Fulminant Cerebral Fat Embolism: Case Description and Review of the Literature

The release of fat and bone marrow fragments is a common occurrence following traumatic and nontraumatic events. In most cases, they go symptomless or cause only minor disturbances, but occasionally they can determine a multiorgan dysfunction whose severity ranges from mild to fatal. The authors describe the case of a patient who became deeply comatose and ultimately died after a traffic accident in which he suffered the exposed right femoral and tibial fracture in the absence of other injuries. He underwent the external fixation of the fractured bones 2 hours after the admission under general anesthesia. Three hours later, he failed to awake at the suspension of the anesthetic agents and became anisocoric; a CT scan demonstrated a diffuse cerebral edema with the herniation of the cerebellar tonsils; these abnormalities were unresponsive to the treatment and the brain death was one day later. The causes, the mechanisms, the symptoms, the prevention, and the treatment of the syndrome are reviewed and discussed

The Conundrum of Septic Shock Imitators in Patients with Hematologic Cancers: Case Presentation and Possible Differential Diagnoses

The authors describe the case of a patient treated with several cycles of chemotherapy due to an advanced stage non-Hodgkin lymphoma. One daafter the last cycle, he was admitted to our Intensive Care Unit with a septic shock-like clinical picture which didn't respond to the aggressive treatment and the patient died a few hours later. The autoptical findings cast some doubts on the diagnosis, and demonstrated the presence of other factors imitating its symptoms. In this article, the mimickers of septic shock are reviewed and discussed, as some of them require an aggressive immunosuppression instead of the recommended treatment for septic shock

Fatal Septic Shock in a Patient with Hemophagocytic Lymphohistiocytosis Associated with an Infectious Mononucleosis

6noThe authors describe the case of a young woman who developed a clinical pictures resembling a septic shock-related multiple organ dysfunction syndrome a couple of months after having been diagnosed suffering from a hemophagocytic lymphohistiocytosis associated with an infectious mononucleosis. Despite the aggressive treatment, which included antibiotics, vasopressors, IV immunoglobulins, and the use of an extracorporeal device aimed to remove mediators released both during sepsis and the cytokine storm determined by the hemophagocytic lymphohistiocytosis, the patient died. At the autopsy, an extremely uncommon aggressive lymphoma of Epstein-Barr virus-positive T-lymphocytes with systemic involvement was discovered.openopenBerlot, Giorgio; Tomasini, Ariella; Zandonà, Lorenzo; Leonardo, Eugenio; Bussani, Rossana; Zarrillo, NadiaBerlot, Giorgio; Tomasini, Ariella; Zandonà, Lorenzo; Leonardo, Eugenio; Bussani, Rossana; Zarrillo, Nadi

Regional citrate-calcium anticoagulation during polymyxin-B hemoperfusion: A case series

Introduction: So far, only heparin-based anticoagulation has been proposed during polymyxin-B hemoperfusion. However, postsurgical septic patients can be at high risk of bleeding due to either surgical complications or septic coagulation derangement. Consequently, heparin should not represent in some cases the anticoagulation regimen of choice in this type of patients. Methods and results: We present a case series of four postsurgical septic patients treated with polymyxin-B hemoperfusion using regional citrate anticoagulation. All the treatments were performed without complications. During each treatment, there were no episodes of filter clotting, no bleeding, and no metabolic complications for any of the patients. Conclusion: To our knowledge, this is the second published report on the use of citrate anticoagulation during polymyxin-B hemoperfusion. Our case series continued to show that regional citrate anticoagulation regimen is feasible and safe during polymyxin-B hemoperfusion treatment in postsurgical septic patients

Polymyxin-B hemoperfusion in septic patients: analysis of a multicenter registry

Background: In 2010, the EUPHAS 2 collaborative group created a registry with the purpose of recording data from critically ill patients suffering from severe sepsis and septic shock treated with polymyxin-B hemoperfusion (PMX-HP) for endotoxin removal. The aim of the registry was to verify the application of PMX-HP in the daily clinical practice. Methods: The EUPHAS 2 registry involved 57 centers between January 2010 and December 2014, collecting retrospective data of 357 patients (297 in Europe and 60 in Asia) suffering from severe sepsis and septic shock caused by proved or suspected infection related to Gram negative bacteria. All patients received atleast one cycle of extracorporeal endotoxin removal by PMX-HP. Results: Septic shock was diagnosed in 305 (85.4 %) patients. The most common source of infection was abdominal (44.0 %) followed by pulmonary (17.6 %). Gram negative bacteria represented 60.6 % of the pathogens responsible of infection. After 72 h from the first cycle of PMX-HP, some of the SOFA score components significantly improved with respect to baseline: cardiovascular (2.16 \ub1 1.77 from 3.32 \ub1 1.29, p < 0.0001), respiratory (1.95 \ub1 0.95 from 2.40 \ub1 1.06, p < 0.001) and renal (1.84 \ub1 1.77 from 2.23 \ub1 1.62, p = 0.013). Overall 28-day survival rate was 54.5 % (60.4 % in abdominal and 47.5 % in pulmonary infection). Patients with abdominal infection treated with PMX-HP within 24 h from the diagnosis of septic shock had a 28-day survival rate of 64.5 %. Patients showing a significantly cardiovascular improvement after PMX-HP had a 28-survival rate of 75 % in comparison to the 39 % of patients who did not (p < 0.001). Cox regression analysis found the variation of cardiovascular, respiratory and coagulation SOFA to be independent covariates for 28-day survival. In European patients were observed a higher 28-day (58.8 vs. 34.5 %, p = 0.003), ICU (59 vs. 36.7 %, p = 0.006) and hospital survival rate (53.2 vs. 35 %, p = 0.02) than in Asian patients. However, the two populations were highly heterogeneous in terms of source of infection and severity scores at admission. Conclusion: The EUPHAS 2 is the largest registry conducted outside Japan on the clinical use of PMX-HP in septic patients. Data analysis confirmed the feasibility of PMX-HP to treat septic patients in daily clinical practice, showing clinical benefits associated with endotoxin removal without significant adverse events related to the extracorporeal technique