Israel Medical Association Journal

Reversible cerebral vasoconstriction syndrome (RCVS) comprises a group of conditions characterized by reversible vasoconstrictions of cerebral arteries. Clinical manifestations include sudden-onset severe headaches with or without additional neurologic signs and symptoms [1].

The incidence of RCVS is 2.7 cases per million adults. It predominantly affects women, and about 9% of all RCVS cases occur during the postpartum period [2,3]. Other possible precipitating factors, such as subarachnoid hemorrhage, ischemic stroke, intracranial hemorrhage, and exposure to vasoactive drugs, have also been reported in association with RCVS [2]. The exact pathophysiology of RCVS is not well understood, although hormonal influences have been suggested as possible contributing factors.

Alkalosis-induced cerebral vasoconstriction is described but not well understood. Hyperventilation is commonly used in neurologic patients to decrease intracranial pressure and cerebral blood flow. Hyperventilation causes cerebral vasoconstriction directly by hypocapnia and may indirectly affect through alkalosis.

We present a case of RCVS in a postpartum patient admitted to the intensive care unit (ICU) with severe metabolic alkalosis necessitating hemodialysis.

Background: The authors describe a multifaceted cross-infection control program that was implemented to contain an epidemic of multidrug-resistant microorganisms (MRO) (carbapenem resistant Pseudomonas aeruginosa and Acinetobacter baumannii; extended spectrum β-lactamase producing Klebsiella pneumoniae, Escherichia coli, Enterobacter Cloacae, and Proteus mirabilis; and ‎methicillin-resistant Staphylococcus aureus and Candida species). 

Objectives: To assess the effect of a control program on the incidence of cross-infection with MRO.

Methods: Clinical criteria triaged patients into a high-risk wing (HRW) or a low-risk wing (LRW). Strict infection control measures were enforced; violations led to group discussions (not recorded). Frequent cultures were obtained, and use of antibiotics was limited. Each quarter, the incidence of MRO isolation was reported to all staff members. 

Results: Over a 6 year period, 1028 of 3113 patients were placed in the HRW. The incidence of MRO isolation within 48 hours of admission was 8.7% (HRW) vs. 1.91% (LRW) (P < 0.001). Acquired MRO infection density was 30.4 (HRW) vs. 15.6 (LRW) (P < 0.009). After the second year, the incidence of group discussions dropped from once or twice a month to once or twice a year.

Conclusions: These measures contained epidemics. Clinical criteria successfully triaged HRW from LRW patients and reduced cross-infection between the medical center wings. The quarterly reports of culture data were associated with improved staff compliance. MRO epidemic control with limited resources is feasible. 

 

Background: Optimal oxygen supply is the cornerstone of the management of critically ill patients after extubation, especially in patients at high risk for extubation failure. In recent years, high flow oxygen system devices have offered an appropriate alternative to standard oxygen therapy devices such as conventional face masks and nasal prongs.

Objectives: To assess the clinical effects of high flow nasal cannula (HFNC) compared with standard oxygen face masks in Intensive Care Unit (ICU) patients after extubation.

Methods: We retrospectively analyzed 67 consecutive ventilated critical care patients in the ICU over a period of 1 year. The patients were allocated to two treatment groups: HFNC (34 patients, group 1) and non-rebreathing oxygen face mask (NRB) (33 patients, group 2). Vital respiratory and hemodynamic parameters were assessed prior to extubation and 6 hours after extubation. The primary clinical outcomes measured were improvement in oxygenation, ventilation-free days, re-intubation, ICU length of stay, and mortality.

Results: The two groups demonstrated similar hemodynamic patterns before and after extubation. The respiratory rate was slightly elevated in both groups after extubation with no differences observed between groups. There were no statistically significant clinical differences in PaCO₂. However, the use of HFNC resulted in improved PaO₂/FiO₂ post-extubation (P < 0.05). There were more ventilator-free days in the HFNC group (P < 0.05) and fewer patients required re-intubation (1 vs. 6). There were no differences in ICU length of stay or mortality.

Conclusion: This study demonstrated better oxygenation for patients treated with HFNC compared with NRB after extubation. HFNC may be more effective than standard oxygen supply devices for oxygenation in the post-extubation period.

Objective: To report our experience with terlipressin treatment for facilitation of transport to distant facilities for diagnostic or therapeutic procedures in septic patients treated with norepinephrine.

Methods:  We conducted a retrospective analysis of the records of our ICU[1], identifying the patients with septic shock who required norepinephrine for hemodynamic support.

Results: Terlipressin was given to 30 septic shock patients (15 females and 15 males) who were on high dose norepinephrine (10 μg/min or more) in order to facilitate their transport outside the ICU. The dose of terlipressin ranged from 1 to 4 mg, with a mean of 2.13 ± 0.68 mg. The dose of norepinephrine needed to maintain systolic blood pressure above 100 mmHg decreased following terlipressin administration, from 21.9 ± 10.4 μg/min (range 5–52 μg/min) to 1.0 ± 1.95 (range 0–10) (P < 0.001). No patients required norepinephrine dose adjustment during transport. No serious complications or overshoot in blood pressure values were observed following terlipressin administration. Acrocyanosis occurred only in eight patients receiving more than 1 mg of the drug. The overall mortality rate was 50%.

Conclusions: Our data suggest that terlipressin is effective in septic shock. Because it is long-acting and necessitates less titration it might be indicated for patient transportation.