Sympathetic hyperactivity syndrome following cerebral fat embolization

To date, there have been no reports of paroxysmal sympathetic hyperactivity syndrome (PSHS) associated with cerebral fat embolization. We describe the case of a young male who developed acute brain injury and acute hypoxemic respiratory failure secondary to significant fat embolization following a traumatic femur injury. Our patient demonstrated episodes of significant hypertension, tachycardia, fever and extensor posturing. Extensive evaluation lead to the diagnosis and appropriate treatment for PSHS. Ultimately, the patient went on to have a good neurologic recovery after a prolonged hospitalization. We will discuss PSHS diagnostic criteria, pathophysiology and treatment options. This diagnosis should be considered in all brain-injured patients with paroxysms of autonomic instability and abnormal movements

Sympathetic hyperactivity syndrome following cerebral fat embolization

To date, there have been no reports of paroxysmal sympathetic hyperactivity syndrome (PSHS) associated with cerebral fat embolization. We describe the case of a young male who developed acute brain injury and acute hypoxemic respiratory failure secondary to significant fat embolization following a traumatic femur injury. Our patient demonstrated episodes of significant hypertension, tachycardia, fever and extensor posturing. Extensive evaluation lead to the diagnosis and appropriate treatment for PSHS. Ultimately, the patient went on to have a good neurologic recovery after a prolonged hospitalization. We will discuss PSHS diagnostic criteria, pathophysiology and treatment options. This diagnosis should be considered in all brain-injured patients with paroxysms of autonomic instability and abnormal movements

Customized Reference Ranges for Laboratory Values Decrease False Positive Alerts in Intensive Care Unit Patients

<div><p>Background</p><p>Traditional electronic medical record (EMR) interfaces mark laboratory tests as abnormal based on standard reference ranges derived from healthy, middle-aged adults. This yields many false positive alerts with subsequent alert-fatigue when applied to complex populations like hospitalized, critically ill patients. Novel EMR interfaces using adjusted reference ranges customized for specific patient populations may ameliorate this problem.</p><p>Objective</p><p>To compare accuracy of abnormal laboratory value indicators in a novel vs traditional EMR interface.</p><p>Methods</p><p>Laboratory data from intensive care unit (ICU) patients consecutively admitted during a two-day period were recorded. For each patient, available laboratory results and the problem list were sent to two mutually blinded critical care experts, who marked the values about which they would like to be alerted. All disagreements were resolved by an independent super-reviewer. Based on this gold standard, we calculated and compared the sensitivity, specificity, positive and negative predictive values (PPV, NPV) of customized vs traditional abnormal value indicators.</p><p>Results</p><p>Thirty seven patients with a total of 1341 laboratory results were included. Experts’ agreement was fair (kappa = 0.39). Compared to the traditional EMR, custom abnormal laboratory value indicators had similar sensitivity (77% vs 85%, P = 0.22) and NPV (97.1% vs 98.6%, P = 0.06) but higher specificity (79% vs 61%, P<0.001) and PPV (28% vs 11%, P<0.001).</p><p>Conclusions</p><p>Reference ranges for laboratory values customized for an ICU population decrease false positive alerts. Disagreement among clinicians about which laboratory values should be indicated as abnormal limits the development of customized reference ranges.</p></div

Normal and abnormal Laboratory Values displayed by both Interfaces subclassified according to Gold Standard Judgment.

<p>Percentage of true positive (TP), false positive (FP), true negative (TN) and false negative (FN) values shown relative to the total number of laboratory values displayed by each interface as percent (number). Truly abnormal laboratory test results (TP) commonly signal health-care providers the need to take action with regards to their patients’ health status. Laboratory values falsely indicated as abnormal (FP) represent in this sense a distraction or “noise” clouding this important “signal”. While an abnormal value in the traditional interface reflects a true abnormality in roughly 1 out of 9 times this “signal-to-noise ratio” is 1 in 4 (i.e. more than twice as high) in the novel interface.</p

Studyflow and Results.

<p>Sensitivity, Specificity, Positive and Negative Predictive Values (PPV, NPV) are given as estimate (95%-Confidence Interval). Only specificity and negative predictive values differed significantly (for details see text).</p