Critical Care

Last 50 Critical Care Postings

(Click on title to be directed to posting, most recent listed first, CME offerings in Bold)

Management of Life Threatening Post-Partum Hemorrhage with HBOC-201 
   in a Jehovah’s Witness
Tracheal Stoma Necrosis: A Case Report
April 2017 Critical Care Case of the Month
March 2017 Critical Care Case of the Month
Ultrasound for Critical Care Physicians: Unchain My Heart
February 2017 Critical Care Case of the Month
January 2017 Critical Care Case of the Month
December 2016 Critical Care Case of the Month
Ultrasound for Critical Care Physicians: A Pericardial Effusion of Uncertain 
   Significance
Corticosteroids and Influenza A associated Acute Respiratory Distress 
   Syndrome
November 2016 Critical Care Case of the Month
October 2016 Critical Care Case of the Month
September 2016 Critical Care Case of the Month
Ultrasound for Critical Care Physicians: Unraveling a Rapid Drop of 
   Hematocrit
Fluid Resuscitation for Septic Shock – A 50-Year Perspective:
   From Dogma to Skepticism
August 2016 Critical Care Case of the Month
Ultrasound for Critical Care Physicians: Complication of a Distant
   Malignancy
July 2016 Critical Care Case of the Month
Ultrasound for Critical Care Physicians: Now My Heart Is Still 
   Somewhat Full
June 2016 Critical Care Case of the Month
May 2016 Critical Care Case of the Month
Design of an Electronic Medical Record (EMR)-Based Clinical Decision
   Support System to Alert Clinicians to the Onset of Severe Sepsis
April 2016 Critical Care Case of the Month
Ultrasound for Critical Care Physicians: Two’s a Crowd
March 2016 Critical Care Case of the Month
February 2016 Critical Care Case of the Month
Ultrasound for Critical Care Physicians: Hungry Heart
January 2016 Critical Care Case of the Month
Ultrasound for Critical Care Physicians: The Pleura and the Answers that 
   Lie Within
December 2015 Critical Care Case of the Month
Ultrasound for Critical Care Physicians: 50 Ways to Line Your Liver
November 2015 Critical Care Case of the Month
Ultrasound for Critical Care Physicians: The Martian
October 2015 Critical Care Case of the Month: A Moldy But Gooey
Ultrasound for Critical Care Physicians: Shortness of Breath
September 2015 Critical Care Case of the Month: If You Don't Look, 
   You Won't Find 
August 2015 Critical Care Case of the Month: A Diagnostic Branch 
   of Medicine
Ultrasound for Critical Care Physicians: Take a Deep Breath
July 2015 Critical Care Case of the Month: An Unusual Presentation 
June 2015 Critical Care Case of the Month: Just Ask the Nurse
Acute Pregabalin Withdrawal: A Case Report and Review of the Literature
Organ Failure in Acute Pancreatitis and Its Impact on Outcome in Critical
   Care
Ultrasound for Critical Care Physicians: Tiny Bubbles
May 2015 Critical Care Case of the Month: An Infected Leg
April 2015 Critical Care Case of the Month: Half-Sided Light House
March 2015 Critical Care Case of the Month: It’s Not Always Sepsis
Ultrasound for Critical Care Physicians: Now My Heart Is Even More Full
February 2015 Critical Care Case of the Month: A Bloody Mess
Physical Examination in the Intensive Care Unit: Opinions of Physicians at
   Three Teaching Hospitals
Analysis of a Fatal Left Ventricular Assist Device Infection: A Case Report
   and Discussion

 

For complete critical care listings click here.

The Southwest Journal of Pulmonary and Critical Care publishes articles directed to those who treat patients in the ICU, CCU and SICU including chest physicians, surgeons, pediatricians, pharmacists/pharmacologists, anesthesiologists, critical care nurses, and other healthcare professionals. Manuscripts may be either basic or clinical original investigations or review articles. Potential authors of review articles are encouraged to contact the editors before submission, however, unsolicited review articles will be considered.

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Friday
Apr282017

Management of Life Threatening Post-Partum Hemorrhage with HBOC-201 in a Jehovah’s Witness

Andrea Mytinger, DO1

Elyce Sheehan, MD1

Nathan Blue, MD2

Kendall P. Crookston, MD, PhD3

Ali I. Saeed, MD 4

 

1Department of Internal Medicine, 2Department of Maternal and Fetal Medicine, 3Departments of Pathology of Transfusion Medicine, and 4Divisions of Pulmonary, Sleep and Critical Care Medicine

University of New Mexico School of Medicine

Albuquerque, NM USA

 

Abstract

Background: Post-partum hemorrhage remains the leading cause of maternal mortality worldwide. The obstetrician and critical care physician should be aware of local alternative treatment options for symptomatic anemia secondary to post-partum hemorrhage in patients who cannot receive red blood cell transfusion. Transfusion may not be an option due to strong personal belief, lack of compatible blood, or blood shortage.

