SESSION TYPE: Critical Care Student/Resident Case Report Posters IIPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION:

Intensive care patients often have multiple comorbidities and very complex treatment plans. Pinpointing an exact precipitating factor responsible for a patient's rapid health decline is difficult. Late or inappropriate identification can further complicate the picture. Swift action and maintaining a broad differential is paramount in order to correctly identify the cause and treat appropriately.

CASE PRESENTATION:

We present a 40-year-old African American female who developed multiorgan system dysfunction secondary to sepsis and complications of antiretroviral therapy. She has a history of CKD on dialysis, NSTEMI s/p MVR, and HIV on antiretroviral therapy. She presented with acute lower back pain radiating to right upper thigh associated with 10-day history of progressive weakness, pain, and anorexia. On the second day of admission she became lethargic. Severe bradycardia (HR 30's), hypotension (BP 80/40), hypoglycemia (glucose 19), low oxygen saturation (O2 sat 80's) and metabolic acidosis with pH 7.11, HCO3 14, and lactate level of 11.9 mmol/L were noted. She failed to respond to narcan and D50. Upon admission she had blood cultures drawn and Vancomycin was started. Blood cultures grew staphylococcus epidermidis and septic shock was considered. However, this was not an exact fit given absence of fever, no elevated WBC, severe bradycardia, and no strong evidence of infection. Cardiogenic shock, endocarditis, meningitis, and encephalitis were excluded. Elevated cardiac enzymes were thought to be secondary to underlying kidney failure. The patient had hepatomegaly and elevated liver enzymes (ALT 508, AST 992), which were most likely secondary to hypoperfusion, underlying liver disease, or complications of antiretroviral therapy. For the past year she was on Efavirenz and Tenofovir, which has a blackbox warning for lactic acidosis and severe hepatomegaly. Her liver function prior to admission was normal. The antiretroviral therapy was held and liver function and lactate levels subsequently returned to baseline.

DISCUSSION:

As seen in this case, the exact cause of the patient's decline was unclear but rather confounded by multiple comorbidities. Lactic acidosis secondary to antiretroviral therapy presents with nonspecific symptoms making the diagnosis difficult. Our patient was subject to an extensive workup and evaluation.

CONCLUSIONS:

The immediate recognition of antiretroviral therapy as a culprit was important in preventing further decline. This case highlights the importance of thorough evaluation and proper identification of medications and their potential side effects especially in intensive care patients whose health is very precarious to subtle alterations.1) Vired package insert. Foster City, CA: Gilead Sciences, 2001.DISCLOSURE: The following authors have nothing to disclose: Shiayin Yang, Youngsook YoonNo Product/Research Disclosure InformationUniversity of Toledo, Holland, OH.

SESSION TYPE: Critical Care Student/Resident CasesPRESENTED ON: Monday, October 22, 2012 at 01:45 PM - 03:00 PM

INTRODUCTION:

Asymmetric parenchymal lung disease causing hypoxemic respiratory failure can be difficult to manage with conventional and even rescue modes of ventilation due to different ventilation-perfusion ratios and compliances in the two lungs. Synchronous independent lung ventilation (SILV) with two ventilators has the potential to more effectively treat refractory hypoxemia by individually tailoring ventilation to each lung.

CASE PRESENTATION:

A 55 year-old woman presented with dyspnea for 2 weeks. She reported fever, chills, productive cough with yellow sputum, and right-sided chest pain, started 1 week after returning from the Philippines. She was tachypneic and hypoxic with SaO2 88% on room air. A chest x-ray revealed a diffuse right-sided infiltrate, and a chest CT scan revealed a 7x6x4 cm rounded abscess in the densely consolidated right upper lobe (Figure 1), right lower lobe compression by a moderate pleural effusion, and mild left lower lobe atelectasis. Hypoxemia rapidly worsened, and she underwent emergency intubation. Due to persistent hypoxemia on Bilevel Pressure Control Ventilation with 100% FiO2 even after right chest tube insertion, she was started on Airway Pressure Release Ventilation (APRV), but the hypoxemia was refractory. Rescue ventilation with High Frequency Oscillation Ventilation (HFOV) was attempted, with 100% FiO2 and a mean airway pressure of 36 cmH2O, but her pO2 remained in the 40s. SILV was initiated after a double-lumen endotracheal tube was inserted, with the settings shown in Table 1. On 100% FiO2, her SaO2 improved to 94%. SILV was converted back to conventional ventilation with a single-lumen endotracheal tube 5 days later after the patient improved dramatically. Her Legionella urine antigen was positive, and she was treated with azithromycin and moxifloxacin for 3 weeks, at which point she was weaned off oxygen and discharged.

