Swallowing Disorders in Severe Brain Injury in the Arousal Phase.

The objective of this study was to determine the clinical characteristics of swallowing disorders in severe brain injury in the arousal phase after coma. Between December 1, 2013 and June 30, 2014, eleven patients with severe acquired brain injury who were admitted to rehabilitation center (Male 81.8 %; 40.7 ± 14.6 years) were included in the study. Evaluation of swallowing included a functional examination, clinical functional swallowing test, and naso-endoscopic swallowing test. All patients had swallowing disorders at admission. The first functional swallowing test showed oral (77.8 %) and pharyngeal (66.7 %) food bolus transport disorders; and alterations in airway protection mechanisms (80 %). Swallowing test under endoscopic control showed a disorder in swallowing coordination in 55.6 % of patients tested. Seven (63.6 %) patients resumed oral feeding within an average of 6 weeks after admission to rehabilitation center and 14 weeks after acquired brain injury. Six (85.7 %) of these seven patients continued to require modified solid and liquid textures. Swallowing disorders are a major concern in severe brain injury in the arousal phase. Early bedside assessment of swallowing is essential for detection of swallowing disorders to propose appropriate medical rehabilitation care to these patients in a state of altered consciousness.

Increased prevalence of psoriasis in patients with coronary artery disease: results from a case-control study.

BACKGROUND: The incidence of myocardial events has been reported to be increased in patients with psoriasis. OBJECTIVES: To investigate whether psoriasis is an independent risk factor for coronary artery disease (CAD). METHODS: We compared the prevalence of psoriasis between case patients with a diagnosis of CAD based on coronary angiography findings and control patients with no CAD referred to the emergency surgery department for an acute noncardiovascular condition. Case and control patients were examined for the presence of psoriasis by two dermatologists. The prevalence of psoriasis was compared among patients with CAD according to CAD severity. Five-hundred cases and 500 age- and sex-matched controls were included. RESULTS: Using matched univariate analysis, the prevalence of psoriasis was about twofold higher in CAD case patients than in control patients [8·0% vs. 3·4%, odds ratio (OR) 2·64; 95% confidence interval (CI) 1·42-4·88]. Using unconditional multivariate analysis, the association of psoriasis with CAD appeared to be borderline significant (OR 1·84; 95% CI 0·99-3·40). Psoriasis in patients with CAD was significantly associated with three-vessel involvement relative to one-or two-vessel involvement (13·1% vs. 6·1%; OR 3·07; 95% CI 1·50-6·25). CONCLUSIONS: The prevalence of psoriasis is twofold higher in patients with CAD than in control patients without CAD. It is associated with a more severe coronary artery involvement.

Evaluation of pulse pressure variation validity criteria in critically ill patients: a prospective observational multicentre point-prevalence study.

BACKGROUND: Respiratory variation in pulse pressure (ΔPP) is commonly used to predict the fluid responsiveness of critically ill patients. However, some researchers have demonstrated that this measurement has several limitations. The present study was designed to evaluate the proportion of patients satisfying criteria for valid application of ΔPP at a given time-point. METHODS: A 1 day, prospective, observational, point-prevalence study was performed in 26 French intensive care units (ICUs). All patients hospitalized in the ICUs on the day of the study were included. The ΔPP validity criteria were recorded prospectively and defined as follows: (i) mechanical ventilation in the absence of spontaneous respiration; (ii) regular cardiac rhythm; (iii) tidal volume ≥8 ml kg(-1) of ideal body weight; (iv) a heart rate/respiratory rate ratio >3.6; (v) total respiratory system compliance ≥30 ml cm H2O(-1); and (vi) tricuspid annular peak systolic velocity ≥0.15 m s(-1). RESULTS: The study included 311 patients with a Simplified Acute Physiology Score II of 41 (39-43). Overall, only six (2%) patients satisfied all validity criteria. Of the 170 patients with an arterial line in place, only five (3%) satisfied the validity criteria. During the 24 h preceding the study time-point, fluid responsiveness was assessed for 79 patients. ΔPP had been used to assess fluid responsiveness in 15 of these cases (19%). CONCLUSIONS: A very low percentage of patients satisfied all criteria for valid use of ΔPP in the evaluation of fluid responsiveness. Physicians must consider limitations to the validity of ΔPP before using this variable.