Case: A 21-year-old woman, gravida 1 para 1001, was transferred to a tertiary care center for management of severe post-partum hemorrhage (hemoglobin 4.2 g/dL). She had undergone emergent dilation and curettage followed by Bakri tamponade balloon placement at an outside facility. As a member of the Jehovah’s Witness faith, she refused red blood cell transfusion. HBOC-201, a bovine hemoglobin based oxygen carrier, was successfully used to reverse symptomatic, life-threatening anemia.

Conclusion:  HBOC-201 can act as a means to reverse severe end-organ damage for patients with severe post-partum hemorrhage and should be considered when no other treatment options are available.

 

Teaching Points

  1. HBOC-210 (Hemopure®) is a bovine hemoglobin-based oxygen carrier (HBOC), used as a means to reverse severe anemia in those patients who cannot receive RBC transfusion.
  2. The current generation of HBOCs carry fewer side effects than their predecessors. Common side effects include transient hypertension, abdominal complaints, jaundice, elevated liver and pancreatic enzymes and decreased urine output.
  3. The teratogenic effects of HBOC-201 remains unknown in humans.

 

Introduction

Worldwide, there are an estimated 14 million pregnancy-related hemorrhages each year and 25% of maternal mortality can be attributed to post-partum hemorrhage (1). While the majority of post-partum hemorrhage leading to acute blood loss anemia is treated with red blood cell (RBC) transfusion, there remains a significant subset of patients who are unable to receive this life-saving modality. In instances where RBC transfusion is not an option due to lack of compatible blood, blood shortage, or strong patient personal beliefs, there remain alternative options for management. We report the case of a young Jehovah’s Witness who presented with symptomatic anemia secondary to severe post-partum hemorrhage, treated successfully with an experimental protocol using HBOC-201 (Hemopure®).

 

Case

A 21-year-old female, gravida 1 para 1001, Jehovah’s Witness was transferred to a tertiary care hospital for management of post-partum hemorrhage after spontaneous vaginal delivery at 40 weeks of gestation. The patient received 3 boluses of intravenous oxytocin, 800mcg of misoprostol and 1 dose of intramuscular (IM) carboprost trimethamine. She then underwent a dilation and curettage for presumed retained products of conception. A Bakri tamponade balloon catheter (Figure 1) was placed vaginally and the patient was transferred for a higher level of care.

Figure 1.  An example illustration of the Bakri vaginal tamponade balloon, placed in the uterus in attempt to apply pressure to bleeding vessels.

 

Prior to delivery, the patient’s hemoglobin (Hb) and hematocrit (Hct) were initially 12.4 g/dL and 36.4 %, respectively, which decreased to 5.5 g/dL and 16.4%.

On arrival, the patient ‘s heart rate was 148 beats per minute while on 2L of oxygen. The blood pressure was 93/36 mmHg. She was pale and tired-appearing with conjunctival pallor.  Her abdomen exhibited generalized mild tenderness to palpation. The Bakri balloon was in place with 100 mL of drainage noted. Laboratory results revealed Hb of 4.2 g/dL, lactate of 1.2 mmol/L and troponin I of 1.820 ng/mL. The patient refused transfusion of RBC, and the other major blood products, citing her faith. After a prolonged discussion, the patient consented to the use of HBOC-201.

The patient received 2 units of HBOC-201 along with 1,000 mg of ascorbic acid. Her Hb increased from 4.2 g/dL to 4.8 g/dL, much less than the anticipated 1 g/dL increase with each unit of HBOC-201 raising concern for ongoing hemorrhage. An ultrasound was performed which revealed ongoing bleeding from the lower uterine segment behind the balloon. Methylergonovine 0.2mg IM every 6 hours was started and the patient received two additional units of HBOC-201 however, during infusion of the second unit her oxygen requirement increased from 2L by nasal cannula to 15L high flow mask at 80% FiO2. The transfusion was stopped and a chest radiograph revealed diffuse parenchymal opacities with prominent interstitial markings and small bilateral pleural effusions suggestive if fluid overload / pulmonary edema. The patient then underwent gel foam uterine artery embolization by Interventional Radiology for definitive management.

