Multiple limb compartment syndrome as a manifestation of capillary leak syndrome secondary to metformin and dipeptidyl peptidase IV inhibitor overdose: A case report

Microfluidics as a Powerful Tool to Investigate Microvascular Dysfunction in Trauma Conditions: A Review of the State-of-the-Art

Skeletal muscle trauma such as fracture or crush injury can result in a life-threatening condition called acute compartment syndrome (ACS), which involves elevated compartmental pressure within a closed osteo-fascial compartment, leading to collapse of the microvasculature and resulting in necrosis of the tissue due to ischemia. Diagnosis of ACS is complex and controversial due to the lack of standardized objective methods, which results in high rates of misdiagnosis/late diagnosis, leading to permanent neuro-muscular damage. ACS pathophysiology is poorly understood at a cellular level due to the lack of physiologically relevant models. In this context, microfluidics organ-on-chip systems (OOCs) provide an exciting opportunity to investigate the cellular mechanisms of microvascular dysfunction that leads to ACS. In this article, the state-of-the-art OOCs designs and strategies used to investigate microvasculature dysfunction mechanisms is reviewed. The differential effects of hemodynamic shear stress on endothelial cell characteristics such as morphology, permeability, and inflammation, all of which are altered during microvascular dysfunction is highlighted. The article then critically reviews the importance of microfluidics to investigate closely related microvascular pathologies that cause ACS. The article concludes by discussing potential biomarkers of ACS with a special emphasis on glycocalyx and providing a future perspective.

Therapeutic Plasma Exchange in Severe Rhabdomyolysis: A Case-Control Study

INTRODUCTION

 Rhabdomyolysis is a serious condition that can cause acute kidney injury (AKI), compartment syndrome, severe metabolic and electrolyte derangement leading to arrhythmias, and even death. Total plasma exchange (TPE) has been used as a treatment modality to clear myoglobin, but the evidence is limited. In this study, we aim to investigate the use of TPE in critically ill rhabdomyolysis patients.

METHODS

 We retrospectively chart reviewed adult patients admitted to the intensive care unit (ICU) with a diagnosis of rhabdomyolysis between 2012 and 2021. We dichotomized patients into two groups based on whether TPE was used or not in addition to standard care. PRISMA machines with TPE2000 filters and either 5% albumin or fresh frozen plasma were used in the TPE group.

RESULTS

 The patients' age ranged from 23 years to 87 years (mean 49.4, SD 18.1), and 51% were male. Initial creatinine ranged from 0.6 to 16mg/dL (mean 3.4, SD 2.7), creatinine phosphokinase (CPK) from 403-93,232 U/L, and myoglobin from 934 to >20,000. The Sequential Organ Failure Assessment (SOFA)scores on admission ranged from 6 to 17 (mean 7.23, SD 3.40). Overall, 28.78% (N=19) of the patients received therapeutic plasma exchange. The overall mortality in our study was 31.9%, with the length of ICU stay ranging from 1-25 days (mean 7.10, SD 5.91) among survivors. Older age and the presence of shock were predictive of mortality in univariate and multivariate analyses. There was no statistically significant association in mortality between the TPE and non-TPE groups (36.84% in TPE vs. 36.17% in the non-TPE group, OR 0.7209, p=0.959). Only two patients in the non-TPE group developed CKD/ESRD on long-term follow-up.

CONCLUSION

Our study showed that TPE administration in critically ill patients with rhabdomyolysis did not improve mortality or length of ICU stay. Further studies are required to elucidate its indication and effect on long-term renal outcomes.

Severe edema and blood blisters of the lower extremities caused by sitagliptin, a dipeptidyl peptidase-4 inhibitor

Severe edema and blood blisters can occur as adverse events associated with sitagliptin. A history of dipeptidyl peptidase-4 inhibitors should be considered when examining patients with edema and blood blisters of uncertain cause.

Atraumatic Bilateral Acute Compartment Syndrome of the Lower Legs: A Review of the Literature

Bilateral acute compartment syndrome of the legs is a very rare presentation that requires emergency surgical intervention. Atraumatic bilateral cases are almost unheard of in medicine. There is currently no link between compartment syndrome and cognitive impairment or mental health. A systematic literature search was performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines using the following keywords in multiple databases: compartment syndrome, atraumatic, spontaneous, bilateral, both, lower leg, acute, compartmental pressure, and fasciotomy. Atraumatic, bilateral, acute, and confirmed compartment syndrome cases were included. In total, 33 cases of atraumatic bilateral acute compartment syndrome (ABACS) were identified, of those 72.7% of cases were males. A form of cognitive impairment was found in 66% of cases. The medical history of the cases included substance abuse (nine patients), mental health illness (seven patients), and hypothyroidism (four patients). Within the reports, there was evidence of a misdiagnosis or delayed management in 19 cases (57.6%). Creatinine kinase (CK) was measured in 28 cases with a mean CK of 110,893 IU/L. Compartment pressure measurements were used in only 12 cases. A total of 29 cases were managed with bilateral four-compartment fasciotomy. This review highlights that ABACS is a condition with high rates of misdiagnosis or delay in treatment. Associations found included patients with cognitive impairment on presentation, mental health conditions, substance misuse, and elevated levels of CK. In addition, this review demonstrates that this condition is less rare than previously thought with serious morbidity and mortality.

Veno-venous-extracorporeal membrane oxygenation treatment for severe capillary leakage syndrome: A case report

BACKGROUND

Capillary leak syndrome (CLS) is characterized by the leakage of large amounts of fluid and plasma proteins into the interstitial space, resulting in hypoalbuminemia, hypovolemic shock, elevated blood concentration, systemic progressive edema, and multiple serosal cavity effusion. Clinical syndromes such as cavity effusion pose a grave threat to the life and health of the patient.

CASE SUMMARY

A 58-year-old female patient was admitted to the hospital after being in a coma for 6 h following accidental ingestion of a pesticide. She was treated with phencyclidine hydrochloride and pralidoxime iodide for detoxification, mechanical ventilation to maintain oxygen supply, continuous renal replacement therapy to maintain the internal environment, and hemoperfusion to promote the excretion of toxins. She also received a transfusion of red blood cells and massive fluid resuscitation. However, her blood pressure was not maintained. The patient was diagnosed with CLS due to pesticide poisoning. Oxygenation was difficult to maintain under full ventilator support; therefore, veno-venous-extracorporeal membrane oxygenation (VV-ECMO) treatment was given 13 h after admission. Her oxygenation level improved, but a large amount of ascites and pleural effusion soon became apparent. We continued drainage with an indwelling drainage tube, and the ECMO flow stabilized. The leakage gradually decreased, and ECMO was discontinued 3 d later. On the 6^th day, the patient recovered from unconsciousness, but on gastroscopic evaluation, severe erosions were found in her entire stomach. With the family’s consent, treatment was stopped, and the patient was discharged from the hospital on the 7^th day.

CONCLUSION

ECMO, liquid resuscitation and management, and improvement in plasma colloidal osmotic pressure, circulation, and tissue oxygen supply are crucial in treating CLS.