 20-cm, 12 French catheter, the longest available catheter in the country at the time. The patient was placed in a prone position, and the catheter was smoothly inserted with ultrasound guidance, resulting in good flow. Subsequent haemodialysis sessions were carried out regularly.

Ultraselective angioembolisation of splenic artery for atraumatic spleen rupture in a patient of systemic lupus erythematosus.

A systemic lupus erythematosus (SLE) patient in her mid-30s presented with spontaneous splenic haematoma and rupture. She rapidly deteriorated despite packed red cells and fresh frozen plasma transfusions. She underwent emergent ultraselective angioembolisation of the splenic artery and got stabilised. Spontaneous or atraumatic splenic rupture is rare in SLE and splenic artery embolisation may be life-saving.

Clostridium perfringens-induced liver abscess with severe haemolysis.

Clostridium perfringens is notorious for causing skin and soft tissue infections and food poisoning. Rarely, C. perfringens infections are associated with severe haemolysis, with a mortality rate of >80%. A previously healthy man in his 70s who presented with fever as his chief symptom was promptly admitted to a regional core hospital. Over the next 3 hours, shock and multiple organ failure ensued, leading to referral to our hospital for intensive care. We suspected a liver abscess caused by C. perfringens infection with haemolysis, findings of severe haemolysis and a liver mass with gas production that appeared within a few hours. Though surgical drainage was contemplated, low blood pressure resulted in death within 3 hours of arrival at our hospital. The next day, a blood culture confirmed C. perfringens, proving the diagnosis. Improving patient outcomes requires increased awareness of the disease and early detection.

An indigenously developed tele-ICU model to treat severe cases of envenomation in remote regions in India.

In cases of severe envenomation due to snakebites, patients require antivenom, intensive care management, including respiratory support, haemodynamic monitoring and renal replacement therapy. Early recognition and treatment of complications such as acute kidney injury, rhabdomyolysis and coagulopathy are important to improve outcomes.Tele-ICU models can play a critical role in providing access to critical care expertise and nuanced support to remote healthcare facilities that may not have the necessary resources or expertise to manage complex cases of envenomation. With the help of telemedicine technology, remote intensivists can provide timely guidance on diagnosis and ongoing management, improving the quality of care and outcomes for patients. We discuss two patients in resource-constrained regions of India with severe envenomation who were managed with tele-ICU support.