HELLP Needs Aggressive Help

HELLP (Hemolysis Elevated Liver Enzymes and Low Platelets) syndrome is a multi-system pregnancy associated disorder, commonly seen in patients with pre-eclampsia but can occur alone. It is significantly associated with maternal-fetal morbidity and mortality.

A triad of hemolysis elevated liver enzymes and thrombocytopenia after 24 weeks of gestation is diagnostic of this syndrome. HELLP syndrome is classified depending on simple parameters but it dictates severity of the disease. Frequently encountered complications with HELLP syndrome are hemorrhagic stroke, disseminated intravascular coagulation, pulmonary edema, acute renal failure and hepatic rapture. The aggressive supportive care of failing organs with high dose of steroids will decrease the duration of HELLP syndrome, decreases intensive care and hospital stay of these patients as well as reduction in fetal complications. HELLP syndrome is associated with significant increase in morbidity and mortality of pregnant patients; hence it is of vital importance that not only obstetrician, but acute care physicians and intensivist should be aware of this clinical entity. We report a case of Classl, normotensive postpartum HELLP syndrome complicated by pulmonary edema and acute renal failure, successfully managed in our intensive care unit.

Blind Nasogastric Tube Insertion: Be careful

Nasogastric tubes are used in all specialties of medical practice. In critically ill patients, these feeding tubes provide enteral nutrition, which maintains enteric mucosal integrity as well as the immune system of the body, less risk of sepsis and decrease in length of intensive care stay. The insertion of nasogastric tube (NGT) is being considered as a simple blind bedside procedure but this procedure is not free of complications and can be fatal as these tubes can be malpositioned into the respiratory tract or central nervous system. Critically ill patients with endotracheal and tracheostomy tube are at particular risk for malpositioning of the nasogastric tubes due to loss of protective reflexes. Here we report three cases, two intubated and one patient with tracheostomy, in whom the enteral feeding tube was malpositioned into the respiratory system, detected early and a new one inserted in correct position, confirmed by x-ray. The aim of this report is to increase awareness about malpositioning of gastric feeding tubes, proper confirmation of their positioning, risk factors for malpositioning and its prevention.

Critical Care of Gynecological and Obstetric Patients: A decade of surgical intensive care experience

Despite the emergence of therapeutic advances, the morbidity and mortality still occur in the obstetric patients, although intensive care utilization by obstetric and gynecological patient, are still rare compared to the general population. Majority of obstetric patients needed the intensive care therapy compared to gynecological patients. The aim of our study was to know the indications for the intensive care admission by obstetric and gynecological patients, length of stay and outcome of these patients.

Methods: We retrospectively reviewed the medical records of all obstetric and gynecological patients admitted to our Surgical and Trauma Intensive Care Units (SICU and TICU) from February 1995 to March 2005. Indication for admission, nationality, age, and length of stay in ICU, severity of disease and outcome of these patients were recorded. Data analyzed with SPSS program.

Results: A total of 182 patients were admitted to the SICU of the Hamad Medical Corporation in Doha, Qatar, from the Women's Hospital. 159 (87%) patients were obstetric patients and 23 (13%) patients gynecological patients, 126 (69.6%) patients were admitted post Lower Segment Caesarean Section (LSCS). The most common indication for admission was 73 (39.3%) patients obstetric hemorrhage and Disseminated Intravascular Coagulation (DIC), and then 44 (25.3%) patients of hypertensive disorder of pregnancy. The major anesthesia related indication was scoline apnea, 21 (11.6%). Total three obstetric patients died, two due to severe sepsis and multi-organ failure and one due to cerebral sinus thrombosis, giving mortality rate of 1.66%.

Conclusion: Intensive care therapy required by gynecological and obstetric patient is less than the general population. The commonest indication for admission was obstetric hemorrhage, DIC, and hypertensive disorders of pregnancy. The mortality was due to septic shock with multi-organ failure, and cerebral venous sinus thrombosis.

