Aspergillus flavus endocarditis--to prevaricate is to posture.

Fungal endocarditis represents both a diagnostic and therapeutic challenge to the treating team. The critical care physician will see a rising incidence as older and more immuno-compromised patients are being supported in their intensive care units. Aspergillus sp. endocarditis represents less than 25% of all cases of fungal endocarditis and is associated with a mortality of around 80%. Early diagnosis may assist with definitive management. We review a case of Aspergillus endocarditis, and review the literature as to optimal methods of detection, imaging modalities of choice, and management, both surgical and medical.

The use of recombinant activated factor VII for refractory bleeding post complex cardiothoracic surgery.

We reviewed the outcome following use of recombinant activated factor VII (rVIIa) in patients with major bleeding post cardiothoracic surgery in our unit between January 2002 and July 2004. The unit consists of 16 cardiothoracic intensive care beds in a public metropolitan teaching hospital which serves as a referral centre for heart and lung transplant surgery. Patients with refractory bleeding following cardiothoracic surgical procedures who were treated with rVIIa were identified. A total of 12 episodes of rVIIa use were recorded in ten patients, including three episodes with ventricular assist devices, and 5 heart and/or lung transplants. The median dose used was 85 microg/kg. Chest tube drainage decreased in all patients following administration of rVlIIa; median chest tube drainage decreased from 445 ml/h to 171 ml/h (P = 0.03). Despite cessation of bleeding, mortality was high when rVIIa was used after more than 24 hours. In six episodes, despite early rVIIa use (within six hours), continued bleeding necessitated return to theatre, where a surgical source of bleeding was found. In this small retrospective study, rVIIa significantly reduced bleeding that was refractory to standard blood product transfusion. In this series of patients, those that did not respond to rVIIa early in the postoperative phase were found to have a surgical source of bleeding.

Diseases of the aorta in the critically ill.

OBJECTIVE: To review diseases of the aorta that commonly require management in the critical care unit. DATA SOURCES: Articles and published reviews on aortic dissection, traumatic aortic rupture and aortic aneurysm. SUMMARY OF REVIEW: The aorta is the largest arterial vessel of the body and disorders that can lead to rupture (e.g. aortic dissection, traumatic aortic rupture and aortic aneurysm) are life threatening. Aortic dissections are usually classified for surgical purposes as those that involve the ascending aorta (i.e. type A dissections) which are usually managed surgically and all other dissections (i.e. type B dissections) which are usually managed non surgically. Recently, endoluminal aortic stents have been used to manage type B dissections. Traumatic aortic rupture usually follows an antero-posterior thoracic injury with 60% occurring just distal to the origin of the left subclavian artery and 25% at the ascending aorta. Treatment consists of open surgical repair ensuring that the aortic cross clamp times are less than 30 minutes to reduce the development of ischaemic cord lesions. Aortic aneurysm commonly occurs in the abdominal aorta and is usually surgically resected if > 5 cm in diameter. Post-operative care is commonly undertaken in the intensive care unit to monitor haemodynamic, respiratory and fluid and electrolyte status to reduce the incidence of renal and respiratory failure. While angiography is often used to diagnose these disorders, transoesophageal echocardiography, helical computed tomography (CT) and magnetic resonance imaging are becoming more commonly used and in selected conditions are recommended as the investigations of choice. CONCLUSIONS: Aortic dissection, aortic aneurysm and aortic trauma may lead to aortic rupture with exsanguination and management commonly requires surgical intervention and postoperative care in a critical care unit.