On hospital day 2 the patient’s heart rate was 114 beats per minute and Hb was 5.2 g/dL, prompting infusion of an additional 2 units of HBOC-201. Due to continued hypoxia and radiographic evidence of fluid overload, diuretic therapy was administered. Her oxygen requirement decreased to 5L by nasal cannula, however did not improve from there despite a negative fluid balance, so a CT scan of the chest was performed which revealed significant bilateral basal atelectasis. The patient’s oxygen requirement resolved with incentive spirometry. The Bakri vaginal balloon was removed and minimal bleeding was observed.

On hospital day 3 the patient’s blood pressure increased to 176/78 mmHg. This, in the setting of proteinuria, peripheral edema and elevated aspartate aminotransferase (AST) to 104 unit/L (6-58 Unit/L) raised a suspicion for post-partum preeclampsia with severe features. Intravenous magnesium sulfate was briefly initiated for seizure prophylaxis, however it was discontinued after her blood pressure stabilized and the hypertension was attributed to a possible side effect of HBOC-201.

The patient received a total of 7.5 units of HBOC-201 over the course of 4 days in the MICU. Her troponin peaked on hospital day 2 at 2.930 ng/mL, and continued to downtrend with multiple infusions of HBOC-201. The patient’s own hematocrit began rising on hospital day 5 (Figure 2).

Figure 2.  Illustration of the hemoglobin and hematocrit over the course of the patient’s hospitalization and at her first out-patient follow up visit. The arrows indicate when HBOC-201 was infused.  Troponin I is also depicted on this graph to illustrate the resolution of severe end-organ damage due to the severe anemia.

 

The patient was transferred to the obstetrics floor on hospital day 7. In accordance with recent post-partum hemorrhage recommendations, she received 1025 mg of IV iron dextran. She was discharged home in stable condition on hospital day 8 with a Hb of 6.7 g/dL and Hct of 21%. Outpatient follow-up revealed significant improvement in anemia with a Hb of 9.2 g/dL and Hct of 30% one week after discharge.

 

Discussion

Acute post-partum hemorrhage leading to severe anemia remains the leading cause of maternal death worldwide (2). While the majority of post-partum hemorrhage leading to acute blood loss anemia is treated with transfusion of packed RBC or other blood products, there are certain subsets of patients who are unable to accept these products. This case demonstrates the use of a bovine hemoglobin-based oxygen carrier in a Jehovah’s Witness patient with severe post-partum hemorrhage who refused blood products. There have been multiple case reports regarding the use of HBOC-201 in severely anemic Jehovah’s Witness patients; however, there is no published report to our knowledge on the use of HBOC-201 in patients with symptomatic post-partum hemorrhage.

Hemoglobin-based oxygen carriers were developed in response to the infectious issues associated with donor RBC and in an attempt to come up with an alternative treatment in those situations where RBC transfusion was not an option. The first generation of these products was known to cause renal toxicity and coagulopathy (3,4). HBOC-201 is a second generation HBOC that is a cell-free, stroma-free, polymerized version of bovine hemoglobin. Because it contains no cell membrane, it is compatible with all blood types (no cross matching is needed).  The shelf life is 36 months at room temperature (5) (no refrigeration or sophisticated supply network is needed). A number of randomized control trials have been done to evaluate HBOC-201 (and other similar products) as a potential RBC replacement.  However, after infusion the short 24-hour half-life and statistical increase in adverse events associated with administration made it apparent that these HBOCs were not interchangeable with RBC for routine transfusion. While they are not interchangeable, many clinicians feel that the risk-benefit profile is favorable in severely anemic patients who cannot receive RBC. HBOC-201 is not yet approved for use in the United States, and therefore cannot be used outside of clinical trials. Several compassionate use studies are available in the United States to treat patients with life-threatening anemia when no other treatment option is available. Worldwide only a few countries have approved the use of HBOC-201 (6).

The side effect profile of the second generation HBOC’s is much preferable to that of the first (4). Reported class effects of HBOC use include hypertension, esophageal dysmotility and increased risk for myocardial infarction, all of which are related to vasoconstriction secondary to increased nitric oxide scavenging in these products (5). HBOC-201 in particular, has not been reported to increase risk of myocardial infarction. Rather, it has been reported that HBOC-201 reduces cardiac hypoxia in the setting of severe anemia (7). Mongan et al. (8) found that, while HBOC-201 causes transient systemic and pulmonary hypertension in swine, blood flow to 8 major organs, including the heart, was unchanged compared to controls. Serruys et al. (9) found no significant change in coronary blood flow and no vasoconstriction in humans pre-oxygenated with HBOC-201 prior to Percutaneous Coronary Intervention for coronary artery disease. In this case, the patient presented with troponinemia, indicating type 2 demand ischemia in the setting of severe anemia. Troponin levels began to down-trend after HBOC-201 infusion.