Prevalence and evaluation of oropharyngeal dysphagia in patients with severe acute respiratory syndrome coronavirus 2 infection in the intensive care unit.

OBJECTIVE: The main objective was to assess the prevalence of dysphagia in the intensive care unit in patients with coronavirus disease 2019.Methods. A cohort, observational, retrospective study was conducted of patients admitted to the intensive care unit for severe acute respiratory syndrome coronavirus 2 pneumonia at the University Hospital of Rouen in France. RESULTS: Over 4 months, 58 patients were intubated and ventilated, 43 of whom were evaluated. Screening revealed post-extubation dysphagia in 62.7 per cent of patients. In univariate analysis, a significant association was found between the presence of dysphagia and: the severity of the initial pathology, the duration of intubation, the duration of curare use, the degree of muscle weakness and the severity indicated on the initial scan. At the end of intensive care unit treatment, 22 per cent of the dysphagic patients had a normal diet, 56 per cent had an adapted diet and 22 per cent still received exclusive tube feeding. CONCLUSION: Post-extubation dysphagia is frequent and needs to be investigated.

Covid-19 severe hypoxemic pneumonia: A clinical experience using high-flow nasal oxygen therapy as first-line management.

PURPOSE: To report a French experience in patients admitted to Intensive Care Unit (ICU) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) requiring high fractional concentration of inspired oxygen supported by high flow nasal cannula (HFNC) as first-line therapy. METHODS: Retrospective cohort study conducted in two ICUs of a French university hospital. All consecutive patients admitted during 28-days after the first admission for SARS-CoV-2 pneumonia were screened. Demographic, clinical, respiratory support, specific therapeutics, ICU length-of-stay and survival data were collected. RESULTS: Data of 43 patients were analyzed: mainly men (72%), median age 61 (51-69) years, median body mass index of 28 (25-31) kg/m2, median simplified acute physiology score (SAPS II) of 29 (22-37) and median PaO2/fraction of inspired oxygen (FiO2) (P/F) ratio of 146 (100-189) mmHg. HFNC was initiated at ICU admission in 76% of patients. Median flow was 50 (45-50) L/min and median FiO2 was 0.6 (0.5-0.8). 79% of patients presented at least one comorbidity, mainly hypertension (58%). At day (D) 28, 32% of patients required invasive mechanical ventilation, 3 patients died in ICU. Risk factors for intubation were diabetes (10% vs. 43%, P=0.04) and extensive lesions on chest computed tomography (CT) (P=0.023). Patients with more than 25% of lesions on chest CT were more frequently intubated during ICU stay (P=0.012). At ICU admission (D1), patients with higher SAPS II and Sequential Organ Failure Assessment (SOFA) scores (respectively 39 (28-50) vs. 27 (22-31), P=0.0031 and 5 (2-8) vs. 2 (2-2.2), P=0.0019), and a lower P/F ratio (98 (63-109) vs. 178 (126-206), P=0.0005) were more frequently intubated. Among non-intubated patients, the median lowest P/F was 131 (85-180) mmHg. Four caregivers had to stop working following coronavirus 2 contamination, but did not require hospitalization. CONCLUSION: Our clinical experience supports the use of HFNC as first line-therapy in patients with SARS-COV-2 pneumonia for whom face mask oxygen does not provide adequate respiratory support.

A-mode ultrasound in the diagnosis of maxillary sinusitis in ventilated patients.

PROBLEMS/OBJECTIVES: The diagnosis of maxillary sinusitis in intensive care patients remains problematic. However, it is essential since maxillary sinusitis causes numerous complications and there is an effective treatment. The aim of this study was to compare A-mode ultrasound with sinus computed tomography (CT) for the diagnosis of maxillary sinusitis in intubated patients in critical care undergoing mechanical ventilation. METHODOLOGY: Prospective clinical study in 140 maxillary sinuses in the surgical ICU of a university hospital. In each intubated and mechanically ventilated patient undergoing cerebral CT scan for any reason, a bedside A-mode ultrasonography of the maxillary sinuses was performed the same day. The A-mode ultrasound result was compared with the result of the sinus CT scan for the diagnosis of maxillary sinusitis. RESULTS: Sensitivity, specificity, positive predictive value and negative predictive value of A-mode ultrasound compared with CT were 66.7%, 94.7%, 75.0% and 92.2% respectively. All the empty sinuses were correctly identified as being empty. CONCLUSIONS: Given its very good specificity and negative predictive value, bedside A-mode ultrasound may be a useful first-line examination for intubated and mechanically ventilated patients in intensive care, especially to eliminate suspicion of maxillary sinusitis.