Post-operative Fat Embolism Syndrome: A case report and review of literature

Fat embolism occurs in all patients with long bone fractures and intra-medullary reaming of long bone but is usually asymptomatic. A few patients will have pulmonary, cerebral and dermal dysfunction; this triad is called fat embolism syndrome (FES). We report a case of FES developed after intramedullary nailing of both femurs that was successfully managed in our surgical intensive care unit (SICU).

Second toe proximal phalanx interposition bone graft to correct a failed Keller's arthroplasty. A new technique

We present a case report of a novel salvage technique for a failed Keller's arthroplasty using nonvascularised phalanx transfer from the second toe to the hallux on the same foot. The technique restores length, function and relieves pain.

Necrotizing fasciitis and its association with Diabetes Mellitus

To analyze the different presentation, types of infection, predisposing factors (particularly diabetes mellitus) of necrotizing fasciitis; a rare potentially fatal rapidly progressing necrotizing infection of subcutaneous tissue and superficialfascia with secondary necrosis of overlying skin, the medical records were reviewed retrospectively of 94 patients (71 male; 23 female) admitted to the surgical intensive care unit of Hamad General Hospital, Qatar, between January 1995 and February 2005. Fifty-three patients (56.4%) were diabetic with a mean age of 55 years compared with 40.2 years in non-diabetic patients. Type 1 necrotizing fasciitis, especially of the perineal and genital regions, was more common in diabetic patients whereas type 2 necrotizing fasciitis, especially of torso and upper limbs, was more common in non-diabetic patients. Overall 63.4% of cases were type 2 necrotizing fasciitis. E.coli was the most common bacterium isolated from necrotic tissue of diabetic patients and streptococci were the most common cause of necrotizing fasciitis in non-diabetic patients. Fifteen (16%) patients died but there was no significant difference in mortality between the groups, eight (15.1%) diabetic, seven (17.1%) non-diabetic, although diabetic patients were significantly older.

Peripartum Cardiomyopathy: Report of two cases and review of literature

Peripartum cardiomyopathy (PPCM) is a rare condition affecting women in late pregnancy or up to five months of the postpartum period. The signs, symptoms and treatment of PPCM are similar to that of heart failure. Early diagnosis and proper management are the cornerstones for a better outcome for these patients. We report two cases of peripartum cardiomyopathy which were treated in the surgical intensive care unit (SICU) of Hamad General Hospital, Qatar.

An electrocardiographic algorithm for the prediction of the culprit lesion site in acute anterior myocardial infarction

BACKGROUND

Although the 12-lead electrocardiogram (ECG) has been found useful in identifying the left anterior descending (LAD) coronary artery as the infarct-related artery in acute myocardial infarction (MI), it has traditionally been felt to be incapable of localizing the culprit lesion within the LAD itself. Such a capability would be important, because anterior MI due to proximal LAD lesions carry a much worse prognosis than those due to more distal or branch vessel lesions.

HYPOTHESIS

This study investigated whether certain ECG variables--especially an ST-segment injury pattern in leads aVL and/or V1--would correlate with culprit lesion site, and an ECG algorithm was developed to predict culprit lesion site.

METHODS

The initial ECGs of 55 patients who had undergone cardiac catheterization after an anterior or lateral MI were reviewed to identify the leads with an ST-segment injury pattern; the corresponding catheterization films were then reviewed to identify the location of the culprit lesion; and these separate findings were then compared.

RESULTS

The sensitivity and specificity of an ST-injury pattern in aVL in predicting a culprit lesion before the first diagonal branch were 91 and 90%, respectively; the same values in predicting a lesion prior to the first septal branch were 85 and 78%. ST-segment elevation in V1, on the other hand, was a much less sensitive and specific predictor of a preseptal lesion. Overall, our algorithm correctly identified the culprit lesion location in 82% of our patients.

