[Intermediate-high risk pulmonary embolism: identification and treatment].

Patients with intermediate-high risk pulmonary embolism have a different mix of clinical symptoms. Optimal treatment of patients with intermediate high-risk pulmonary embolism is necessary to prevent short-term mortality. According to the current guidelines, the use of standard coagulation is the treatment of choice in hemodynamic stable patients with intermediate-high risk pulmonary embolism.

Suboptimal plasma concentrations with posaconazole suspension as prophylaxis in critically ill COVID-19 patients at risk of Covid-associated pulmonary aspergillosis.

What Is Known And Objective: The safety and efficacy of different antifungal agents in the prophylaxis of invasive fungal infection in patients with haematological disorders are known. We comment on the poor bioavailability of posaconazole suspension to suggest that it is not useful in critically ill COVID patients.

Comment: The increased mortality and high incidence of COVID-associated pulmonary aspergillosis (CAPA) might justify administration of off-label posaconazole for preventing CAPA, being the only drug officially registered for prophylaxis of fungal infections.

Successful treatment of fulminant postoperative bleeding due to acquired haemophilia.

Acquired haemophilia is a rare but life-threatening phenomenon in patients who have undergone surgical treatment. We describe a patient with a history of pancreatic cancer and a conventional pancreaticoduodenectomy, who underwent elective resection of an enterocutaneous fistula, complicated by fulminant haemorrhagic shock, caused by acquired haemophilia A. Eventually, the bleeding was controlled by a combination of aggressive haemostatic and immunosuppressive therapy.

Electroencephalogram predicts outcome in patients with postanoxic coma during mild therapeutic hypothermia.

Objective: To assess the value of electroencephalogram for prediction of outcome of comatose patients after cardiac arrest treated with mild therapeutic hypothermia.

Design: Prospective cohort study.

Setting: Medical ICU.

Pulmonary leucostasis syndrome presented by unilateral pulmonary infiltrates.

A 48-year-old woman presented with suspected acute myelogenous leukaemia with a leucocyte count of 80×10(9)/L. On admission, she had high fever and shortness of breath. Chest X-ray demonstrated unilateral consolidations of right lung suggestive for pneumonia and broad spectrum antibiotics were started.

Mixed venous O2 saturation and fluid responsiveness after cardiac or major vascular surgery.

Background: It is unclear if and how SvO2 can serve as an indicator of fluid responsiveness in patients after cardiac or major vascular surgery.

Methods: This was a substudy of a randomized single-blinded clinical trial reported earlier on critically ill patients with clinical hypovolemia after cardiac or major vascular surgery. Colloid fluid loading was done for 90 min, guided by changes in pulmonary artery occlusion pressure (PAOP) or central venous pressure (CVP).

Global end-diastolic volume increases to maintain fluid responsiveness in sepsis-induced systolic dysfunction.

Background: Sepsis-induced cardiac dysfunction may limit fluid responsiveness and the mechanism thereof remains unclear. Since cardiac function may affect the relative value of cardiac filling pressures, such as the recommended central venous pressure (CVP), versus filling volumes in guiding fluid loading, we studied these parameters as determinants of fluid responsiveness, according to cardiac function.

Methods: A delta CVP-guided, 90 min colloid fluid loading protocol was performed in 16 mechanically ventilated patients with sepsis-induced hypotension and three 30 min consecutive fluid loading steps of about 450 mL per patient were evaluated.

Volume-limited versus pressure-limited hemodynamic management in septic and nonseptic shock.

Objectives: To evaluate the effect of hemodynamic management guided by upper limits of cardiac filling volumes or pressures on durations of mechanical ventilation and lengths of stay in critically ill patients with shock.

Design: Prospective, randomized, clinical trial.

Setting: Mixed intensive care unit of a large teaching hospital and mixed intensive care unit of a tertiary care, academic medical center.

Use of synthetic colloids in sepsis: a critical review on efficacy, safety and patient benefits.

In this narrative review, the studies and analyses are discussed that pertain to benefits and detriments of synthetic colloids versus natural colloids or crystalloids used for fluid resuscitation in sepsis and septic shock. The relative amount of fluid infusions used to reach clinical or hemodynamic end-points are reviewed, as well as potential toxicity of starch solutions on the kidney. Hence, it cannot be excluded that adverse effects partly offset beneficial hemodynamic effects that are similar to that of natural colloids, so that in most analyses a mortality benefit of synthetic colloid fluid resuscitation in sepsis and septic shock cannot be demonstrated.