[Interest of D-lactate as a colic hypoperfusion marker during aortic abdominal aneurysm surgery]. / Intérêt du D-lactate comme marqueur de l'hypoperfusion colique lors de la chirurgie des anévrismes de l'aorte abdominale.

OBJECTIVE: D-lactate is the dextrogyre form of the lactate usually measured in intensive care. Its bacterial origin should make it a marker of translocation during gut ischemia. The aim was to test D-lactate as a postoperative marker of colic hypoperfusion measured during aortic surgery. STUDY DESIGN: Prospective observational cohort study. PATIENTS AND MEASUREMENTS: Patients operated for abdominal aortic aneurysm. Two groups were stratified on inferior mesenteric arterial residual pressure (IMArP) measured during the surgery: Colic hypoperfusion during surgery (CHs) group: patients with an IMArP < 40 mmHg. CONTROL GROUP: patients with an IMArP > or = 40 mmHg. Baseline data such as age, duration of aortic clamping and severity score (IGS II) were collected. The D-lactate was measured in postoperative at admission time in ICU and then daily. D-lactate(max) defined the maximum value of D-lactate for one patient. MAIN RESULTS: Twenty-nine patients were included, 23 in the control group and 6 in the CHs group. Groups were comparable at baseline. D-lactate(max) was significantly higher in the CHs group (median: 0.13 mmol/l; min-max: 0.03-0.9 mmol/l) than in the control group (0.03; 0-0.26 mmol/l, p=0.007). CONCLUSION: D-lactate could be postoperative marker of colic hypoperfusion measured during surgery for abdominal aortic aneurysm.

[Extensive purpura and septic schock in two patients with Capnocytophaga canimorsus]. / Purpura extensif au cours d'un choc septique à Capnocytophaga canimorsus: deux observations.

INTRODUCTION: Capnocytophaga canimorsus is a Gram negative bacillus present in oral flora and in saliva of dogs and cats. It can be responsible for septicaemia and meningitides in some patients after dog or cat bite two patient with a septic shock due to C. canimorsus, who presented with an extensive pupura are reported. CASE REPORT: A 50 year-old man with a past history of splenectomy was referred to an emergency department for a shock with vomiting, abdominal pain and generalized ecchymotic purpura culture samples isolated C. canimorsus in peritoneal fluid. Purpura occurred secondary to a disseminated intravascular coagulation. Despite intensive care and major antibiotherapy, the patient rapidly died. Four days previously, the patient administered pills in his dog mouth. The second patient was a 39 year old alcoholic man who was hospitalised for vomiting and septic shock witch occurred 24 hours after a dog bite. He presented with a livido and a diffuse purpura associated with necrotic lesions. Cultures of blood samples isolated C. canimorsus. CONCLUSION: These severe infections due to C. canimorsus should be avoided by the routine use of early antibiotherapy with amoxicilline and clavulanic acid in patients with dog or cat bite, particularly if patient with associated debilitating disorders.

Residents in tutored practice exchange groups have better medical reasoning as measured by script concordance test: a controlled, nonrandomized study.

STUDY OBJECTIVE: Clinical reasoning by anesthesiology residents in emergency situations where optimal management is uncertain could be improved by setting up a tutored practice exchange group. This study attempted to evaluate the impact of a practice exchange group (PEG), tutored by a senior anesthesiologist, on anesthesiology residents in emergency situations. Changes in clinical reasoning were measured by script concordance tests (SCT). DESIGN: We conducted a controlled, non-randomized study. SETTING AND PARTICIPANTS: Participants are residents in anesthesiology in Rouen, Caen and Amiens University Hospitals. INTERVENTIONS: Two resident groups were made up without randomization. The first group was the control group and consisted of residents from Amiens University Hospital and Caen University Hospital. The second study group (PEG group) consisted of residents from Rouen University Hospital, who followed weekly PEG sessions. Two groups had the same learning objectives except the PEG. MEASUREMENTS: In both the control group and the study group, each resident's clinical reasoning was assessed in the same formal manner by SCT. The primary outcome measurement of this study was to compare SCT results in the study group with PEG training (PEG group) with those without (control group). MAIN RESULTS: Performance in the SCT, expressed as degree of concordance with the expert panel (95% CI), was better in the PEG group (64% [62.1%-66%]) than in control group (60% [57.5%-62.8%])) (P= .004). CONCLUSION: Our study strongly suggests that an expert-directed, peer-conducted educational training program may improve the clinical reasoning of anesthesiology residents as measured by SCT.

