Tracheal compression caused by an innominate artery aneurysm after thoracic aortic aneurysm repair in a patient with Marfan disease

A 43-year-old man was admitted to the intensive care unit because of weaning impairment. His medical history revealed hypertension, marfan disease, bentall procedure, partial aortic arch replacement, and replacement of the aortic arch with bypasses to the left common carotid, proximal innominate, and left subclavian arteries. Now a thoracoabdominal aortic aneurysm (crawford extent ii) with dissection necessitated aortic replacement from the previous graft to the iliac bifurcation. Extubation attempts early after surgical intervention failed. After transfer to the intensive care unit, weaning was impaired by desaturation caused by sputum retention. Resistance during advancement of a suction tube into the trachea was noted. Bronchoscopy showed 90% stenosis caused by external compression. A computed tomographic (ct) scan (figure 1) visualized tracheal compression between the spinal column and the aneurysmatic innominate artery (maximal diameter of 3 cm). During reoperation, the innominate artery aneurysm was excluded, new bypasses to the right carotid and subclavian arteries were constructed, and fibrotic tissue compromising the patency of the trachea was transected. During the operation (positive-pressure ventilation), bronchoscopy revealed spontaneous deployment and a fully patent lumen. Five days postoperatively, bronchoscopy during spontaneous breathing (zero positive pressure) revealed tracheomalacia and a remaining stenosis of 60%. Several hours after extubation, coughing and increased inspiratory effort resulted in desaturation and stridor. Reintubation was necessary for another week. After 14 days, the patient was discharged from the hospital without stridor or dyspnea. A ct scan performed after 5 months showed persistent tracheomalacia with a diameter reduction of approximately 60% (figure 2). The patient was free of symptoms.download full-size imagefigure 1. Ct scan of the cervical region showing 90% tracheal stenosis caused by compression of the trachea between the spinal column and the aneurysmatic innominate artery (Ø 3 cm)

Gas within the wall of the stomach due to emphysematous gastritis: case report and review

Gas within the wall of the stomach due to emphysematous gastritis: case report and review. van Mook WN, van der Geest S, Goessens ML, Schoon EJ, Ramsay G. Department of Intensive Care, University Hospital Maastricht, PO Box 5800, 6202 AZ Maastricht, The Netherlands. [email protected] Emphysematous gastritis is a rare variant of phlegmonous gastritis due to invasion of the stomach wall by gas-forming bacteria. We present a case of emphysematous gastritis in a 66-year-old woman admitted with septicaemia, and a review of gas in the wall of the stomach is given with focus on emphysematous gastriti

Human intestinal spirochaetosis: any clinical significance?

Contains fulltext : 58281.pdf (publisher's version ) (Closed access)Spirochaetes are well known causative agents of diarrhoea in veterinary medicine. In human medicine the relationship between presence of spirochaetes in the colon on the one hand, and its clinical significance on the other, is far less clear. In the majority of cases the colonization of the colon with these micro-organisms seems to represent a commensal relationship with the host, and is almost always a coincidental finding with no association with the clinical symptoms of the patient whatsoever. Very infrequently the organism may become invasive. In this article the literature on human intestinal spirochaetosis is reviewed, and key points for daily clinical practice are emphasized

Peripartum cardiomyopathy: a condition intensivists should be aware of

Peripartum cardiomyopathy: a condition intensivists should be aware of. de Beus E, van Mook WN, Ramsay G, Stappers JL, van der Putten HW. Department of Intensive Care Medicine, University Hospital Maastricht, PO Box 5800, 6202 AZ, Maastricht, The Netherlands. We use an illustrative case of severe peripartum cardiomyopathy with congestive heart failure to introduce this topic and proceed to cover its pathophysiology, incidence, management and outcome

Influence of antibiotic therapy on the cytological diagnosis of ventilator-associated pneumonia

OBJECTIVE: To assess the influence of antibiotics on the value of various cytological parameters, and their combinations, in diagnosing ventilator-associated pneumonia (VAP). DESIGN: Prospective study. SETTING: The general intensive care unit (17 beds) of the University Hospital Maastricht. PATIENTS: Three hundred and thirty-five episodes of clinically suspected VAP (defined by the clinical and radiological criteria previously described by Bonten et al.) in 282 patients were studied. INTERVENTIONS: No additional interventions were conducted. MEASUREMENTS AND RESULTS: Bronchoalveolar lavage fluid cytology included a total cell count per millilitre, differential cell count and the percentage of infected cells (cells containing phagocytised organisms). Antibiotic therapy from 72 h prior to lavage was recorded. Areas under the curve (AUCs) of receiver operating characteristic curves were calculated for various cytological parameters and their combinations, in patients with and without antibiotic therapy. In 126 episodes (37.6%) in 106 patients, VAP was confirmed. There was no difference in AUCs between patients with and without antibiotic therapy for any parameter studied. The most prominent AUCs were (for patient groups with and without antibiotics combined): total cell count, 0.65; percentage polymorphonuclear neutrophils, 0.71; and percentage infected cells, 0.90. The combination of percentage infected cells with any other cytological parameter did not increase the AUC. CONCLUSION: Antibiotic therapy did not influence the predictive value of the percentage infected cells in BALF in diagnosing VAP