CONCLUSION

Based on our findings, we conclude that a ST-segment injury pattern in aVL during an anterior myocardial infarction predominantly reflects a proximal LAD lesion and therefore constitutes a high-risk finding.

Regional Necrotizing Fasciitis and its Outcome

Necrotizing fasciitis, a devastating progressive destructive infection of subcutaneous tissue and fascia, is a surgical emergency with a high mortality and morbidity. To analyze the location of necrotizing fasciitis, mode of presentation, microbiological characteristics, comorbid conditions, morbidty and mortality, records were reviewed retrospectively of all ninety-five patients admitted with necrotizing fasciitis to the surgical intensive care unit of Hamad General Hospital between January 1995 and February 2005. Fifteen patients died (15.1%). All patients had leucocytosis and fever on admission with a mean SOFA score varying from 8 to 10.3 according to the type of necrotizing fasciitis involved (Type 1 or 2) and the regions affected. All received aggressive fluid replacement therapy and all underwent debridement at least twice. The most common comorbid condition was Diabetes mellitus. Type 1 necrotizing fasciitis was common in gluteal, cervical and perineal regions; Type 2 was common in chest, axilla, leg and foot regions. Necrotizing fasciitis of the chest, axilla and gluteal regions had the highest mortality while necrotizing fasciitis of the perineum and genitalia had the lowest mortality.

Critical Illness Polyneuropathy in an Obstetric Patient: A case report and review

Recently it has been found that many critically ill patients develop secondary neuromuscular disorders following admission to intensive care units (ICU). One of these is critical illness polyneuropathy (CIP), a widespread symmetrical disorder affecting the peripheral nervous system and often associated with sepsis and multi-organ dysfunction. Two percent of all intensive care patients and as many as 80% of septic patients develop critical illness polyneuropathy which leads to a considerably increased risk of in-hospital mortality. The exact etiology of the condition is not known but various risk factors, differential diagnosis, treatment, management and prognosis are discussed in this report of ci woman who, following caesarian section, developed CIP, septic shock, multi-organ failure and subsequently died.

Acute Pancreatic Nine Years of Surgical ICU Experience

Acute pancreatitis has a variety of presentations from self-limiting abdominal pain to development of local and systemic complications resulting in sepsis, multi-organ dysfunction, extended intensive care stay and death. Very good quality of life in survivors justifies an optimal therapy in an intensive care setup. The records of 91 patients with acute pancreatitis were reviewed retrospectively. There was a significant difference (p < 0.001) between those with edematous pancreatitis and those with necrotic pancreati-tis as regards the length of ICU stay and severity scores: Ranson and SOFA (Sepsis-related Organ Failure Assess-ment). The most common cause of pancreatitis was biliary (70.3%) followed by hyperlipidemia (12.1%), post ERCP (5.5%), trauma (4.4%), idiopathic (6.6%) and in one case, ascariasis. Common associated diseases were hypertension (33%) and diabetes mellitus (25.3%). Six patients with necrotic pancreatitis died. It is concluded that acute pancreatitis treated in an in-tensive care unit has a favorable outcome and that a com-bination of Ranson and SOFA scores with CT index helps in establishing the prognosis.

Detection of recurrent breast cancer after TRAM flap reconstruction

Breast cancer remains a significant cause of morbidity and mortality among women today. The transverse rectus abdominis myocutaneous (TRAM) flap has played a substantial role in the reconstruction of defects secondary to mastectomy. Although such reconstruction has not been shown to adversely affect survival or local recurrence, specific screening modalities for recurrence in this population of patients have not been delineated. Three patients were examined retrospectively at the authors' institution. They presented with local recurrences of breast cancer after mastectomy and TRAM flap reconstruction. All patients' recurrences were detected on physical examination, and all had the diagnosis of recurrent carcinoma made on biopsy of the mass. A review of the literature demonstrates that mammography, ultrasound, magnetic resonance imaging (MRI), computed tomography (CT), scintimammography, and biopsy have all been used as adjuncts to clinical examination in detecting recurrence. Subsequent treatment of recurrent breast cancer is determined by the results of a metastatic workup and the receptor status of the tumor. The most reliable form of diagnosis of recurrent breast cancer after TRAM flap reconstruction remains fine-needle, core, or open biopsy if indicated.