DISCUSSION:

In SILV, the respiratory rate is kept the same for both lungs, while PEEP, tidal volumes, and inspiratory flow rates are set independently. This patient's hypoxemia likely improved with SILV by avoiding overdistention of the more compliant lung, thus minimizing shunting of blood flow to the more diseased lung. SILV may have also been more lung protective, as low tidal volumes accounting for the different compliances of each lung could be used, and higher PEEP could be applied selectively to the more affected lung to improve alveolar recruitment, without overdistending the less affected lung.

CONCLUSIONS:

Legionella can cause a severe necrotizing pneumonia, and a Legionella urinary antigen should be ordered in critically-ill pneumonia patients, especially if risk factors are present. SILV is a viable rescue option for persistent hypoxemia from asymmetric parenchymal lung disease which is not corrected by conventional and rescue modes of ventilation.1) Anantham D, Jagadesan R, Tiew PE. Clinical review: Independent lung ventilation in critical care. Crit Care. 2005;9(6):594-600.DISCLOSURE: The following authors have nothing to disclose: Ekamol Tantisattamo, Reid IkedaNo Product/Research Disclosure InformationDepartment of Medicine, University of Hawaii John A. Burns School of Medicine, Honolulu, HI.

Skeletal muscle metastasis is a very rare event in patients with oesophageal cancer. We herein report and discuss a case of a 65 years old man with history of gastro-esophageal reflux disease referred to our department for pyrosis associated to persistent low back pain. Oesophageal endoscopy and transesophageal endo-sonography showed a tumour localized in the lower third of the esophagus, histologically proved to be adenocarcinoma. Clinical staging procedures detected a two centimetres vascularized nodular lesion placed into right para-vertebral muscles at the level of L4 as the only sign of potential distant disease (versus a differential diagnosis of primitive sarcoma). The muscle lesion was completely removed and confirmed as secondary adenocarcinoma. Due to this evidence a chemotherapy protocol was initiated. After nine months the patient underwent transhiatal oesophagectomy. To the best of our knowledge this is the first reported case of a soft tissue metastasis from oesophageal cancer resected with radical intent. KEY WORDS: Low back pain, Oesophageal adenocarcinoma, Skeletal muscle metastasis.

Background:

there were 13,371 disability reports in Jalisco during 2008 about lumbar spine injuries; most of them were permanent and required evaluation of lumbar capabilities. The objective was to evaluate the functionality of the lumbar spine through the Oswestry questionnaire and isokinetic evaluation in pensioners with lumbar injury.

Methods:

a comparative study on 20 workers with disability status of lumbar injury was done. Isokinetic exercises to identify musculoskeletal capacity and the Oswestry questionnaire to know the percentage of disability were applied.

Results:

The Oswestry questionnaire showed 60 % average on lumbar spine functionality. A peak torque average was 44 Nw on the assessing isokinetic extension. Mean and mode of zero in fatigue at work were estimated. The flexion peak torque was -75.5 Nw. The average and mode power were 40 V. Both the mean and mode work fatigue were zero.

Conclusions:

Isokinetic evaluation was not normal in any of the workers, confirming disability status.

Painful vertebral body hemangiomas have been successfully treated with vertebroplasty and kyphoplasty. Sacral hemangiomas are uncommon and as such painful sacral hemangiomas are rare entities. We report what we believe is only the second successful treatment of a painful sacral hemangioma with CT-guided sacroplasty. A 56-year-old woman with a history of right-sided total hip arthroplasty and lipoma excision presented to her orthopedic surgeon with persistent right-sided low back pain which radiated into her buttock and right groin and hindered her ability to walk and perform her activities of daily living. MRIs of the thoracic spine, lumbar spine and pelvis showed numerous lesions with imaging characteristics consistent with multiple hemangiomas including a 2.2×2.1 cm lesion involving the right sacrum adjacent to the right S1 neural foramen. Conservative measures including rest, physical therapy, oral analgesics and right-sided sacroiliac joint steroid injection did not provide significant relief. Given her lack of improvement and the fact that her pain localized to the right sacrum, the patient underwent CT-guided sacroplasty for treatment of a painful right sacral hemangioma. Under CT fluoroscopic guidance, a 10 gauge introducer needle was advanced through the soft tissues of the back to the margin of the lesion. Biopsy was then performed and after appropriate preparation, cement was then introduced through the needle using a separate cement filler cannula. Appropriate filling of the right sacral hemangioma was visualized using intermittent CT fluoroscopy. After injection of approximately 2.5 cc of cement, it was felt that there was near complete filling of the right sacral hemangioma. With satisfactory achievement of cement filling, the procedure was terminated. Pathology from biopsy taken at the time of the procedure was consistent with hemangioma. Image-guided sacroplasty with well-defined endpoints is an effective, minimally invasive and safe procedure. Patients with painful sacral hemangiomas can be treated with this technique with no significant complications.