[Complications during the intrahospital transport in critically ill patients]. / Complications durant le transport intrahospitalier de malades critiques de réanimation.

INTRODUCTION: Intrahospital transport (IHT) of mechanically ventilated critically ill patients is associated with an important risk of complications. OBJECTIVES: The purpose of this study was to assess the incidence of complications occurring during the IHT and to analyse the causes and the consequences of such complications. PATIENTS AND METHODS: All the IHT performed in mechanically ventilated patients, hospitalised in medical and surgical intensive care units of a university hospital were prospectively included during a three-month period. Complications were defined as follows: patient related problems (desaturation, restlessness, haemodynamic instability, extubation) and ventilator related problems (breakdown or defect of the material). RESULTS: 123 IHT concerning 64 patients were analysed, with 64 IHT were realised for diagnostic procedure (computed tomography) and 59 for therapeutic procedure (surgical procedure or interventional radiology). At least one patient related problem occurred during 41 IHT (33%) (desaturation n = 11, agitation n = 21, haemodynamic alterations n = 19, extubation n = 0). In two patients, these complications led to cardiac arrest. Patient related problems were observed more frequently in sedated patient (66 %, p = 0.0001) as well as during IHT for diagnostic procedure (p = 0.03). A ventilator problem occurred in 26 transports (21 %) and was more frequently reported when a turbine ventilator was used (p = 0.0056). CONCLUSION: This study supports the fact that IHT of mechanically ventilated critically ill patients, is a high-risk procedure associated with potentially severe complications. This finding emphasises the need of standardised procedures and medical surveillance during IHT.

What are the perspectives for ventilated tetraplegics? A French retrospective study of 108 patients with cervical spinal cord injury.

OBJECTIVE: Tetraplegic patients are often difficult to manage in intensive care units (ICU). The aim of our study was to calculate the incidence of patients in ICU with cervical spinal cord injury with special focus on tetraplegic patients on ventilation support and their future perspectives. MATERIALS AND METHODS: This retrospective study included patients with cervical spinal cord injury in Upper Normandy, between 2002 and 2012. Data analyzed included age, sex, past medical history, date of onset of quadriplegia, level of neurological involvement, AIS grade, and ventilatory status. RESULTS: One hundred and eight patients were included (49.0 ± 21.1 years). The most common etiology was fall (50 patients [46.3%]). Incidence was calculated at 12.7 per one million inhabitants. Tracheotomy was performed in 40.7% of patients. Long-term mechanical ventilation was required for 6.5%. At the end of the study, 9 patients (9.6%) were permanently hospitalized, 61 patients (64.9%) had returned home but none of the four ventilated patients had been discharged. CONCLUSION: The conclusion of this work is that the future of highly tetraplegic patients is compromised, especially for those who remain reliant on mechanical ventilation.

Acute diaphragmatic changes induced by starvation in rats.

The aim of this study was to assess in an in vivo rat model the effects of total starvation for 4 d on diaphragmatic strength and endurance. Twenty-four rats were divided equally into a control (CTL) group and a starved (ST) group. Diaphragmatic strength was assessed and endurance index was calculated. Starvation induced a parallel decrease in body weight and diaphragmatic weight amounting to 18% of the control group. Diaphragmatic contractility was impaired in the ST group. This reduction was associated with a significant reduction in transdiaphragmatic pressure (Pdi) for all the frequencies of stimulation, except 20 Hz, in the ST animals as compared with the CTL animals; however, no significant difference in Pdi expressed per gram of diaphragmatic mass was observed. Endurance index was 0.63 +/- 0.01 1.4 +/- 0.02 in the ST and CTL animals (p less than 0.01), respectively. We conclude that a 4-d total fast produces a reduction in diaphragmatic weight, which is associated with a decreased diaphragmatic strength and reduced endurance capacity.

Acute lung injury complicating imported Plasmodium falciparum malaria.

