[Subarachnoid haemorrhage presenting clinically as circulatory arrest in acute myocardial infarction]. / Subarachnoïdale bloeding met de klinische presentatie van een circulatiestilstand bij acuut myocardinfarct.

A 59-year-old woman and a 41-year-old man were both brought to the Cardiac Emergency Clinic with circulatory arrest on the basis ofpulseless electrical activity. The first patient had had no prodromal symptoms and the second patient had visited his general practitioner 2 weeks earlier because of pain in the head and neck. In both patients, electrocardiography and echocardiography suggested acute myocardial infarction. However, both patients proved to be suffering from a subarachnoid haemorrhage (SAH) and both died. One-third ofthe patients with SAH are comatose at presentation. Cardiac manifestations such as ECG-abnormalities, cardiac arrhythmias, cardiopulmonary arrest, elevated troponin values, and signs of left ventricular dysfunction are common. These findings can be misleading and may have catastrophic consequences if anticoagulant therapy is initiated because of a presumed myocardial infarction. Low-threshold CT-scanning of the brain is therefore advised for patients who remain comatose after resuscitation for cardiac arrest in the presence of an atypical anamnesis.

[Pneumatosis intestinalis; no disease, but a symptom]. / Pneumatosis intestinalis; geen ziekte, maar een symptoom.

In three patients, men aged 77, 83 and 69 years, pneumatosis intestinalis was detected during CT for abdominal pain occurring in the first patient after an aortic stent had been placed, and during laparotomy because of ileus in the latter two patients. The first patient underwent removal of an ischaemic intestinal segment but died later due to infection around the prosthesis. The other two patients recovered after conservative therapy. Pneumatosis intestinalis is defined as the presence of gas in the wall of the gastrointestinal tract. Often it is detected by accident during abdominal radiographic examination or laparotomy. Pneumatosis intestinalis is a symptom and has been found in a wide variety of diseases. The clinical condition of the patient and the underlying disease determine the clinical significance of pneumatosis intestinalis and the therapy. The main issue is whether surgical intervention is necessary because of intestinal ischaemia or perforation.

[The aortocaval fistula, a rare complication of an aneurysm of the abdominal aorta]. / De aortocavale fistel, een zeldzame complicatie van een aneurysma van de abdominale aorta.

Four patients, 3 men aged 73, 60 and 81 years with hemodynamic instability and 1 man aged 80 with abdominal symptoms and breathlessness appeared to have an arteriovenous fistula secondary to spontaneous rupture of an atherosclerotic aneurysm: between the aorta and the V. cava inferior or between the A. and the left V. iliaca communis. One patient died, one patient had postoperative decompensatio cordis, one suffered a deep vein thrombosis and the 4th recovered without symptoms. The presence of an aortocaval fistula has to be considered in patients with a symptomatic abdominal aneurysm with a harsh bruit heard over the abdomen, signs of high venous pressure and peripheral hypoperfusion. When no rupture of the aneurysm is found at laparotomy in symptomatic patients, the presence of a fistula is rare, but has to be considered. Furthermore, a fistula can be the underlying cause of therapy-resistant heart failure or acute renal dysfunction. Pre-operative identification can lead to decrease of morbidity and mortality of the phenomenon.

[Lithium, a potentially dangerous drug]. / Lithium, een potentieel gevaarlijk geneesmiddel.

Two patients with a bipolar disorder, a woman aged 56 and a woman aged 68, who had used lithium for more than 30 years, were seen with side effects from this medication. Both patients were treated by their general practitioner and had not visited a psychiatrist for many years. The first patient had a chronic lithium intoxication with cerebellar signs and eventually coma, diabetes insipidus, hyperthyroidism, hyperparathyroidism and psoriasis. After 6 weeks of treatment in the intensive-care unit she made a good recovery. The second patient had several lithium side effects. She was diagnosed with diabetes insipidus, hyperparathyroidism due to a parathyroid adenoma, hypothyroidism and a sick-sinus syndrome. A pacemaker was implanted 4 years earlier. The adenoma was surgically removed. After other medication was tried, the patient was once again given lithium, on which she was able to function well. The first patient had lithium concentrations above the therapeutic value for several years and both patients experienced a delay before their signs and symptoms were attributed to lithium. Lithium treatment should be monitored by an experienced psychiatrist.

Lactate measurements in critically ill patients with a hand-held analyser.

OBJECTIVE: To compare a recently introduced hand-held lactate analyser to a reference point of care analyser (POCI) and the hospital laboratory in a critical care setting. SETTING: 10-bed surgical/medical intensive care unit in a teaching hospital. PATIENTS AND METHODS: In 39 critically ill patients, 50 convenience measurement cycles consisting of three paired measurements at 30-min intervals were carried out with a hand-held analyser, reference POCI and hospital laboratory using arterial blood samples. Duplicate measurements with the hand-held analyser were done in 129 blood samples. RESULTS: Lactate levels ranged from 1.1 to 21.0 mmol/l. Regression analysis of the hand-held analyser and laboratory showed a slope of 1.01, bias of -0.38 mmol/l, R(2) = 0.97 and mean error of 14.9 %. Reference POCI versus laboratory: slope = 1.07, bias = -0.29 mmol/l, R(2) = 0.98 and mean error of 6.4 %. Hand-held analyser versus reference POCI: slope = 0.90, bias = 0.09 mmol/l and R(2) = 0. 92. The hand-held analyser showed acceptable precision. CONCLUSION: The hand-held lactate analyser can reliably measure arterial blood lactate levels in critically ill patients.