Prediction of time of death after withdrawal of life-sustaining treatment in potential donors after cardiac death*

OBJECTIVE: Organ donation after cardiac death increases the number of donor organs. In controlled donation after cardiac death donors, the period between withdrawal of life-sustaining treatment and cardiac arrest is one of the parameters used to assess whether organs are suitable for transplantation. The objective of this study was to identify donation after cardiac death donor characteristics that affect the interval between withdrawal of life-sustaining treatment and cardiac death. DESIGN: Prospective multicenter study of observational data. PATIENTS: All potential donation after cardiac death donors in The Netherlands between May 2007 and June 2009 were identified. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 242 potential donation after cardiac death donors, 211 entered analysis, 76% of them died within 60 mins, and 83% died within 120 mins after withdrawal of life-sustaining treatment. The median time to death was 20 mins (range 1 min to 3.8 days). Controlled mechanical ventilation, use of norepinephrine, absence of reflexes, neurologic deficit as cause of death, and absence of cardiovascular comorbidity were associated with death within 60 and 120 mins. The use of analgesics, sedatives, or extubation did not significantly influence the moment of death. In the multivariable logistic regression analysis, controlled mechanical ventilation remained a risk factor for death within 60 mins, and norepinephrine administration and absence of cardiovascular comorbidity remained risk factors for death within 120 mins. The clinical judgment of the intensivist predicted death within 60 and 120 mins with a sensitivity of 73% and 89%, respectively, and a specificity of 56% and 25%, respectively. CONCLUSION: Despite the identification of risk factors for early death and the additional value of the clinical judgment by the intensivist, it is not possible to reliably identify potential donation after cardiac death donors who will die within 1 or 2 hrs after life-sustaining treatment has been withdrawn. Consequently, a donation procedure should be initiated in every potential donor

[Cross-border healthcare: EU citizens as patients].

With the free movement of people within the European Union (EU), it occurs that EU citizens need healthcare in and different country, other than their country of origin. Identification of patients is important, and the EU is currently implementing a digital Patient Summary to provide physicians with essential information concerning an European patient. Physicians should be aware that the obligation concerning informed consent carries extra weight for patients with a language barrier. A professional interpreter can facilitate bridging this linguistic barrier. All patients who die within the Netherlands are subject to Dutch legislation on organ donation. The reimbursement of care is regulated within the EU by Regulations (No 883/2004 and No 987/2009) and the Directive on the application of patients' rights in cross-border healthcare. In principle, unplanned care is always reimbursed, whereas planned clinical care requires permission from the patient's health insurer

Intensive care medicine trainees' perception of professionalism: a qualitative study.

Item does not contain fulltextThe Competency-Based Training program in Intensive Care Medicine in Europe identified 12 competency domains. Professionalism was given a prominence equal to technical ability. However, little information pertaining to fellows' views on professionalism is available. A nationwide qualitative study was performed. The moderator asked participants to clarify the terms professionalism and professional behaviour, and to explore the questions "How do you learn the mentioned aspects?" and "What ways of learning do you find useful or superfluous?". Qualitative data analysis software (MAXQDA2007) facilitated analysis using an inductive coding approach. Thirty-five fellows across eight groups participated. The themes most frequently addressed were communication, keeping distance and boundaries, medical knowledge and expertise, respect, teamwork, leadership and organisation and management. Medical knowledge, expertise and technical skills seem to become more tacit when training progresses. Topics can be categorised into themes of workplace-based learning, by gathering practical experience, by following examples and receiving feedback on action, including learning from own and others' mistakes. Formal teaching courses (e.g. communication) and scheduled sessions addressing professionalism aspects were also valued. The emerging themes considered most relevant for intensivists were adequate communication skills and keeping boundaries with patients and relatives. Professionalism is mainly learned 'on the job' from role models in the intensive care unit. Formal teaching courses and sessions addressing professionalism aspects were nevertheless valued, and learning from own and others' mistakes was considered especially useful. Self-reflection as a starting point for learning professionalism was stressed.1 januari 201