STUDY OBJECTIVE: To characterize adult patients with acute lung injury complicating severe imported Plasmodium falciparum malaria. DESIGN AND SETTING: Retrospective study of patients with severe P falciparum malaria admitted to the medical ICU of a university hospital infectious diseases department. PATIENTS: Forty adults with complicated malaria, with (group 1, 12 patients) or without (group 2, 28 patients) acute lung injury. RESULTS: Patients with acute lung injury had a higher simplified acute physiology score on admission (24.2 +/- 3.2 vs 13.7 +/- 0.7 in group 2, p < 0.0001) and a longer time interval to adequate antimalarial therapy (8.8 +/- 2.5 vs 4.9 +/- 0.6 days in group 2, p = 0.046). Of the nine group 1 patients given mechanical ventilation, eight had a PaO2/FIO2 < or = 200 mm Hg. Two patients with moderate hypoxemia received oxygen through a nasal tube and one received continuous positive airway pressure via a face mask. Acute renal failure, unrousable coma, metabolic acidosis, and shock were significantly more common among group 1 patients. The number of complications of malaria was significantly higher in patients with acute lung injury (4.7 +/- 0.5 vs 1.6 +/- 0.1 in group 2, p < 0.0001). Five patients, including four with acute lung injury, had evidence of bacterial infection (pneumonia or primary bacteremia) at ICU admission. Four patients with acute lung injury died (33%) vs one patient without acute lung injury (4%, p = 0.022). CONCLUSIONS: Acute lung injury is more likely to occur in patients with extremely severe, multisystemic P falciparum malaria. In patients with acute lung injury and septic shock, bacterial coinfection should be suspected and treated empirically since it contributes substantially to early mortality.

Short-term effects of methylene blue on hemodynamics and gas exchange in humans with septic shock.

OBJECTIVE: The aim of this study was to investigate the acute effects of methylene blue (MB), an inhibitor of the L-arginine nitric oxide pathway, in patients with septic shock. DESIGN: A prospective, open, single-dose study. SETTING: The medical ICU of a university hospital. PATIENTS: Six patients with severe septic shock. INTERVENTIONS: Complete hemodynamic values were recorded before and 20 min after the infusion of intravenous MB (3 mg kg(-1)). Arterial pressure was then monitored during the next 24 h or until death. MEASUREMENTS AND RESULTS: Methylene blue increased the mean arterial pressure from 69.7 +/- 4.5 to 83.7 +/- 5.1 mmHg (p = 0.028) and the mean pulmonary artery pressure, from 34.3 +/- 7.2 to 38.7 +/- 8.0 mmHg (p = 0.023). Systemic vascular resistance index was increased from 703.1 +/- 120.6 to 903.7 +/- 152.2 dyne.s.cm(-5).m(-2) (p = 0.028) and pulmonary vascular resistance index, from 254.6 +/- 96.9 to 342.2 +/- 118.9 dyne.s.cm(-5) .m(-2) (p = 0.027). The PaO2/FIO2 decreased from 229.2 +/- 54.4 to 162.2 +/- 44.1 mmHg (p = 0.028), without significant modification of intrapulmonary shunting. Heart rate, cardiac index, right atrial pressure, DO2, VO2, oxygen extraction and arterial lactate were essentially unchanged. Sequential measurements of arterial pressure demonstrated a return to baseline level in 2-3 h. All but one patients died, three in shock and two in multiple organ failure. CONCLUSIONS: MB induces systemic and pulmonary vasoconstriction in patients with septic shock, without significant decrease in cardiac index. The worsening of arterial oxygenation following MB injection may limit its use in patients with the adult respiratory distress syndrome. Larger studies are required to determine whether MB improves the outcome of patients with septic shock.

Influence of medical speciality and experience on interpretation of helicoidal thoracic computed tomography in blunt chest trauma.