Cardiac filling volumes versus pressures for predicting fluid responsiveness after cardiovascular surgery: the role of systolic cardiac function.

Introduction: Static cardiac filling volumes have been suggested to better predict fluid responsiveness than filling pressures, but this may not apply to hearts with systolic dysfunction and dilatation. We evaluated the relative value of cardiac filling volume and pressures for predicting and monitoring fluid responsiveness, according to systolic cardiac function, estimated by global ejection fraction (GEF, normal 25 to 35%) from transpulmonary thermodilution.

Methods: We studied hypovolemic, mechanically ventilated patients after coronary (n = 18) or major vascular (n = 14) surgery in the intensive care unit.

Greater cardiac response of colloid than saline fluid loading in septic and non-septic critically ill patients with clinical hypovolaemia.

Background And Objective: The haemodynamics of crystalloid and colloid fluid loading may depend on underlying disease, i.e. sepsis versus non-sepsis.

Hepatosplanchnic ischemia/reperfusion is a major determinant of lung vascular injury after aortic surgery.

Objectives: To study risk factors, including the level of cross-clamping and ischemia/reperfusion, for lung vascular injury after aortic surgery.

Design: Single-center prospective observational study.

Patients And Methods: Twenty-seven consecutive and mechanically ventilated patients were included within 3 h after elective aortic surgery, i.

Acute refractory hyperkalaemia and fatal cardiac arrest related to administration of liposomal amphotericin B.

A 36-year-old male with acute myeloid leukaemia was treated with liposomal amphotericin B for a breakthrough fungal infection with Absidia corymbifera during voriconazole and caspofungin therapy for invasive pulmonary aspergillosis. Four episodes of hyperkalaemia developed with a highly probable relation to infusion of liposomal amphotericin B, of which the last episode was characterised by severe, refractory hyperkalaemia and fatal cardiac arrest. The available literature on severe hyperkalaemia and cardiac arrest during administration of both conventional and liposomal amphotericin B is reviewed here and revealed only four similar cases.

Relative value of pressures and volumes in assessing fluid responsiveness after valvular and coronary artery surgery.

Background And Aims: Cardiac function may differ after valvular (VS) and coronary artery (CAS) surgery and this may affect assessment of fluid responsiveness. The aim of the study was to compare VS and CAS in the value of cardiac filling pressures and volumes herein.

Methods: There were eight consecutive patients after VS and eight after CAS, with femoral and pulmonary artery catheters in place.

Spontaneous remission of acute myeloid leukaemia after recovery from sepsis.

Spontaneous remission of acute myeloid leukaemia (AML) is extremely rare and usually of short duration. We report two patients with documented AML who developed spontaneous remission of their leukaemia shortly after an episode of severe sepsis and respiratory failure requiring mechanical ventilation. The underlying mechanisms of spontaneous remission remain unclear but an association with preceding blood transfusions and severe systemic infections has been reported.

Management of invasive pulmonary aspergillosis in non-neutropenic critically ill patients.

During recent years, a rising incidence of invasive pulmonary aspergillosis (IPA) in non-neutropenic critically ill patients has been reported. Critically ill patients are prone to develop disturbances in immunoregulation during their stay in the ICU, which render them more vulnerable for fungal infections. Risk factors such as chronic obstructive pulmonary disease (COPD), prolonged use of steroids, advanced liver disease, chronic renal replacement therapy, near-drowning and diabetes mellitus have been described.

Transpulmonary dilution-derived extravascular lung water as a measure of lung edema.

Purpose Of Review: This review highlights current insights concerning the (measurement of) extravascular lung water as an index of pulmonary edema, by transpulmonary dilution techniques. The focus is on the applicability of the technique at the bedside in monitoring critically ill patients.

Recent Findings: Several (animal) studies have been performed to validate the technique by postmortem gravimetry in different conditions.

Biomarkers of acute renal injury and renal failure.

Acute renal failure (ARF) is a frequent problem in the intensive care unit and is associated with a high mortality. Early recognition could help clinical management, but current indices lack sufficient predictive value for ARF. Therefore, there might be a need for biomarkers in detecting renal tubular injury and/or dysfunction at an early stage before a decline in glomerular filtration rate is noted by an increased serum creatinine.

[Life threatening hyperkalemia: the value of the electrocardiogram].

In two men, aged 19 and 64, with chronic renal insufficiency and subacute symptoms of malaise and weakness of the leg muscles, broad QRS complexes were seen in the ECG. The younger patient developed an asystole and resuscitation was unsuccessful. His blood potassium level was found to be 8.