Common side effects of HBOC-201 in particular include transient hypertension, abdominal complaints, jaundice, elevated liver and pancreatic enzymes (10) and bovine methemoglobinemia (11). To prevent the increased oxidation of infused HBOC-201 to methemoglobin, ascorbic acid is co-administered; methemoglobin levels should be monitored and treated with methylene blue should they become significantly elevated (5).

This patient did experience increased hypoxia while receiving a unit of HBOC-201 which resulted in concern for transfusion reaction and transient discontinuation of the HBOC-201 infusion. It must be noted that HBOC-201 contains no cellular or plasma components, thus many transfusion reactions such as Transfusion Related Acute Lung Injury (TRALI) are an impossibility. HBOC-201 has been associated with volume overload; as it is a colloid this is a known complication (12). Volume overload was suspected, however, the patient did not improve with diuresis, and a chest CT revealed profound atelectasis. Given that her hypoxia greatly improved with incentive spirometry and ambulation, this was deemed unlikely to be a reaction associated with HBOC-201, but rather related to being bed-bound and critically ill.

One unit of HBOC-201 will raise serum Hb from 0.5g/dL to 2g/dL (12). One to two units of HBOC-201 are typically given for Hb levels <6 g/Dl, with additional units provided to maintain a goal Hemoglobin greater than 6g/dL (11, 12). With a half-life of 19-24 hours (5, 13), HBOC-201 must be infused regularly until the patient’s bone marrow production of RBC is sufficient, as evidenced by increases in hematocrit. It should be noted that HBOC-201 will only increase serum hemoglobin and not hematocrit; an initial decrease in hematocrit may be seen after infusion secondary to hemodilution (12).

The patient presented above experienced both transient hypertension and an increase in her serum AST, raising concern for post-partum preeclampsia. She was started on treatment for severe preeclampsia, however these affects were later attributed to the HBOC-201.

HBOC-201 is currently not recommended during pregnancy. One animal study in rats indicated that HBOC-201 infusion during organogenesis resulted in decreased litter size and increased incidence of external fetal malformations. This was thought to be related to decreased function of an inverted yolk sac, the primary nutritive organ for rat pups in utero (14). Holson et al. (15) performed a similar study on dogs which did not reveal a statistically significant difference in fetal malformations or other study end-points when compared to control. Canines and humans do not have an inverted yolk sac. Thus, it has been hypothesized that teratogenic effects of HBOC-201 do not apply to humans, however, more studies are needed. At least one US expanded access study allows pregnant women with the potential of massive blood loss (e.g. those with placenta accreta, placenta percreta) to consent to the study while still pregnant. However, HBOC-201 cannot be given until after delivery.

HBOC-201 in this case was utilized as a means to reverse severe end-organ damage due to anemia. This Jehovah’s Witness patient refused blood products, citing religious beliefs. Jehovah’s Witnesses in general will not receive “primary” blood components which include red blood cells, platelets and plasma. Other components, including albumin, clotting factors and HBOCs are considered “conscience items” through the church, where-in the individual can decide for themselves if they wish to receive them (5). With an estimated 1.2 million Jehovah’s Witnesses in the United States alone, alternative treatment options for this patient population are imperative (5).

While transfusion of allogeneic blood products remains the standard of care for treatment of severe post-partum hemorrhage, there are certain situations where this is not available. These might include lack of resources in a rural setting, blood product shortages, and inability to cross-match blood products given patient antibodies or patient denial of blood products due to personal or religious beliefs. HBOC’s are currently not approved for use in the United States, however they can be used on a limited compassionate use basis with FDA IND and local IRB approval, either as part of a planned expanded use study or on an emergency approval basis. Referral to a center with an expanded use protocol should be considered for a woman with the potential for massive bleeding who cannot receive RBC.

 