OBJECTIVE: To compare the quality of interpretation of chest helicoidal computed tomography (HCT) by physicians with different levels of experience and medical specialty. DESIGN: Prospective observational study. SETTING: Trauma critical care unit at a French university hospital (US equivalent: level 1). PATIENTS: HCT of 50 consecutive patients with blunt chest trauma were assessed by four groups of physicians [residents in anaesthesiology (n=5), residents in radiology (n=5), senior anaesthesiologists (n=5), and senior radiologists (n=5)]. Interpretation from each physician was compared with a grid obtained from an expert interpretation by a senior radiologist and a senior anaesthesiologist. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: No group of observers performed better than another in their interpretation of lung and parietal injuries on HCT. In contrast, senior radiologists were better than anaesthesiologists for the diagnosis of pneumomediastin. However, residents in radiology performed better than other physicians in detecting the presence of gastric and tracheal tubes. CONCLUSIONS: Compared with anaesthesiologists, senior radiologists seem more expert in the diagnosis of HCT mediastinal injuries whereas residents in radiology were better at detecting resuscitation materials in thoracic trauma patients. This article reinforces the usefulness of the interpretation of the HCT by a senior radiologist in the case of blunt chest trauma. This also reinforces the usefulness of an aspect team of radiologists and anaesthesiologists in the case of trauma. The logical usefulness of a systematic interpretation of the images should be borne in mind.

[Infectious complications linked to the use of Diprivan. Precaution of administration]. / Complications infectieuses liées à l'utilisation du Diprivan. Précautions d'emploi.

In order to avoid the risk of severe infection by bacterial contamination of propofol, all users of this agent, should be reminded of the required aseptic technique "for the correct use of Diprivan". These points have recently been listed by Zeneca Pharma. They mainly include the following items: 1. Propofol is to be administered immediately after opening the vials and/or ampoules and the duration of the same continuous infusion should not excede 12 hours. 2. Disposable equipment (syringes, infusion sets, 3-way stopcoks, infusion bottles) should be used and restricted to one patient only. 3. One ampoule or vial of diprivan, once opened, must be used for one patient only. The remaining solution must be discarded. 4. Disinfection of the ampoule neck or vial stopper using and antiseptic solution before opening, is a strongly measure recommended. 5. Finally, hand washing should be routine, prior to these manipulations. As far as the above mentioned precautions are strictly followed, this anaesthetic agent may be used safely, even in case of prolonged sedation.

[Pulmonary tuberculosis in 1996. Recent data and practical consequences for the anesthesiologist]. / Tuberculose pulmonaire en 1996. Données récentes et conséquences pratiques pour le médecin anesthésiste.

Tuberculosis is one of the most widespread diseases, occurring in more than eight million persons, and about three million die annually of tuberculosis. In industrialized countries, the incidence has increased significantly over the last 10 years. HIV infection is a main factor leading to this increase. Outbreaks of nosocomial tuberculosis among patients and healthcare workers have been reported. Tuberculosis is often caused by multidrug-resistant bacilli in patients with HIV infection. Physicians must be aware of this danger and careful adherence to guidelines is required to prevent further nosocomial spread of the disease. Airborne transmission by inhalation of infectious aerosol justifies appropriate measures for respiratory isolation to protect medical staff and other patients from the transmission of tuberculosis. In combination with some anaesthetic agents, antituberculous drugs may be responsible for hepatic toxicity. Influence of tuberculosis on regional anaesthesia and mechanical ventilation is also considered.

[Selenium deficiency favors the appearance of heart failure after multiple injury]. / Carence en sélénium favorisant la survenue d'une défaillance cardiaque après un polytraumatisme.

A 47-year-old multiple trauma patient, experiencing a C. Difficile colitis with diarrhoea, developed diffuse oedema with peritoneal and pleural effusion due to global heart failure. Selenium deficiency, reported in trauma patients, may explain the occurrence of cardiomyopathy. The role of selenium in cardiac dysfunction and the various situations inducing a selenium deficiency are discussed.

[An unusual cause of acute respiratory distress]. / Une cause inhabituelle de détresse respiratoire aiguë.

A 54-year-old patient was admitted to our ICU for ketoacidosis with acute respiratory distress (ARD). The main and unusual cause of ARD was hypophosphataemia. Patient-related risk factors for chronic hypophosphataemia were malnutrition, chronic alcoholism, and diabetes mellitus. Correction of the metabolic acidosis by insulin therapy resulted in intracellular penetration of phosphate and potassium, causing severe hypophosphataemia and hypokaliaemia responsible for ARD. This case provides an opportunity for reviewing the main causes and consequences of hypophosphataemia, and for emphasising the value of monitoring serum phosphate levels and providing supplemental phosphate in ICU patients at risk for phosphate depletion.