Cloning and characterisation of ITGAV, the genomic sequence for human cell adhesion protein (vitronectin) receptor alpha subunit, CD51

The integrin family of receptors serves as major receptors for extracellular matrix-mediated cell adhesion and migration, cytoskeletal organisation, cell proliferation, survival, and differentiation. The alpha-V integrins consist of a subset which share a common alpha-V subunit combined with one of five beta subunits (beta-1, 3, 5, 6, or 8). The alpha-V integrins have been implicated in a number of developmental processes, including vasculogenesis and angiogenesis, and are therapeutic targets for inhibition of angiogenesis and osteoporosis. The human cDNA for alpha-V integrin (ITGAV) consists of a 5,717-bp transcript with a coding sequence (CDS) of 3,146 bp encoding a 150-kDa mature peptide. Here we describe the gene structure of ITGAV.

Spontaneous intramural atrial hematoma presenting as a left atrial mass

We describe an unusual case of spontaneously occurring intramural atrial hematoma with no communication with either atrium. The diagnosis of left atrial mass was made from transthoracic echocardiography. Subsequent examination with transesophageal echocardiography confirmed a large mass essentially filling the whole left atrium but failed to provide an etiologic diagnosis, which was eventually made at surgery.

Growth inhibition of human breast cancer cells by herbs and phytoestrogens

Epidemiologic studies have suggested that consumption of phytoestrogen-rich foods may protect against breast cancer, and phytoestrogens such as genistein have been reported to both inhibit and stimulate the growth of some human breast cancer cells. The phytoestrogens genistein, daidzein, biochanin A, and coumestrol were tested and found to inhibit serum-stimulated growth in both T-47D and MCF-7 breast cancer cells at 10-100 microM. Extracts of several estrogenic herbs, including hops, black cohosh and vitex, inhibited growth of T-47D cells. These in vitro results suggest that certain herbs and phytoestrogens may have potential in the prevention of breast cancer.

Mast cells of the bovine trachea: staining characteristics, dispersion techniques and response to secretagogues

Sections of the lower trachea of cattle, fixed in either Carnoy's or formalin, were stained with toluidine blue, alcian blue, or alcian blue and safranin O to study the mast cell population. After toluidine blue staining, about twice as many cells in tissue fixed in Carnoy's contained dark blue granules compared with tissue fixed in formalin. In addition, for the first time in cattle, a population of cells containing red granules was identified after staining with alcian blue and safranin O. Most of these red granules were formalin sensitive. An enzymatic dispersal technique for mast cells is described that yielded 9.4+/-0.4% mast cells (percentage of nucleated cells) with a viability of 92.3+/-0.6%. Spontaneous histamine release was 3.3+/-0.8%. Dispersed mast cells were challenged with various immunological and nonimmunological secretagogues. The calcium ionophores, A23187, ionomyocin, and BrX537A, were effective in releasing up to 94% of histamine in mast cells in a dose-response relationship. Pasteurella haemolytica culture supernate caused about 10% histamine release at a dose of 0.5 mg/mL after correction for spontaneous release. The average histamine content of the mast cells was 6.6+/-1.0 pg/cell. Cytospins of dispersed cells fixed in Carnoy's and stained with alcian blue and safranin O contained mast cells with blue and red granules, and a few cells with a mixture of both granule types. Based on the effects of type of fixation, staining characteristics and histamine content, a mix of subtypes of mast cells is present in the bovine trachea. However, functionally they respond to secretagogues differently than rodent mast cells. Without an immunological secretagogue, studies to determine compounds that will be effective in blocking mast cell degranulation will be limited.