References

  1. Enakpene CA, Morhason-Bello IO, Enakpene EO, Arowojolu AO, Omigbodun AO. Oral misoprostol for the prevention of primary post-partum hemorrhage during third stage of labor. J Obstet Gynaecol Res. 2007 Dec;33(6):810-7. [CrossRef] [PubMed]
  2. Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014 2(6):e323–e333.[CrossRef] [PubMed]
  3. Creteur J, Vincent JL. Hemoglobin solutions. Crit Care Med. 2003 Dec;31(12 Suppl):S698-707. [CrossRef] [PubMed]
  4. Marinaro J, Smith J, Tawil I, Billstrand M, Crookston KP. HBOC-201 use in traumatic brain injury: case report and review of literature. Transfusion. 2009 Oct;49(10):2054-9. [CrossRef] [PubMed]
  5. Epperla N, Strouse C, VanSandt AM, Foy P. Difficult to swallow: warm autoimmune hemolytic anemia in a Jehovah's Witness treated with hemoglobin concentrate complicated by achalasia. Transfusion. 2016 Jul;56(7):1801-6. [CrossRef] [PubMed]
  6. Greenburg AG, Kim HW. Hemoglobin-based oxygen carriers. Crit Care. 2004;8 Suppl 2:S61-4. [CrossRef] [PubMed]
  7. Fitzgerald MC, Chan JY, Ross AW, Liew SM, Butt WW, Baguley D, et al. A synthetic haemoglobin-based oxygen carrier and the reversal of cardiac hypoxia secondary to severe anaemia following trauma. Med J Aust. 2011 May;194(9):471-3. [PubMed]
  8. Mongan PD, Moon-Massat PF, Rentko V, Mihok S, Dragovich A, Sharma P. Regional blood flow after serial normovolemic exchange transfusion with HBOC-201 (Hemopure®) in anesthetized swine. J Trauma. 2009 Jul;67(1):51-60. [CrossRef] [PubMed]
  9. Serruys PW, Vranckx P, Slagboom T, Regar E, Meliga E, de Winter RJ, et al. Haemodynamic effects, safety, and tolerability of haemoglobin-based oxygen carrier-201 in patients undergoing PCI for CAD. EuroIntervention. 2008 Mar;3(5):600-9. [CrossRef] [PubMed]
  10. Van Hemelrijck J, Levien LJ, Veeckman L, Pitman A, Zafirelis Z, Standl T. A safety and efficacy evaluation of hemoglobin-based oxygen carrier HBOC-201 in a randomized, multicenter red blood cell controlled trial in noncardiac surgery patients. Anesth Analg. 2014 Oct;119(4):766-76. [CrossRef] [PubMed]
  11. Jordan SD, Alexander E. Bovine hemoglobin: a nontraditional approach to the management of acute anemia in a Jehovah's Witness patient with autoimmune hemolytic anemia. J Pharm Pract. 2013 Jun;26(3):257-60. [CrossRef] [PubMed]
  12. Mer M, Hodgson E, Wallis L, Jacobson B, Levien L, Snyman J, et al. Hemoglobin glutamer-250 (bovine) in South Africa: consensus usage guidelines from clinician experts who have treated patients. Transfusion. 2016 Sep. [CrossRef] [PubMed]
  13. Donahue LL, Shapira I, Shander A, Kolitz J, Allen S, Greenburg G. Management of acute anemia in a Jehovah's Witness patient with acute lymphoblastic leukemia with polymerized bovine hemoglobin-based oxygen carrier: a case report and review of literature. Transfusion. 2010 Jul;50(7):1561-7. [CrossRef]  [PubMed]
  14. Stump DG, Holson JF, Harris C, Pearce LB, Watson RE, DeSesso JM. Developmental toxicity in rats of a hemoglobin-based oxygen carrier results from impeded function of the inverted visceral yolk sac. Reprod Toxicol. 2015 Apr;52:108-17. [CrossRef] [PubMed]
  15. Holson JF, Stump DG, Pearce LB, Watson RE, DeSesso JM. Absence of developmental toxicity in a canine model after infusion of a hemoglobin-based oxygen carrier: Implications for risk assessment. Reprod Toxicol. 2015 Apr;52:101-7. [CrossRef] [PubMed] 

Cite as: Mytinger A, Sheehan E, Blue N, Crookston KP, Saeed AI. Management of life threatening post-partum hemorrhage with HBOC-201 in a Jehovah’s witness. Southwest J Pulm Crit Care. 2017;14(4):177-84. doi: https://doi.org/10.13175/swjpcc031-17 PDF

Thursday
Apr272017

Tracheal Stoma Necrosis: A Case Report

Stella Pak, MD

Arjan Flora, MD 

Young-Sook Yoon, MD

 

Department of Medicine

University of Toledo Medical Center

Toledo, OH, USA

 

Abstract

Acute tracheal dilatation, due to an overinflated cuff, has been reported early in the course of mechanical ventilation through an endotracheal tube. Tracheal stoma necrosis is a rare complication, but such can accompany acute tracheal dilation. Herein, we report a case of tracheal necrosis 9 days following tracheostomy placement in a 71-year old woman associated with overinflation of the tracheal tube cuff. This case report aims to 1) add to the scant body of knowledge about the diagnosis and management for the patients with tracheal stoma necrosis and 2) raise awareness for error-traps in interpreting diagnostic images, specifically satisfaction of search error, inattentional blindness error, and alliterative error.