Transient post-renal obstruction may protect the kidney against nephrotoxic damage--a case report.

In critically ill patients, acute renal failure is mostly multifactorial in origin. In general, the simultaneous presence of several deleterious factors tends to aggravate the renal damage. The present case report describes a patient with multifactorial acute renal failure, in whom one of the factors contributing to the renal failure, i.e. transient unilateral post-renal obstruction, apparently protected the obstructed kidney against damage from other causes.

Colonization and infection in surgical intensive care patients--a prospective study.

Nosocomial infections are a major problem in intensive care patients. Thirty-nine patients, requiring intensive care for 5 days or more (mean 15.8 days) were prospectively investigated, to determine the relation between colonisation and nosocomial infection. Thrice weekly, cultures from the oropharynx, respiratory and digestive tract were obtained. Colonization with aerobic gram-negative microorganisms of the oropharynx, respiratory and digestive tract significantly increased during the stay in the Intensive Care Unit. In 29 patients (74%) 78 nosocomial infections were diagnosed. The most frequent nosocomial infections were pneumonia (26 patients, 66.6%), catheter-related bacteraemia (11 patients, 28.2%), and wound infections (7 patients, 17.9%). In 59 instances (75.6%), colonization with the same potential pathogenic microorganism preceded the nosocomial infection. The overall mortality was 25.6% (10 patients), bacteraemia with aerobic gram-negative microorganisms being the cause of death in 7 patients.

Acute folate deficiency in a critically ill patient.

A 19-year-old male patient developed thrombocytopenia and leukopenia due to acute folate deficiency while recovering from a multiple organ failure syndrome. Risk factors for acute folate deficiency are extensive tissue damage due to sepsis, trauma or surgery and acute renal failure requiring renal replacement therapy. The diagnosis is based on bone marrow examination showing marked megaloblastic changes whereas serum folate levels and red cell folate levels are normal. Recognition of this serious complication of critical illness is important because it should be readily prevented by folic acid therapy.

The influence of extravascular lung water on cardiac output measurements using thoracic impedance cardiography.

The purpose of this study was to investigate the influence of pulmonary oedema as measured with the double indicator dilution technique on the accuracy of cardiac output (CO) measurement using thoracic impedance cardiography (TIC) compared with thermodilution in thirteen sepsis patients. Differences in the Kubicek and Sramek-Bernstein equation with respect to pulmonary oedema were explored theoretically and experimentally. From a parallel two cylinder model a hypothesis can be derived that CO determined with the Kubicek equation is oedema independent, whereas CO determined using the Sramek-Bernstein equation is oedema dependent. Experimentally, CO determined using Kubicek's equation correlated better with thermodilution CO (r = 0.75) than CO determined with the Sramek-Bernstein equation (r = 0.25). The effect of oedema on the accuracy of TIC was investigated by comparing the differences in the CO of impedance and thermodilution to the extravascular lung water index. For the Kubicek equation the difference was not influenced by oedema (r = 0.04, p = 0.84), whereas for the Sramek-Bernstein equation the difference was affected by oedema (r = 0.39, p = 0.05). Thus, the effects of pulmonary oedema on the accuracy of TIC measurements can better be understood with the parallel cylinder model. Moreover, the Kubicek equation still holds when pulmonary oedema is present, in contrast to the Sramek-Bernstein equation.

[Selective decontamination of the digestive tract reduces mortality in intensive care patients]. / Selectieve darmdecontaminatie voorkomt sterfte bij intensive-carepatiënten.

Selective decontamination of the digestive tract (SDD) is a strategy designed to prevent or minimize the impact of infections by potentially pathogenic micro-organisms in critically ill patients requiring long-term mechanical ventilation. SDD is a four-component protocol to control the three types of infections occurring in intensive care patients: (a) a parenteral antibiotic, cefotaxime, for a few days to prevent primary endogenous infections that generally occur 'early'; (b) the topical antimicrobial drugs colistine (polymyxin E), tobramycin and amphotericin B (together: PTA) used throughout the stay in the intensive care unit (ICU) to prevent secondary endogenous infections developing in general 'late'; (c) a high standard of hygiene to prevent exogenous infections that may occur throughout the ICU stay; (d) surveillance samples of throat and rectum to distinguish between the three types of infection, to monitor compliance and efficacy of treatment and to detect emergence of resistance at an early stage. The most recent and rigorous meta-analysis examined 33 randomized SDD trials involving 5727 patients. It shows significant reductions, in overall mortality by 20% and in the incidence of lower airway infections by 65%. It failed to detect any report on the emergence of resistance and associated superinfections and/or out-breaks in the 33 studies covering a period of more than 10 years. Using the criterion of cost-per-survivor, four recent randomised trials showed that it is cheaper to produce a survivor using SDD than with the traditional approach.

[Spread and control of a methicillin-resistant Staphylococcus aureus in an academic hospital]. / Verspreiding en bestrijding van een meticilline-resistente Staphylococcus aureus in een academisch ziekenhuis.

Between December 1988 and March 1989 twelve patients in the Utrecht University Hospital developed an infection with a methicillin-resistant Staphylococcus aureus (MRSA). Twenty other patients and 39 personnel members became colonized with the same MRSA strain. In spite of early isolation measures, progression of this epidemic was probably caused by the extreme degree of contagiousness of the first patient, who had a drug-induced allergic skin eruption. It seems likely that spread occurred via personnel and via a computer tomographic scanner. To contain the epidemic it was necessary to institute a special isolation ward with dedicated personnel. Although several MRSA strains have been introduced in the University Hospital since 1986, the strain we describe here is the only one which spread epidemically.