Case Report

A 71-year-old woman with a history of chronic respiratory failure on mechanical ventilation presented to the emergency department for bleeding around the tracheostomy site. The tracheostomy was recently inserted 9 days prior to admission. A chest radiograph demonstrated left lower lobe atelectasis, pleural effusion, and cardiomegaly that was consistent with pre-existing congestive heart failure (Figure 1).

Figure 1. Chest radiograph (AP) performed during first admission.

 

The cuff overinflation was demonstrated as a spherical shaped hypolucent region surrounding the trachea. However, the lesion escaped attention possibly because the focus of attention was limited to the thoracic compartment. A CT of the soft tissue in the neck ruled out the possibility of hematoma or infection. However, the features suggestive of overinflation of tracheostomy tube once again escaped attention. The spherical shaped hypolucent area, representing the cuff, was 3.9 cm in the anterior-posterior axis and 3.8 cm along the right-left axis.

A fiberoptic bronchoscopy through the tracheostomy tube revealed a large blood clot obstructing the distal end of the tube. A necrotic lesion around the stoma was also found. Careful observation via the bronchoscope during the procedure revealed no tearing or rupture. The patient was conservatively treated with vancomycin and cefepime for treatment of a ventilator-associated pneumonia. The oozing of blood from the tracheostomy stopped on with conservative wound care, including cleaning and dressing. She returned back to her baseline and was subsequently discharged on 3rd day of admission. During this first admission, a tracheostomy tube exchange was not done due to bleeding from the stoma.

The patient was readmitted 12 days after discharge for an episode of hematemesis of approximately 400 mL of bright red blood. A chest radiograph showed satisfactory position of tracheotomy tube and cardiomegaly at baseline (Figure 2).

Figure 2.  Chest radiograph (AP) after readmission.

 

For the third time, the features suggestive of cuff-overinflation went unnoticed, delaying accurate diagnosis and proper treatment.

As a part of the patient’s evaluation, a CT of the chest with intravenous contrast was done, revealing the overinflated cuff of the trachea tube into the soft tissue of the neck (Figure 3).

Figure 3. Thoracic CT scan showing the overinflated tracheostomy cuff in the (A) coronal, (B) sagittal, and (C) axial views.

 

The ovoid shaped hypolucent area, representing the cuff, was 5.3 cm in the anterior-posterior axis and 4.6 cm along the right-left axis.

The Shiley proximal tracheal tube was urgently replaced with a portex Bivona tracheal tube. The new tracheostomy tube is more extensible, soft, and longer in distal length. Postoperatively, the patient was kept ventilated in the ICU. Repeated chest CT showed the new tracheostomy tube in satisfactory position and normalization of trachea shape. She made an uneventful recovery and was discharged 8 days after the tracheotomy tube replacement.

Discussion

A case of nonfatal hemorrhage due to innominate artery erosion with soft tissue necrosis at the stoma site of a tracheostomy is presented. In this ventilator-dependent patient with a recent tracheotomy stoma creation, an overinflated cuff of a tracheotomy tube was the key culprit in the pathology. Tracheal tube cuff pressure should be monitored so that it does not exceed a reasonable estimate of capillary perfusion pressure. Cuffs with pressure over 25 mmHg can compress the surrounding soft tissue, including delicate vascular structures. The damage to the vasculature in contact with the tube can result in ischemic necrosis in the soft tissue. If left untreated, these necrotic regions can develop infection or undergo fibrosis, leading to progressive stenosis (1).

A number of cognitive errors led to multiple episodes of misdiagnosis in this patient. Satisfaction of search error is a type of false negative error caused by premature termination of search after an abnormality has been detected (2). In this patient, we readily detected several abnormalities—cardiomegaly, pulmonary atelectasis, and pleural effusion. These initial findings likely led us to subconsciously neglect later findings.

Inattentional blindness error is a false negative error caused by the psychological lack of attention on an unexpected stimulus (3). In the present case, none of the diagnostic imaging was taken to check for cuff-overinflation. The images from the first admission were ordered for a concern of NG tube malposition, infection, and hematoma. The images ordered during the second admission were ordered to check the tracheotomy tube position. The thoracic compartment (the area for the expected abnormalities) received a disproportionately large amount of attention, whereas only a scant amount of attention was paid to the neck compartment.

Alliterative error is an error caused by a preconceived notion from a previous interpretation by a colleague or oneself (4). The negative finding in the previous reports could have affected the subsequent interpretative performance.

To the best of our knowledge, there are only 3 other cases of soft tissue necrosis caused by cuff overinflation. In two of these cases, the extended trachea did not recoil back to the previous size (5, 6). In the presented case, the stretched trachea recoiled back, similar to the case described by Sachdeva and his colleagues (7). The prognostic value of this difference in recovery is unknown, but might have a significant clinical implication. To explore the clinical relevance of this finding, more data on this condition is needed.

Teaching Points

  1. Careful attention should be paid to cuff inflation pressure in patients presenting with bleeding at the tracheostomy site.
  2. Conscious efforts to avoid well-known errors in diagnostic image interpretation, such as satisfaction of search error, and inattentional blindness error, should be made to improve diagnostic accuracy.

References

  1. De Leyn P, Bedert L, Delcroix M, et al. Tracheotomy: clinical review and guidelines. Eur J Cardiothorac Surg. 2007 Sep;32(3):412-21. [CrossRef] [PubMed]
  2. Ashman CJ, Yu JS, Wolfman D. Satisfaction of search in osteoradiology. AJR Am J Roentgenol. 2000 Aug;175(2):541-4. [CrossRef] [PubMed]
  3. Richards A, Hannon EM, Derakshan N. Predicting and manipulating the incidence of inattentional blindness. Psychol Res. 2010 Nov;74(6):513-23. [CrossRef] [PubMed]
  4. Berlin L. Malpractice issues in radiology. Alliterative errors. AJR Am J Roentgenol. 2000 Apr;174(4):925-31. [CrossRef] [PubMed]
  5. Rhodes A, Lamb FJ, Grounds RM, Bennett ED. Tracheal dilatation complicating tracheal intubation. Anaesthesia. 1997 Jan;52(1):70-2. [CrossRef] [PubMed]
  6. Honig EG, Francis PB. Persistent tracheal dilatation: onset after brief mechanical ventilation with a "soft-cuff" endotracheal tube. South Med J. 1979 Apr;72(4):487-90. [CrossRef] [PubMed]
  7. Sachdeva A, Pickering EM, Reed RM, Shanholtz CB. Ice cream cone sign: reversible ballooning of the trachea due to tracheostomy tube cuff overinflation. BMJ Case Rep. 2016 May 4;2016. [CrossRef] [PubMed]

Cite as: Pak S, Flora A, Yoon Y-S. Tracheal stoma necrosis: a case report. Southwest J Pulm Crit Care. 2017;14(4):172-6. doi: https://doi.org/10.13175/swjpcc032-17 PDF 

Sunday
Apr022017

April 2017 Critical Care Case of the Month

Robert A. Raschke, MD

Banner University Medical Center-Phoenix

Phoenix, AZ USA

 

Critical Care Case of the Month CME Information

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive 0.25 AMA PRA Category 1 Credits™ for each case they complete. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity. 

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours 

Lead Author(s): Robert A. Raschke, MD.  All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.

Learning Objectives:
As a result of this activity I will be better able to:

  1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
  2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
  3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
  4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine

Current Approval Period: January 1, 2017-December 31, 2018

Financial Support Received: None

 

History of Present Illness

A 20-year-old woman was transferred from another medical center for care. She was pregnant and initially presented with a one day history of crampy abdominal pain with nausea and vomiting after eating old, bad tasting chicken two days previously. She had pain of her right arm and a non-displaced humeral fracture was seen on x-ray. The etiology of the fracture was unclear. Her illness rapidly progressed to respiratory distress requiring intubation. The fetus had deceleration of heart tones leading to a cesarean section and delivery of a non-viable infant. Subsequently, she had rapid progression of shock and anuria.

Past Medical History

She had a previous history of a seizure disorder which was managed with levetiracetam, clonazepam, and folic acid. There was a previous intentional opiate overdose 2 years earlier. One month prior to admission she had visited her husband in Iraq. After returning to the US 3 weeks prior to admission, she developed a sore throat and was treated with penicillin. She smokes tobacco hookah and marijuana. There is a positive family history of gout.

Physical Examination

  • Vital signs: heart rate 109, blood pressure 102/78 mm Hg while on norepinephrine, respiratory rate 22, temperature 36.5º C.
  • General: She was sedated and intubated. She had a splint on her right arm.
  • Lungs: clear anteriorly
  • Heart: regular rhythm without murmur
  • Abdomen: firm without palpable organomegaly or masses.
  • Neurological examination: There was movement of all extremities. Muscle tone was normal. Deep tendon reflexes were normal. Plantar reflexes were down going.
  • Skin: diffuse erythematous macular popular rash on the trunk and back (Figure 1).

Figure 1. Photograph of patient’s back showing rash.

Initial Laboratory Evaluation

  • CBC: hemoglobin 14.5 gm/dL, platelet count 299,000 cells/mcL, WBC 41,000 cells/mcL, vacuolated polymorphonuclear leukocytes were noted
  • Electrolytes: Na+ 135 mmol/L, K+ 4.9 mmol/L, Cl- 95 mmol/L, HCO3- 18 mmol/L
  • Renal function: creatinine 3.9 mg/dL, blood urea nitrogen (BUN) 59 mg/dL
  • Liver enzymes: AST 294 (normal 8-48 U/L), ALT 303 (normal 7-55 U/L), ALP 187 (normal 45-115 U/L).       
  • Glucose: 58

Which of the following should be done immediately? (Click on the correct answer to proceed to the second of five pages)

  1. Bedside echocardiography
  2. Liver biopsy
  3. Urine drug screen
  4. 1 and 3
  5. All of the above

Cite as: Raschke RA. April 2017 critical care case of the month. Southwest J Pulm Crit Care. 2017;14(4):134-40. doi: https://doi.org/10.13175/swjpcc039-17 PDF

Thursday
Mar022017

March 2017 Critical Care Case of the Month

Kyle J. Henry, MD

Banner University Medical Center Phoenix

Phoenix, AZ USA

 

Critical Care Case of the Month CME Information

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive 0.25 AMA PRA Category 1 Credits™ for each case they complete. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity. 

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours 

Lead Author(s): Kyle J. Henry, MD.  All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.

Learning Objectives:
As a result of this activity I will be better able to:

  1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
  2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
  3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
  4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine

Current Approval Period: January 1, 2015-December 31, 2017

Financial Support Received: None

 

History of Present Illness

A 50-year-old man presented to the emergency room via private vehicle complaining of 5 days of intermittent chest and right upper quadrant pain. Associated with the pain he had nausea, cough, shortness of breath, lower extremity edema, and palpitations. 

Past Medical History, Social History, and Family History

He had a history of hypertension and diabetes mellitus but was on no medications and had not seen a provider in years. He was disabled from his job as a construction worker. He had smoked a pack per day for 30 years. He was a heavy daily ethanol consumer. He had an extensive family history of diabetes.

Physical Examination

  • Vitals: T 36.4 C, pulse 106/min and regular, blood pressure 96/69 mm Hg, respiratory rate 19 breaths/min, SpO2 98% on room air
  • Lungs: clear
  • Heart: regular rhythm without murmur.
  • Abdomen: mild RUQ tenderness
  • Extremities: No edema noted.

Electrocardiogram

His electrocardiogram is show in Figure 1.

Figure 1. Admission electrocardiogram.

Which of the following are true regarding the electrocardiogram? (Click on the correct answer to proceed to the second of seven pages)

  1. The lack of Q waves in V2 and V3 excludes an anteroseptal myocardial infarction
  2. The S1Q3T3 patter is diagnostic of a pulmonary embolism
  3. There are nonspecific ST and T wave changes
  4. 1 and 3
  5. All of the above

Cite as: Henry KJ. March 2017 critical care case of the month. Southwest J Pulm Crit Care. 2017;14(3):94-102. doi: https://doi.org/10.13175/swjpcc021-17 PDF

Friday
Feb032017

Ultrasound for Critical Care Physicians: Unchain My Heart

William Mansfield, MD

Michel Boivin, MD

 

Division of Pulmonary, Critical Care and Sleep Medicine

Department of Medicine,

University of New Mexico School of Medicine

Albuquerque, NM USA

 

A 46-year-old man presented after a motor vehicle collision. He suffered abdominal injuries (liver laceration, avulsed gall bladder) which were successfully managed non-operatively. The patient remained intubated on mechanical ventilation and remained hypotensive after the injuries resolved. The patient required norepinephrine at low doses to maintain a normal blood pressure. It was noted the patient had a history of remote tricuspid valve replacement. A bedside echocardiogram was then performed to determine the etiology of the patient’s persistent hypotension after hypovolemia had been excluded.

Video 1. Apical four chamber view centered on the right heart.

 

Video 2. Apical four chamber view centered on the right heart, with color Doppler over the right atrium and ventricle.

 

Video 3. Right ventricular inflow view.

 

Figure 1. Continuous-wave Doppler tracing through the tricuspid valve.

 

What tricuspid pathology do the following videos and images demonstrate? (Click on the correct answer to proceed an explanation and discussion)

  1. Mobile vegetation
  2. Tricuspid Regurgitation
  3. Tricuspid Stenosis
  4. All of the above

Cite as: Mansfield W, Boivin M. Ultrasound for critical care physicians: unchain my heart. Southwest J Pulm Crit Care. 2017;14(2):60-4. doi: http://doi.org/10.13175/swjpcc013-17 PDF